Preloaded Fenestrated Stent-Grafts for the Treatment of Juxtarenal Aortic Aneurysms

Purpose: To describe a novel technique for target vessel catheterization in patients with juxtarenal abdominal aortic aneurysms requiring treatment with fenestrated stent-grafts (FSG). Methods: The standard FSG design was modified, substituting a thin-wall tube for the solid central obturator that serves as both an attachment point for the distal end of the graft as well as a top cap retriever. Through this tube, two 0.020-inch wires are run from the hub of the delivery system through the stent-graft, out through each fenestration, and up to the proximal edge of the graft, where they are attached by sutures. The sutures are connected to a trigger wire on the control hub. The preloaded wires facilitate passage of a sheath to the fenestration, providing stability while target vessel catheterization takes place and avoiding the use of a large sheath in the contralateral groin. A third wire attached to the inside of the top cap facilitates its safe retrieval via a 6-mm balloon. The preloaded FSG was used in 5 male patients (mean age 75.6 years) with either juxtarenal aneurysms (n=2) or aneurysms previously treated with infrarenal stent-grafts that had developed type I endoleak (n=3). In 3 cases, a double fenestrated stent-graft was required, and in 2 cases a triple fenestrated device was deployed, with scallops for the superior mesenteric or celiac arteries. Results: Sixteen of 17 target vessels were preserved, and all aneurysms were successfully excluded with no endoleak at completion. In 2 patients, tortuosity encountered during device delivery caused twisting of the wires within the preloaded FSG, preventing successful advancement of a sheath over a preloaded wire. An approach from the contralateral groin was necessary to complete the procedure in 1 case, but the target vessel was lost in the other. Conclusion: The use of a preloaded FSG is feasible and facilitates the catheterization of fenestrations and of target arteries. This method has the potential to reduce procedure times and lower the risk of intraoperative lower limb ischemia.