Parallel Grafts Used in Combination with Physician-Modified Fenestrated Stent Grafts for Complex Aortic Aneurysms in High-risk Patients with Hostile Anatomies.

BACKGROUND: The objective of the study was to evaluate the feasibility and early outcomes of complex aortic aneurysm repair in high-risk patients with hostile anatomies using both parallel stents and physician-modified stent graft (PMSG) techniques to address the renovisceral arteries.

METHODS: Consecutive patients with complex suprarenal (SRA) and thoracoabdominal aortic aneurysms (TAAAs) undergoing endovascular repair using combined parallel stents technique and PMSG between September 2013 and November 2015 were evaluated. All patients required prompt aneurysm treatment. Fenestrations to preserve branch vessels were created in thoracic stent grafts. Depending on the anatomy, chimney or snorkel stents were deployed in renal or visceral arteries as complementary technique to overcome severe angulations or preexisting suprarenal stent. Preoperative, intraoperative, and postoperative data were recorded by means of a prospectively maintained database.

RESULTS: Six high-risk patients with TAAA (type I: n = 2, type III: n = 1) and SRA (n = 3) underwent endovascular repair using both parallel stents technique and PMSG. Indications were painful aneurysms (n = 1) and >70-mm rapidly enlarging aneurysms (n = 5). Ten thoracic components were used, of which 6 were modified intraoperatively. Twenty-one renovisceral arteries were revascularized, using dedicated fenestrations (n = 10, 47.7%), chimney (n = 7, 33.3%), and snorkel stents (n = 4, 19%). The mean operative time was 326 ± 82 min including the device modification time. The mean time for graft modification was 90 ± 15 min. In 1 patient, a rescue chimney stent intended to the superior mesenteric artery was deployed because of failed cannulation through the dedicated fenestration. Technical success rate was 83.3%. One patient died during the early postoperative course from severe stroke. Among surviving patients, 3 required early reinterventions for iliac occluder-related type II endoleak (n = 1), type Ia endoleak (n = 1), and gastroduodenal artery embolization (n = 1). The mean follow-up was 14.2 ± 4.8 months. One early gutter-related type I endoleak resolved during follow-up. No other complications occurred, and all target vessels remained patent.

CONCLUSIONS: PMSG combined with parallel stent provided acceptable short-term results in specific presentation of SRA and TAAA with hostile anatomies in selected high-risk patients with contraindication for standard fenestrated/branched grafts. More reliable outcomes require larger population and follow-up.