Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patients

INTRODUCTION: Fenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms.

METHODS: All patients treated with sm-FBSGs at our institution were retrospectively reviewed. Patients presenting with acute symptoms or an emergency indication for repair were analyzed.

RESULTS: Twelve high-risk patients (nine men), of which seven were at American Society of Anesthesiologists class 4 and five were at class 3, presented with seven symptomatic and five ruptured aortic aneurysms. Mean age was 71 years (range, 52-86 years), and mean maximal aneurysm size was 8.1 cm (range, 5-12 cm). Six patients (50%) had prior aortic surgery or a hostile abdomen. Relevant comorbidities included coronary disease in all 12 patients, and seven (58%) had an ejection fraction≤35%. Nine patients (75%) had severe pulmonary dysfunction. Four aneurysms were pararenal, and eight were thoracoabdominal (two type II, three type III, and three type IV). An average of three visceral vessels (range, 2-4) were treated per patient, with 35 branches targeted. Endografts were successfully implanted in all patients. There was no paraplegia or intraoperative death. One patient (8.3%) died of subarachnoid hemorrhage≤30 days. Reintervention was necessary in two patients, for a type 3 endoleak and for evacuation of a retroperitoneal hematoma. Morbidity included one myocardial infarction, and two patients each with transient respiratory failure and transient renal insufficiency not requiring dialysis. Mean postoperative length of stay was 4 days in the intensive care unit and 8 days in the hospital. At a mean follow-up of 9 months (range, 3-18 months), two patients died of non-aneurysm-related causes. Branch vessel patency was 100%. No late reinterventions were necessary. No type I or III endoleaks occurred. One type II endoleak is under observation.

CONCLUSIONS: Sm-FBSG may play an important role in the treatment of select patients with symptomatic or ruptured complex aortic aneurysms who are at prohibitive risk for open surgery and in whom endovascular repair cannot be delayed to allow implantation of a custom-made commercial device. Until an off-the-shelf fenestrated-branched device is created that does not require a prolonged waiting period, this may be the best option to treat patients with symptomatic or ruptured complex aneurysms that are at excessively high surgical risk.