Four vessel's fenestrated stentFour vessel s fenestrated stent graft for a juxta-renal AAA

Dr Zoghby Kamal Ahmed MD SSC surgDr.Zoghby Kamal Ahmed,MD,SSC-surg.

Dr.Manish Taneja ,MD,FRCR,FAMS

Dr.Benjamin chua ,MBBS, MHSc(Duke),Dr.Benjamin chua ,MBBS, MHSc(Duke), FRCS

HistorHistory

74 y old gentleman Known CHD ,IHD . Long standing DM,HT.g g , COPD

CVA CVA Incidentally detected Juxta-renal aneurysm (7.2 cm) with

( )another smaller aneurysm (4.9 cm) above aortic bifurcation

i “ ” fi tiin a “snow-man” configuration

Anatomical challengesAnatomical challenges

Juxta- renal AAA involving renal and mesenteric Juxta renal AAA involving renal and mesenteric vessels.

Tortuous ,and calcified iliac and femoral arteriesarteries.

Pre operative scanPre-operative scan

SUPERIOR MESENTERICARTERY

RIGHT RENALARTERY

LEFT RENALARTERY

CELIAC ACCESS

ARTERY

3D Reconstruction3D Reconstruction

P ti lPre-operative plan

Pre- graft productionPre graft productionInitial sheet

Final measurements and sizinge su e e s d s g

4 vessel's fenestrated stent graft4-vessel s fenestrated stent graft

Celiac Fenestration

Pre-loaded sheath in SMA

SMA

L ft R lRi ht

Fenestration

Left Renal Fenestration

Right RenalFenestratiFenestration

Access & procedureAccess & procedure

• Operation done under local anesthesia and sedation.

Left axillary and both common femoral arteriesaccessed and 7F sheaths inserted at all three locationsaccessed, and 7F sheaths inserted at all three locations.

Calibration Angiogram performed through pigtailCalibration Angiogram performed through pigtail catheter and final sizing confirmed.

45 cm 7F Destination (Terumo) sheath inserted into left45 cm 7F Destination (Terumo) sheath inserted into left axillary artery.

ProcedureProcedure

Graft inserted through Left femoral sheath positioned andGraft inserted through Left femoral sheath, positioned andunsheathed according to markers.

The wire in the preloaded SMA sheath snared from lefta illar access sing Ensnareaxillary access using Ensnare.

Th 7F h th d d i t ft ll th h SMAThe 7F sheath advanced into graft scallop through SMAfenestration and 6x38 mm Advanta V12 balloon mountedstent graft deployed.

Procedure AngiogramProcedure Angiogram

Main bodyPartiallyPartially deployed

Celiac TrunkTrunk

Advanta V12 stentin the SMA

ProcedureProcedure

C li f t ti l t d th h h th d (6 22)Celiac fenestration cannulated through same sheath and (6x22)Advanta V12 stent graft deployed.

Rest of main graft deployed.

Through Right femoral sheath, right renal artery cannulated and7x38 mm Advanta V12 stent deployed.

Extension piece of 7x59mm Advanta V12 stent deployed into the main body.

procedureprocedure

Same done for left renal artery and (8 x38mm) Advanta V12stent deployed.

Dissection noted at its distal end which was treated with(8x30mm) Precise self expanding bare stent up-to the leftrenal bifurcation.

Procedure AngiogramProcedure Angiogram

Lt. renalArtery

Celiac trunk

Rt. Renal

ArteryArtery

SMA

ProcedureProcedure

Distal main body stent graft bifurcation deployed subsequentlyth i l t t t fi d d i d itionce the proximal stent system was fixed, and in good position

to visceral stents.

Contralateral limb cannulated through Rt.Femoral access, and Iliact i i (14 56) d l dextension piece (14x56) deployed.

f (1 39)Left iliac artery extension piece (14x39),positioned and Deployed.

Moulding of stents overlap points.

Procedure AngiogramProcedure Angiogram

Rt. CIACalibration

Lt. CIA

Completion AngiogramCompletion Angiogram

E d lt 3DEnd result 3D

F ll CT t 6 thFollow-up CT scan at 6 months

Patent all renal and mesenteric vessels with goodPatent all renal and mesenteric vessels with good flow,and preserved Renal function.

No Endoleak after 6 Months follow up CT-Angio