Complex aortic repair using an hybrid custom made endograft (fenestrations + inner branch)

Our first  case performed using a Cook Medical custom made inner branched endograft (1 inner branch + 2fen).

Anastomotic pseudoaneurysm on previous aorto-bifemoral bypass (1985).

We opted for an inner branched graft because of the extremely sharp angle between the aortic axis and RRA and SMA takeoff (narrow inner lumen so no outer branches possible).

CT chronically occluded

LRA revascularized from contralateral femoral access while SMA and RRA from a percutaneous axillary access.

A 10 Fr sheath was advanced from above, over an axillary-femoral through and through in the partially deployed graft (before removing the posterior reducing tie and releasing the graft’s proximal end) using a preloaded guidewire.

This sheath was used for both SMA and RRA bridging stent deployment.
Low flow in RRA at the end of the procedure, so re-cannulation and additional BMS to correct vessel dissection.

Inner branches are definitely going to play a major role in the complex aortic repair panorama