Home-made Fenestrations for Various Pathologies of Abdominal Aorta
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1 Home-made Fenestrations for Various Pathologies of Abdominal Aorta Chen, Jer-Shen Director of Vascular Surgery, Far Eastern Memorial Hospital Clinical Assistant Professor, National Yang-Ming University
2 PAU below L renal artery R renal ~ 1cm higher than L renal PAU immediately below L renal
3 First, a simple one Single fenestration for L renal fenestration ~ 8mm to the edge micropuncture guidewire (COOK) as rim marker thin easy for re-sheath Good radio-opacity easy to see on fluoro Fenestration size ~ 10mm
4 Slow Deployment (I) Another linear marker opposite to the fenestration Carefully face the fenestration to L renal
5 Slow Deployment (II) R Renal dot is too high! Add a 6*60mm Zilver stent as R renal chimney Always plan a bailout procedure! Prepare L arm is necessary
6 Guidewire rim marker had strong artifact effect on CT R renal chimney: ok L renal thrombosis? No! an strong artifact caused by the guidewire tip (angiography proved)
7 Fenestrations on the proximal Type Ia endoleak after EVAR Bilateral Renals at the same level Type Ia endoleak 2 years after EVAR (30mm extension cuff)
8 Scallop & fenestrations 30*80mm TAA extension device Scallop for SMA (10mm) Fenestrations for Renals (5mm) Note one of the three trigger wires
9 Diameter reducing tie is possible! Thread the trigger wires between stent struts Make ties between the trigger wire & stents
10 Re-sheathing
11 EVAR (I) -- Fully deployment of the device -- Two trigger wires still there rotatable under diameter-reducing tie -- Successful cannulation of R Renal (pre-wiring of L renal) Successful cannulation of L renal
12 EVAR (II) 6*50mm Viabahn in both renals Patent SMA & both renals
13 Follow up CT, 1 month later Stable renal function Loss of abdominal pulsatile mass Smooth renal Viabahns
14 Fenestrations on the Distal 6cm Thoraco-abdominal aneurysm 78-year-old female Main aneurysm above celiac Mild aneurysmal change at celiac SMA & renal levels as landing zone
15 Triple fenestrations Single fenestration for SMA/celiac (only 5mm apart) Bilateral renal fenestrations (36-160mm device)
16 Endografting (I) Smaller first Proximal and distal endografting Proximal: mm Distal: 20-82mm
17 Endografting (II) mm device for celiac level sealing Completion angiography
18 Chronic dissecting AAA (5 years after AsAo grafting) -- Pressurized false lumen 2 nd tear (two false lumen) -- tear may be between SMA & Renals Very small true lumen (< 20mm longest at longest diameter)
19 Home-made quadruple fenestrations -- impossible to have diameter-reducing tie (true lumen so small) Large fenestration to allow mal-position 24-79mm TAA device
20 EVAR (I) Intimal tear just around the viscerals We have a mirrored L marker at posterior aspect
21 EVAR (II) The mirrored L marker is the important marker that we can clearly identified
22 Good completion aortography Patent celiac, SMA Patent both renals Sealed intimal tear
23 CT 2 months later -- patent Celiac, SMA, renals -- good true lumen expansion Complete thrombosis of false lumen
24 Conclusion Hand-made fenestration is feasible for most pathologies of abdominal aorta, including PAU, true aneurysm, and even dissecting AAA Hand-made diameter-reducing tie is also possible With detailed CT analysis and careful marking of the holes, correct orientation is not difficult
25 Home-made Fenestrations for Various Pathologies of Abdominal Aorta Chen, Jer-Shen Director of Vascular Surgery, Far Eastern Memorial Hospital Clinical Assistant Professor, National Yang-Ming University
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