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Background: Fenestrated endovascular aortic repair (FEVAR) has been used with increasing frequency to treat juxtarenal aortic aneurysms. We present the pre-operative planning, stent graft design and technique of implantation of a Cook Zenith (Cook Inc., Brisbaine, Australia) customized fenestrated stent graft in an 80-year old female patient with enlarging 6-cm juxtarenal aortic aneurysm.
Technical description: Computed tomography angiography (CTA) with centerline of flow analysis was used for measurements and a customized stent graft was designed with two 6x8mm renal artery fenestrations. Under general anesthesia, bilateral percutaneous trans-femoral access was established with placement of pre-closure sutures. After systemic heparinization, a 20Fr sheath was introduced via the right trans-femoral approach. The sheath valve was punctured for placement of selective catheters to locate both renal arteries. The Cook Zenith fenestrated component was oriented extra-corporeally, introduced and deployed via the left trans-femoral approach. The renal arteries were accessed through the renal fenestrations, and 7Fr hydrophilic sheaths were placed over 0.035” Rosen wires. A diameter-reducing wire, which constrained the device, was removed, the uncovered stent was deployed and the top cap was retrieved. The proximal neck was balloon dilated. Renal alignement stents were deployed and flared proximally using 10mm angioplasty balloons. Selective renal arteriographies showed widely patent renal arteries with no endoleak. The repair was completed with deployment of a distal bifurcated component via the left trans-femoral approach and a right iliac limb extension. Completion angiography showed widely patent target vessels, stent grafts and iliac arteries without endoleak. Total contrast volume, fluoroscopy and operating time were 62ml, 40 and 82 minutes, respectively. The patient was dismissed home next day without complications, and a CTA showed no endoleak or stent-graft complications in 18 months of follow-up.
Conclusion: Customized fenestrated stent-grafts have expanded the indications of endovascular repair to include patients with inadequate infrarenal aortic neck or involvement of the visceral arteries. The technique can be performed using a total percutaneous approach and has the potencial to reduce mortality, morbidity, blood loss, operative time and hospital stay as compared to open surgical repair.