Aorta
AAA

SYMPTOMATIC AAA post EVAR: Homemade FEVAR?

Considering the clinical evaluation and medical history of this 87-year-old patient with symptomatic AAA, suggest a treatment plan prior to uncovering the subsequent course of this case!

Éric Ducasse
Éric Ducasse
Hospital Pellegrin - Bordeaux, France
Professor of vascular surgery

Professor of vascular surgery
Head of unit of vascular surgery CHU Bordeaux - France

Conflicts of interest:

Honoraria from: COOK Médical, Térumo-Vascutek, Siemens, GORE

Part I - Case presentation
  • A 87-year-old male patient with HTN, Afib and hypothyroidism 
  • Biological aortic valve replacement in 2013
  • EVAR for infrarenal AAA in 2015
  • Atrial flutter ablation in 2020

He presented with symptomatic AAA with 2 cm diameter increase.

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Part II - Treatment

Homemade FEVAR with 3 FEN

  • TREO endograft modified by physician, who created 3 fenestrations for SMA and the two renal arteries
  • In the emergency suite with motorized C-Arm and carbon floating table

Stent-graft modification steps

Stent-graft modification steps: Opening of the proximal part of the endograft with sufficiant length for fenestration shape
Opening of the proximal part of the endograft with sufficient length for fenestration shape
Stent-graft modification steps: Fenestration marking in accordance with sizing
Fenestration marking in accordance with sizing
Stent-graft modification steps: Fenestration creation with cautering pen
Fenestration creation with cautering pen
3 fenestrations created for SMA and both renal arteries
Stent-graft modification steps: Goose snare suture for circular reinforcement and radio visibility
Lasso suture for circular reinforcement and radio visibility
Stent-graft modification steps
 
Stent-graft modification steps: Anterior J mark for optimal placement and orientation
Anterior J-mark for optimal positioning and orientation
TREO PMEG with 3 implemented fenestrations
Stent-graft modification steps: Graft reloading with elastic vessel loop
Graft reloading with elastic vessel loop
Stent-graft modification steps
Initial angiogram - SMA and both renal arteries individualization
Target vessels marking
Target vessel marking
PMEG endograft: Delivery and positioning
PMEG endograft: delivery and positioning
Right renal cannulation
                       Left renal cannulation with UF catheter and 0,035 guidewire                                                                                                    
SMA cannulation with Vanchie 3 catheter (Cook Medical, Bloomington, Ind) and Rosen guidewire (Cook Medical, Bloomington, Ind) delivery
7 Fr sheath for SMA and angiogram control after 7 x 37 covered stent delivery. Note the 2 renals stented with 6 x 37 and 6 x 27 iCover covered stents ((iVascular)
Leg adjunction on both sides for perfect exclusion and distal stability
                       Leg adjunction on both sides for perfect exclusion and distal stability.                                                                                                                   

Post-op

  • Uncomplicated
  • Discharged on PO day 5