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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 51-53

Application of a custom-manufactured directional multibranched stent graft to treat thoracoabdominal aneurysms: A case report


1 Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
2 Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha; Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China

Date of Submission04-Dec-2021
Date of Decision10-Jan-2022
Date of Acceptance21-Feb-2022
Date of Web Publication24-Jun-2022

Correspondence Address:
Dr. Chang Shu
Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha; Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.348225

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  Abstract 


OBJECTIVE: The objective of this study was performed to demonstrate the feasibility and effectiveness of a custom-manufactured stent graft (CMSG) with directional multibranches for the treatment of a complex thoracoabdominal aortic aneurysm (TAAA) patient.
METHODS: A 73-year-old man presented with Crawford Type V TAAA was treated with a CMSG with four down-going directional branches including two proximal directional branches for the celiac artery and superior mesenteric artery and two distal side directional branches for the bilateral renal arteries.
RESULTS: Postoperative course was unremarkable and 6-month follow-up demonstrated sac regression, absence of endoleaks, and all of the visceral branches remained patent.
CONCLUSIONS: Total endovascular repair using CMSG with directional multibranches is a suitable alternative in higher risk patients with TAAA who are not suited for open surgery. Longer follow-up is needed to confirm the preliminary results.

Keywords: Endovascular surgery, thoracoabdominal aortic aneurysm, multibranched stent graft


How to cite this article:
He H, Li Q, Ye Z, Shu C. Application of a custom-manufactured directional multibranched stent graft to treat thoracoabdominal aneurysms: A case report. Vasc Invest Ther 2022;5:51-3

How to cite this URL:
He H, Li Q, Ye Z, Shu C. Application of a custom-manufactured directional multibranched stent graft to treat thoracoabdominal aneurysms: A case report. Vasc Invest Ther [serial online] 2022 [cited 2022 Dec 5];5:51-3. Available from: https://www.vitonline.org/text.asp?2022/5/2/51/348225




  Introduction Top


Although open surgery is still the primary treatment option for thoracoabdominal aortic aneurysms (TAAAs), it has relatively high risks of perioperative mortality and morbidity, particularly in elderly patients with severe comorbidities.[1] Endovascular repair has been introduced as alternative to treat complex high-surgical risk TAAAs.[2] However, the hostile anatomy of TAAA affects the long-term efficacy of endovascular repair. We report a case by application of a custom-manufactured stent grafts (CMSGs) with directional multibranches to incorporate target vessels (TVs) for the treatment of TAAAs involving visceral branches.


  Case Report Top


A 73-year-old man presented with abdominal and back pain for 2 years. His medical history was notable for chronic obstructive pulmonary disease, coronary artery disease, and hypertension. Computed tomographic angiography (CTA) showed a TAAA (Crawford Type V) from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac artery (CA) and superior mesenteric artery (SMA) [Figure 1]a. This patient was judged to be high-risk candidate for open surgery because of age (73), comorbidities, and anatomical complexity. An endovascular approach was planned using the CMSGs. It was approved by the ethics committee of the hospital and the patient consented to publication of this report.
Figure 1: (a). Preoperative computed tomographic angiography demonstrates an extent Type V thoracoabdominal aortic aneurysm. (b). Diagram of LifeTech custom-manufactured stent grafts (c). Intraoperative angiography before the implantation of the custom-manufactured stent graft (d). Control angiography after completion of the procedure. (e-g). 6-month computed tomographic angiography follow-up demonstrate successful exclusion of the aneurysm and patent directional branches with no evidence of endoleaks

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Devices design

A CMSG (Lifetech, Shenzhen, China), with 4 down-going directional branches destined for the CA, SMA, and bilateral renal arteries (RAs) was manufactured [Figure 1]b. The devices were constructed with 15% oversizing compared with the native aortic diameter at the level of the proximal neck, and the stent-graft length was chosen to enable a proximal landing zone of at least 25 mm in the healthy aorta and to ensure that planned branches would not be on stent overlap zones. The four down-going directional branches were located outside and fixed at the covering of the stent graft with four gold markers at the external opening (“fish mouth”) and four radiopaque markers. Outer branches had a sealing zone (cylinder) length of 12 mm and a diameter of 8 mm and 9 mm (for the SMA and CA, respectively) or 6 mm and 7.5 mm (for the right renal artery (RRA) and left renal artery (LRA), respectively). The proximal directional branches for the CA and SMA are preloaded with 0.018- inch wires to assist cannulation of the visceral arteries.

Implantation

The procedure was performed under general anesthesia with cerebrospinal fluid drainage and intraoperative monitoring. A right groin incision was made to expose the right femoral artery. The left upper extremity access (UEA) was obtained through surgical exposure of the left brachial artery and a 90 cm 8F long sheath (Cook Medical, Bloomington, Indiana, USA) was introduced through the left subclavian access and placed in the descending aorta. After the digital subtraction angiography (DSA) was performed to confirm the exact origin of the visceral branches [Figure 1]c, the CMSG was advanced under fluoroscopic control with the help of the stiff wire through the right femoral artery. The graft was positioned 2–3 cm above the intended TVs and ensures precise positioning with the “fish mouth” distal opening within 1 cm of the intended TVs ostia to allow adequate space for catheter manipulation and branch catheterization. The stent graft was partially deployed with the tie of the distal part to reposition. After the proximal aortic endografts were in correct place, the preloaded 0.018- inch wires in the main stent graft were then captured into the 8F long sheath with 2 snare wires; then, the 8F sheath was advanced over the 0.018- inch guidewire.

With the help of a 5F VER catheter (Cordis), a Rosen guidewire (Cook Medical, Bloomington, Indiana, USA) was advanced into the SMA, selective angiography was performed after insertion of long sheaths in SMA. Then, the sheath was placed through a stiff wire (Amplatz, Boston Scientific, Marlborough, MA, USA). Two 8 mm × 50 mm Viabahn self-expanding covered stents (Gore and Associates, Flagstaff, AZ, USA) were advanced and deployed in the SMA. After that, the outer branches of the RAs were catheterized from the left UEA using a Rosen guidewire with the help of a long sheath. After the covered stent graft opened completely, the 8F long sheath was advanced over a stiff wire through both the left and right RAs; then, two 7 mm × 100 mm Viabahn self-expanding covered stents were placed into the RRA and LRA, respectively. Similarly, the CA was constructed using 9 mm × 100 mm Viabahn self-expanding covered stent. Kissing balloon angioplasty was performed with 8 or 9-mm angioplasty balloons, respectively. DSA showed that the TAAA was completely excluded, with patent bilateral RAs, SMA, and CA [Figure 1]d. Total endovascular time was 110 min with a fluoroscopy time of 50 min. Total contrast volume used was 170 ml. The postoperative course was unremarkable and 6-month follow-up computed tomography angiography demonstrated sac regression, absence of endoleaks, and all of the visceral branches remained patent [Figure 1]e,[Figure 1]f,[Figure 1]g.

Comments

Endovascular repair has been introduced as a less invasive alternative to conventional open aortic repair and is associated with lower mortality and morbidity. However, the challenge in treating complex TAAAs is the ability to totally exclude the aneurysm while maintaining the flow of visceral branches.[3]

The t-Branch stent graft (Cook Medical, Bloomington, IN, USA) is now available as an off-the-shelf device for the treatment of TAAA and can be available for emergency use.[3] However, the requirements of extensive aortic coverage (200 mm), incorporation of all four renovisceral vessels, and anatomic obstacles limited its application so it is theoretically applicable in 50%–90% of anatomical configuration.[4] Most importantly, at present, t-Branch stent grafts are not available in mainland China.

Whereas off-the-shelf devices and physician-modified designs confer certain advantages, CMSGs are well suited to endovascular repair of complex TAAAs, which offer several options with patient-specific variations in the orientation, location, number, and type of fenestration or branch. The largest clinical experience has been accumulated using CMSGs in the treatment of pararenal aneurysms (PRAs) and TAAAs with high technical success and lower morbidity and mortality compared with traditional open repair.[5]

In this case, the maximum diameter of the supraceliac aorta was 30 mm. Hence, the use of directional branches was advisable as there was enough room to open them at the pararenal/juxtarenal level. The main advantages of this CMSG include (1) serial deployment technique by keeping the endograft constrained, creating space outside of the endograft which is key to facilitate catheter/wire mobility and improve the catheterization success. (2) The internal and external openings of the outer branches were well-visible under fluoroscopy and allowed easy catheterization. (3) The branched-section design provides an overlapping connection for a self-expanding covered stent, potentially reducing the risk of stent migration. Since there is no consensus on the ideal bridging stents for branch artery stenting. We prefer using Viabahn stent grafts for the TVs because of their flexibility. The biggest difference between this CMSG and preexisting t-Branch is this device was manufactured with only one stent at the proximal part in contrast to the fixed three stents of the t-Branch and distal extension through a bifurcated endograft is not always necessary. This leads to less coverage of the thoracic aorta and lowers the paraplegia rates. Besides that, the CMSG can be ordered with different proximal and distal diameters instead of fixed diameter of t-Branch device (34 mm and 18 mm).

The main drawback of CMSGs includes the time delay for device manufacturing and delivering, which prevents their use in patients with symptomatic or ruptured aneurysms.


  Conclusions Top


Endovascular treatment of TAAA involving the visceral branches is safe and feasible using CMSGs with directional multibranches. This technique is effective as showed by stable sac size and freedom from reintervention at short-term follow-up. However, a longer follow-up is needed to confirm the preliminary results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Murana G, Castrovinci S, Kloppenburg G, Yousif A, Kelder H, Schepens M, et al. Open thoracoabdominal aortic aneurysm repair in the modern era: Results from a 20-year single-centre experience. Eur J Cardiothorac Surg 2016;49:1374-81.  Back to cited text no. 1
    
2.
Suckow BD, Goodney PP, Columbo JA, Kang R, Stone DH, Sedrakyan A, et al. National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients. J Vasc Surg 2018;67:1690-7.e1.  Back to cited text no. 2
    
3.
Spanos K, Kölbel T, Theodorakopoulou M, Heidemann F, Rohlffs F, Debus ES, et al. Early outcomes of the t-Branch off-the-shelf multibranched stentgraft in urgent thoracoabdominal aortic aneurysm repair. J Endovasc Ther 2018;25:31-9.  Back to cited text no. 3
    
4.
Sweet MP, Hiramoto JS, Park KH, Reilly LM, Chuter TA. A standardized multi-branched thoracoabdominal stent-graft for endovascular aneurysm repair. J Endovasc Ther 2009;16:359-64.  Back to cited text no. 4
    
5.
Oderich GS, Ribeiro MS, Sandri GA, Tenorio ER, Hofer JM, Mendes BC, et al. Evolution from physician-modified to company-manufactured fenestrated-branched endografts to treat pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2019;70:31-42.e7.  Back to cited text no. 5
    


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