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Back Table Fenestrated Endograft Limb Inversion for Type Ia Endoleak Repair
Fletcher N Pierce, Jr., Ahmed Raza, Shikha Trivedi, Alexander T Eckstrom, Jean M Panneton, David J Dexter, Hosam F El Sayed, Christopher D Murter, Animesh Rathore
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA

While endovascular aortic repair (EVAR) has proven to be safe, it conveys a higher rate of reintervention than open aortic repair. Endoleaks are the most common indication for reintervention.
Endoleaks have prompted vascular surgeons to innovate new endovascular repair techniques. We present a case of a patient with a type Ia endoleak in close proximity to the renal arteries that was successfully treated with a back table physician modified endograft (PMEG) with inversion of the contralateral limb.
In 2017, a 79-year-old male with medical history significant for CAD, MI, stage 3 CKD with an atrophic left kidney, lymphoma in remission, chronic back pain secondary to lumbar spondylosis, and a 60 pack-year smoking history underwent elective EVAR at an outside hospital for a 5.1 x 5.1 cm infrarenal abdominal aortic aneurysm (AAA). This repair utilized a 35 mm x 14 cm Gore Excluder endograft. 30 month ultrasound revealed a type Ia endoleak with sac expansion to 5.6 x 5.9 cm confirmed by CTA. He was referred to us for repair.
The potential surgical options for the patient included:

    1. Open aortic graft explantation and aneurysm repair.
    2. Fenestrated aortic endograft.
    3. Parallel graft repair.
Given the patient’s extensive comorbidities and overall frailty, option 2 was ultimately chosen as it offered a less morbid, yet feasible alternative.
We utilized a Cook Zenith fenestrated endograft with custom fenestrations for the celiac artery, superior mesenteric artery, and right renal artery. We performed back table modification of the distal bifurcated main body. The graft was unsheathed and the contralateral gate was divided flush with the flow-divider. The divided limb was intussuscepted backwards and sutured into the distal main body, allowing it to land directly at the level of the flow-divider of the pre-existing endograft. (Figure 1)

Completion angiogram showed patent visceral and hypogastric arteries, and no endoleak. 11 month follow-up CT scan showed a stable aneurysm sac.

Commercially available endograft devices do not allow for repair of type Ia endoleak in absence of adequate proximal extension options. There is often a short distance between the renal arteries and the bifurcation of the previous endograft. Therefore, entrapment of contralateral iliac limb within ipsilateral iliac limb of the pre-existing endograft is usually avoided by performing an endovascular aorto-uni-iliac (AUI) repair with creation of femoral-femoral bypass.
This back table modification allowed deployment of the bifurcated distal main body over the Gore Excluder’s flow divider avoiding an AUI repair with femoral-femoral bypass, thereby diminishing risk of bypass graft complications, iliac occlusive disease, and lower extremity ischemia. Many institutions are able to utilize this easily reproducible technique. This case demonstrates the effectiveness of back table physician modification to the contralateral endograft limb in treating endoleaks.

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