Three-Dimensional Printing Assisted Physician-Modified Fenestrated Endografts for Thoracic Endovascular Aortic Aneurysm Repair in Zone 1

Summary

This protocol describes an approach for repairing aortic arch aneurysms in Zone 1 using physician-modified fenestrated endografts with the assistance of three-dimensional printing.

Abstract

Aortic arch aneurysm is a life-threatening cardiovascular disorder that requires timely medical intervention. Aneurysms in Zone 1 typically involve multiple branch arteries, making repair challenging. Open surgical repair often results in significant surgical trauma, massive blood loss, and prolonged operative time. With advancements in endovascular technology, fenestrated/branched thoracic endovascular aortic repair (F/B TEVAR) has been employed for aortic arch repair and branch artery reconstruction. Stent grafts for F/B TEVAR require personalized modification and fabrication based on patient anatomy. Physician-modified fenestrated endografts (PMEGs) offer a feasible approach for personalized aortic arch aneurysm repair in Zone 1. However, fabricating PMEGs demands a thorough understanding of anatomy and extensive experience, making it challenging for most surgeons. To simplify this process, three-dimensional printing is used to assist in precise fenestration. PMEGs guided by three-dimensional printing enhance branch artery patency and reduce post-operative endoleaks following F/B TEVAR. Further follow-up is necessary to assess the long-term benefits and efficacy of this technique.

Introduction

Aortic aneurysms are common life-threatening aortic diseases that require timely evaluation and therapeutic intervention¹. Aortic arch aneurysms often involve major arterial branches, including the innominate artery, left common carotid artery, and left subclavian artery¹. According to the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines, the aorta is divided into 11 landing zones². Repairing aortic arch aneurysms in Zone 1 requires reconstruction of the aortic arch branch arteries, posing significant anatomical challenges.

Protocol

The surgical protocols described here were approved by the ethics committee of Nanjing Drum Tower Hospital, affiliated with Nanjing University Medical School. Written was obtained from the patients participating in this study. The details of the reagents and the equipment used are listed in the Table of Materials.

1. Pre-operative assessment

1. Apply the following inclusion criteria: Patients aged over 18 years; confirmed diagnosis of aortic aneurysms in Zone 1 of the aorta using computed tomography angiography (CTA); no contraindications for F/B TEVAR; informed consent for the surgery.
2. A

Results

Twenty-one patients, aged 35 to 87 years, underwent F/B TEVAR for aortic arch aneurysm repair using PMEGs. Blood flow in all aortic arch branch arteries (innominate artery, left common carotid artery, and left subclavian artery) was restored through triple fenestrations in all cases (Figure 4). The average operative time was 234.3 min ± 70.4 min. Intraoperative blood loss was 150 mL (IQR = 300). The post-operative ICU stay averaged 1.2 ± 2.2 days, while the total hospital stay was ...

Discussion

F/B TEVAR is a suitable approach for repairing aortic arch aneurysms in Zone 1, effectively maintaining branch artery patency. Compared with open surgical repair, F/B TEVAR is associated with lower peri-operative morbidity and mortality^15,17. However, endoleaks are likely to occur at fenestration bridging sites post-operatively, potentially requiring reintervention¹⁸. Studies have shown that a greater number of fenestrations increases the ...

Materials

Name	Company	Catalog Number	Comments
3D printer	Stratasys	Eden260VS	Used for printing 3D models
Ankura TAA Stent Graft System	Lifetech	TAA2622B100	Used as the main body stent grafts
Biocompatible PolyJet material	Stratasys	MED610
Fluency Plus Endovascular Stent Graft	Bard Peripheral Vascular	FEM10100	Used as the branch stents
Geomagic Wrap software	OQTON		Used for simulation analysis of vascular remodeling after stent implantation
GORE DRYSEAL Flex Introducer Sheath	W.L. Gore & Associates	DSF1065	Used as the delivery sheaths
GORE VIABAHN Endoprosthesis	W.L. Gore & Associates	VBHR051002A	Used as the branch stents
Hi-Torque Supra Core peripheral extra supportive guide wires	Abbott	1002703	Used as the guidewires
INFINITI DIAGNOSTIC CATHETER	Cordis	SRD6642	Used as the catheters
Lunderquist Extra-Stiff Wire Guide	COOK MEDICAL	G49228	Used as the guidewires
Mimics software	Materialise		Used for performing 3D reconstructions of the aorta
Nester Embolization Coil	COOK MEDICAL	G47332	Used as the coils
PROLENE Polypropylene Suture	Johnson&Johnson MedTech	SXPP1B201	Used as the operative suture
RADIFOCUS Angiographic Catheter	Terumo Interventional Systems	RF-DB1500GM	Used as the catheters
RADIFOCUS Guide Wire M	Terumo Interventional Systems	RF-GA18153M	Used as the guidewires
SurVeil Drug-Coated Balloon	Abbott	SRV03513504010	Used as the expansion balloons
V-18 & V-14 ControlWire Guidewire	Boston Scientific Corporation	39216-71822,  46-850	Used as the guidewires
Valiant thoracic stent graft with Captivia delivery system	Medtronic	VAMF2626C100TU	Used as the main body stent grafts