Mirza Aleem K, Kärkkäinen Jussi M, Tenorio Emanuel R, Lima Guilherme B, Marcondes Giuliana B, Oderich Gustavo S
Advanced Endovascular Aortic Program, Aortic Center, Mayo Clinic, Rochester, MN, USA.
Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
EJVES Vasc Forum. 2020 Sep 6;49:11-15. doi: 10.1016/j.ejvsvf.2020.08.003. eCollection 2020.
Fenestrated branched endovascular aortic repair with custom manufactured devices (CMDs) has been applied to treat post-dissection thoraco-abdominal aortic aneurysms (TAAA), but the long waiting period for device manufacture limits its application in symptomatic or contained ruptured aneurysms.
A 59 year old female presented with a 7 cm chronic post-dissection extent II TAAA. The patient underwent first stage total arch repair with the elephant trunk technique. At the time of the initial placement of the thoracic stent graft a fenestration was created in the septum to perfuse the right renal artery, which originated from the false lumen. A second stage procedure was planned with a CMD, but the patient presented with severe chest pain and lower extremity weakness, which was attributed to compression of the true lumen below the renal arteries due to increased flow into a pressurised false lumen. The patient underwent successful repair using a physician modified endograft (PMEG) with four fenestrations and preloaded guidewires. Follow up at 21 months showed no complications and a widely patent stent graft.
The Zenith Alpha has several advantages over the TX2 platform for modification, notably lower profile fabric and wider Z tents, which provide greater flexibility for the creation of fenestrations or branches. In this case, the creation of a larger fenestration during the first stage procedure probably contributed to pressurisation of the false lumen. PMEGs remain a valuable option for TAAA repair, including chronic post-dissection aneurysms. Their application is particularly useful in symptomatic patients who are not candidates for an off the shelf endograft and cannot wait for a device to be manufactured.
使用定制器械（CMD）进行开窗分支型血管腔内主动脉修复术已被应用于治疗夹层后胸腹主动脉瘤（TAAA），但器械制造的漫长等待期限制了其在有症状或局限性破裂动脉瘤中的应用。
一名59岁女性，患有7厘米的慢性夹层后Ⅱ型TAAA。患者接受了象鼻技术的一期全弓修复术。在最初放置胸主动脉覆膜支架时，在隔膜上开了一个窗，以灌注起源于假腔的右肾动脉。计划进行二期手术，使用CMD，但患者出现严重胸痛和下肢无力，这归因于流入受压假腔的血流增加导致肾动脉下方真腔受压。患者使用带有四个开窗和预装导丝的医生改良型血管内移植物（PMEG）成功完成修复。21个月的随访显示无并发症，且支架移植物广泛通畅。
Zenith Alpha在用于改良方面比TX2平台有几个优势，特别是更薄的织物和更宽的Z形支架，这为开窗或分支的创建提供了更大的灵活性。在这种情况下，一期手术中创建较大的开窗可能导致了假腔的压力升高。PMEG仍然是TAAA修复的一个有价值的选择，包括慢性夹层后动脉瘤。它们的应用对于那些不适合使用现成血管内移植物且无法等待器械制造的有症状患者特别有用。
