Maximizing Proximal Seal Zone in Fenestrated Endografting: Evolution in the Approach to Graft Configuration.
Citation: Journal of Vascular Surgery. 72(6):1891-1896, 2020 12.PMID: 32330599Institution: MedStar Washington Hospital CenterDepartment: Surgery/Vascular SurgeryForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Aortic Aneurysm, Abdominal/su [Surgery] | *Blood Vessel Prosthesis | *Blood Vessel Prosthesis Implantation/is [Instrumentation] | *Endovascular Procedures/is [Instrumentation] | *Mesenteric Artery, Superior/su [Surgery] | *Stents | Aortic Aneurysm, Abdominal/dg [Diagnostic Imaging] | Blood Vessel Prosthesis Implantation/ae [Adverse Effects] | Endoleak/et [Etiology] | Endovascular Procedures/ae [Adverse Effects] | Humans | Mesenteric Artery, Superior/dg [Diagnostic Imaging] | Prosthesis Design | Retrospective Studies | Risk Factors | Time Factors | Treatment Outcome | United StatesYear: 2020Local holdings: Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006ISSN:- 0741-5214
| Item type | Current library | Collection | Call number | Status | Date due | Barcode |
|---|---|---|---|---|---|---|
| Journal Article | MedStar Authors Catalog | Article | 32330599 | Available | 32330599 |
Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006
CONCLUSIONS: Significantly more proximal seal length can be obtained using a ZFEN with a large fenestration for the SMA and two small fenestrations for the renals. Whenever possible, surgeons should consider this configuration in order to maximize proximal seal length and potentially reduce the risk of proximal endoleak. An additional advantage of this approach is that stenting of the SMA to prevent shuttering is unnecessary or impossible, making the procedure more technically facile. Copyright (c) 2020. Published by Elsevier Inc.
METHODS: This is a retrospective cohort study examining the 100 consecutive ZFEN grafts designed for patients at two university centers, from 2012 through 2019. The proximal seal length, from the top of the graft to the beginning of the aneurysm was determined from preoperative CTA. Alternative configurations were evaluated to determine whether they would have provided longer proximal seal.
OBJECTIVES: Fenestrated endografting for juxta- and para-renal abdominal aortic aneurysms (AAA) affords the ability to seal stent grafts in normal aorta at and above the renal arteries. The Zenith fenestrated graft (ZFEN, Cook Medical, Bloomington, IN) is custom-made to surgeon specification, subject to certain manufacturing limitations. The most common configuration in the pivotal trial and in post-approval commercial use has been a scallop for the superior mesenteric artery (SMA) and two small fenestrations for the renal arteries (configuration "A"). An alternative configuration to maximize seal zone length, consisting of a large fenestration for the SMA and two small fenestrations for the renals (configuration "B") has been routinely adopted at our institutions to potentially prevent type IA endoleak.
RESULTS: The two most common configurations were B (N = 45) and A (N = 38). In cases that A was chosen but B could have been built, 5.8 +/- 1.9 mm of seal zone was lost; in cases that B was chosen but A could have been built, 5.8 +/- 2.8 mm of seal zone was gained. In part, due to the increased proximal seal length of configuration B, this configuration has been used more frequently in the last four years of this experience compared to the first four (53% vs. 25%, P = 0.004). Of 95 patients that have completed surgery and follow-up, type Ia endoleaks were observed in 12 patients (13%) on completion angiography, all of which resolved on follow-up imaging without intervention. No SMA was compromised by misalignment of the large fenestration in configuration B.
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