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* These authors contributed equally
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.
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.
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.
The initial approach for aortic arch repair was open surgical repair. DeBakey et al. first successfully repaired an aortic arch aneurysm in 19573. However, several limitations restrict the application of open surgical repair4, including severe surgical trauma, significant blood loss, high complication rates, and prolonged operative duration5. With advancements in endovascular technology, thoracic endovascular aortic repair (TEVAR) has been proven effective for treating thoracic aortic aneurysms and dissections6,7,8. Building on conventional TEVAR, fenestrated/branched thoracic endovascular aortic repair (F/B TEVAR) was developed to address thoracic aortic aneurysms involving branch arteries9,10. Notably, F/B TEVAR has demonstrated high technical success and acceptable post-operative mortality in patients with post-dissection thoracoabdominal aneurysms11,12.
F/B TEVAR can restore normal physiological blood flow and achieve high patency rates in branch arteries following thoracic aortic aneurysm repair13,14. Precise fenestration on the main body stent graft is essential for reconstructing branch arteries. Aortic arch aneurysms in Zone 1 typically involve multiple branch arteries and require stent grafts with triple fenestrations. However, current commercial stents cannot be customized based on individual patient anatomy. Physician-modified fenestrated endografts (PMEGs) offer a viable alternative for personalized treatment of thoracic aortic aneurysms in Zone 115,16.
Successful fabrication of PMEGs requires extensive practice and experience, which can be challenging for many surgeons. To simplify the preparation process, this article presents a method for fabricating PMEGs for F/B TEVAR. Three-dimensional (3D) printing was used to achieve precise fenestration on the main body stent graft, followed by the attachment of branch stents in the appropriate orientation. This study reports a case series of 21 patients who underwent F/B TEVAR using PMEGs, providing novel insights into the efficacy and applicability of this technique.
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
2. Preparation of the 3D-printed model
3. Intraoperative fabrication of PMEGs
4. Surgical procedure
5. Post-operative monitoring and care
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 Β± 70.4 min. Intraoperative blood loss was 150 mL (IQR = 300). The post-operative ICU stay averaged 1.2 Β± 2.2 days, while the total hospital stay was ...
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 mortality15,17. 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 ...
All of the authors declare no conflict of interest.
This work was supported by the Standardization Research and Innovative Application of Regional Vascular Surgery Disease Clinic Database, Jiangsu Provincial Drug Administration Drug Supervision Scientific Research Program Project (No. 202014).
Name | Company | Catalog Number | Comments |
3D printer | Stratasys | Eden260VS | Used for printing 3D models |
Ankura TAA Stent Graft System | LifetechΒ | 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 softwareΒ | OQTON | Used for simulation analysis of vascular remodeling after stent implantation | |
GOREΒ DRYSEAL Flex Introducer Sheath | W.L. Gore & Associates | DSF1065 | Used as the delivery sheaths |
GOREΒ VIABAHNΒ Endoprosthesis | W.L. Gore & Associates | VBHR051002AΒ | 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 softwareΒ | 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,Β 46-850 | Used as the guidewires |
Valiant thoracic stent graft with Captivia delivery system | Medtronic | VAMF2626C100TU | Used as the main body stent grafts |
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