Cook Medical | Zenith t-Branch Thoraco Abdominal Stent Graft
Nine months later, the right CIA was found to beaneurysmal and required intervention (Figure 1A). ACTA demonstrated only a single left renal artery with aninfrarenal aortic diameter of 26 to 27 mm over a lengthof 60 mm (Figure 1B). The right CIA false lumen extendedfrom the aorta into the external iliac artery (EIA) originwith entry and exit fenestrations seen at these respectivepoints. The right CIA aneurysm measured 35 mm inmaximum diameter. The left CIA had a midsegmentangulation and measured 16 to 17 mm in maximumdiameter. Via bilateral groin exposure, the right CIAaneurysm was repaired using a Zenith stent graft with acustom-made inverted limb. The main body was introducedthrough the right common femoral artery (CFA),into the wider lumen of the CIA, and the ipsilateral limbextended into the right EIA. Open ligation of the rightinternal iliac artery (IIA) was performed due to thecomplexity of the anatomy and the difficulty in identifyingthe true lumen from the false lumen. A customizedcontralateral limb was introduced through theleft CFA, and this sealed proximally in the inverted limb,within the main body of the graft and distally above theleft common iliac bifurcation (Figure 1C). A postproceduralangiogram revealed no endoleak, and the patientwas discharged home after 3 days (Figure 2).
Zenith Alpha™ Abdominal Endovascular Graft Bifurcated Main ..
The Zenith Fenestrated stent graftsystem is the first fenestrated device approved for commercial use in the US. Based on theresults of the US prospective trial and large single-centerexperiences, rates of type I and III endoleak, migration,aneurysm rupture, and conversion to open repair areexceptionally low.14 Branch patency averages > 95% withcovered stents.16,20 These results should serve as benchmarksfor comparison with alternative endovasculartechniques of branch vessel incorporation, includingdebranching, snorkel, and physician-modified grafts.
Endovascular repair of complexaneurysms involving the visceral arterieshas become a reality. Fenestrated stentgrafts have been increasingly utilizedto treat pararenal and thoracoabdominalaneurysms. The technique is safe,effective, and can be performed withhigh technical success and low risk ofcomplications in the hands of experiencedphysicians.5 More than 5,500patients have been treated with ZenithFenestrated endografts (more than5,500 with the iliac branch devices andmore than 1,500 with the thoracoabdominalbranch devices worldwide).
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When selecting large fenestrations, it isuseful to review the design outline providedby the manufacturer (Figure 3). I recommendusing large fenestrations only if the stentstruts are located at the edge of the fenestration;fenestrations with struts crossing in themiddle cannot be aligned by a stent, andhigher rates of vessel occlusion have beenreported in these cases.15 Anatomical factorslimiting the use of the Zenith Fenestratedstent graft system include proximal aneurysmextension requiring more than three fenestrations,excessive angulation at the visceralsegment, or inadequate renal artery anatomydue to multiple small accessory renal arteriesor early renal artery bifurcation (Figure 4).
Aortic Intervention | Cook Medical
Clinical experience with the grafts from Gore & Associates and Medtronic are limited at this time, but ongoing studies should provide data in the next few years. The design by Cook Medical has been the benchmark for safety and effectiveness of endovascular treatment of TAAAs, but several questions remain to be answered. It is unclear what percentage of patients will be eligible for an off-the-shelf design. Results thus far have been achieved in high-volume centers of excellence. Given the technical complexity of the cases, such centralization may be an important element to procedural safety. With approval of such devices, however, diffusion of the technology may allow access for more patients but with uncertain consequences for implantation success. Spinal cord injury remains a devastating complication of the procedure, and the incidence remains high at 7% to 8% in most series. Further efforts to reduce the incidence of spinal cord injury are needed.
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The patient underwent an endoluminal graft repairwith a custom-made Zenith device, which had a largefenestration for the SMA and two small fenestrations forthe renal arteries. Visceral artery stenting was performedusing appropriately sized, covered balloon-expandablestents. Due to the previous open repair graft in situ, thedistance between the aortic bifurcation and the renalarteries was limited. As a result, the distal componentwas planned with an inverted contralateral limb and wasintroduced via the right-hand side (Figure 3C). The ipsilateralsegment landed within the right common iliacopen repair graft limb, and the contralateral limb landedwithin the left. A self-expanding bare-metal stentwas inserted to treat a dissection at the origin of theleft EIA. He was discharged home 4 days after surgery(Figure 3D).