Surgeon Modified Fenestrated EVAR 2.0

Clinical case video describing urgent correction of a proximal type I endoleak, in previous standard EVAR procedure, which caused a rapid growth of the residual aneurysmal sac. The patient was unfit for open surgery due to multiple severe comorbidities. Considering the urgency setting, the use of a market available custom-made device was not reasonable. For this reason, the patient underwent endovascular correction using a “surgeon modified” endograft (Medtronic Valiant Navion Thoracic Endograft) designed with four custom fenestrations for visceral and renal vessels.


    Dr. Ugursay Kiziltepe
    April 9, 2020

    Congratulations on the great video… I benefited a lot. I have a question regarding the alignment of the surgeon modified endograft inside the aorta. How do you make sure that graft rotation is correct according to ostiums of visceral arteries? Do you use any overlapping markers that the graft is in the exact position? Do you align after partial deployment? How do you figure out that ostiums are front or rear?
    Thank you very much in advance
    Dr. Ugursay Kiziltepe
    Ankara Turkey

    Professsor Enrico Cieri
    April 12, 2020

    Thank you very much for your feedback and questions. We marked the fenestrations with the radiopaque tip of a 0.014” wire stitched all around the graft holes, in that way is possible to check the position of the fenestrations and align the graft to the vessel ostia (the same we usually do with market available custom devices). A great aid is given by the use of the “fusion” technology. No overlapping markers were fixed to the graft. However, when re-constraining the graft, we marked the “zero” position on the delivery system to help with the correct orientation. We aligned the graft after partial deployment (given by the prolene constriction sutures) and when al target vessels have been cannulated the graft was completely deployed and constriction sutures were broken by ballooning. Regarding the last question, when the graft was still constrained into the delivery system we checked the correct orientation of the fenestrations for the CT and the SMA simply rotating the c-arm in the lateral position. Please take note that is crucial to deploy the graft step by step and according to the anatomical references, adjust the position of any fenestration.

    I just saw the video. It is really impressive the way how the MD’s modified the graft. Really nice work!!

    Professsor Enrico Cieri
    April 12, 2020

    Thank you very much for the feedback!

    Dr. Claudio Goto
    January 1, 2021

    Thank you very much for sharing your experience, nice case! I would like to ask some questions…which stitch did you use to fixate the marker? Which kind of stich is appropriate?
    What is the specification of the cautery that you used?
    Happy new year!

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