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In-Situ Laser Fenestration of a TAMBE as Salvage Technique for Malpositioned SMA Stent
Ikpechukwu Obayi
Mount Sinai, new york, NY
Background: A novel endovascular technique used to salvage and re-establish in-line perfusion of the SMA after inadvertent exclusion during branched stent-graft repair.
Method: A 65-year-old male with a history of smoking, obesity, hypertension underwent TAMBE placement at an outside institution for expanding 5.3cm TAAA. Postoperative-CTA demonstrated >90° TAMBE graft rotation, SMA stent misdeployment within the aneurysm sac below the origin the of the SMA and renals, and a shortened celiac stent deployed proximal to its origin with celiac stenosis distal to the stent. Persistent aneurysm sac perfusion due to malpositioned SMA stent, resulting in a type IIIc endoleak supplying both the native SMA, AAA sac and an accessory right renal artery. Remaining visceral vessels were profused. The patient was asymptomatic and was referred for further management.
Due to high morbidity of open conversion and patient preference, endovascular strategy was selected. The plan included: (1) in-situ laser fenestration of the TAMBE endograft into the SMA with bridging stent placement, (2) celiac stent extension, and (3) embolization of the malpositioned SMA stent.
Results:Initial angiography revealed failure of the SMA stent to engage the native SMA with distal aspect of the stent significantly below the renal arteries. Bilateral renal stents and the celiac stent were patent, though significant stenosis of the proximal celiac artery was noted. Left axillary access was achieved with primary arterial puncture. After placement of a 12Fr sheath, an 8.5Fr steerable sheath was advanced into the endograft, utilizing a snare wire to overcome tortuous anatomy.An initial attempt to catheterize and reposition the SMA stent cranially toward the native SMA origin was unsuccessful. Using preoperative CTA, the optimal site for laser fenestration was identified. A 2mm laser fiber was advanced through the steerable sheath from above and positioned perpendicular to the graft, allowing successful cannulation of the SMA through the newly created fenestration. Intraluminal access was confirmed and exchanged for a Rosen wire. The fenestration was serially dilated and stented with an 8mmX39mm VBX-stent, which was subsequently flared proximally into the endograft. The celiac artery was then cannulated, and the proximal stenosis was treated with balloon angioplasty followed by stent extension.Finally, the SMA portal was cannulated. The malpositioned stent was successfully occluded using a 12mm Amplatzer plug and Nester coil within the mid-segment of the stent. Final angiography confirmed aneurysm exclusion with flow to all visceral vessels without endoleaks. Patient was discharged POD#1 and doing well without any acute concerns.
Conclusion:As branched endovascular aortic repair becomes more widely adopted, the availability of reliable salvage techniques is critical. This case report demonstrates the use of in-situ laser fenestration as a bailout technique to address a malpositioned superior mesenteric artery stent, successfully preserving in-line flow in a safe and effective manner.
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