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!
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.
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](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s8-opening-of-the-proximal.jpg)
Opening of the proximal part of the endograft with sufficient length for fenestration shape
![Stent-graft modification steps: Fenestration marking in accordance with sizing](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s9-fenestration-marking.jpg)
Fenestration marking in accordance with sizing
![Stent-graft modification steps: Fenestration creation with cautering pen](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s10-fenestration-creation.jpg)
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](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s13-goose-snare-suture-for-circular.jpg)
Lasso suture for circular reinforcement and radio visibility
![Stent-graft modification steps](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s15.jpg)
![Stent-graft modification steps: Anterior J mark for optimal placement and orientation](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s16-anterior-j-mark-for-optimal.jpg)
Anterior J-mark for optimal positioning and orientation
TREO PMEG with 3 implemented fenestrations
![Stent-graft modification steps: Graft reloading with elastic vessel loop](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s18-graft-reloading-with-elastic-vessel-loop.jpg)
Graft reloading with elastic vessel loop
![Stent-graft modification steps](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s21_0.jpg)
Initial angiogram - SMA and both renal arteries individualization
![Target vessels marking](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s23-target-vessels-marks_1.jpg)
Target vessel marking
![PMEG endograft: Delivery and positioning](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s24-pmeg-endograft_0.jpg)
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](/sites/default/files/2024-04/symptomatic-aaa-post-evar-s29-leg-adjunction_0.jpg)
Leg adjunction on both sides for perfect exclusion and distal stability.
Post-op
- Uncomplicated
- Discharged on PO day 5
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