Stern Jordan R, Tran Kenneth, Dossabhoy Shernaz S, Sorondo Sabina M, Lee Jason T
Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
J Vasc Surg Cases Innov Tech. 2022 Dec 23;9(1):101091. doi: 10.1016/j.jvscit.2022.101091. eCollection 2023 Mar.
Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique.
Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πD = πD + 2D.
Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively.
This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.
在先前进行血管腔内主动脉修复术（EVAR）或开放性腹主动脉瘤修复术（OR）后，由于距内脏分支的距离较短，近端血管腔内再次干预可能具有挑战性。我们提出了一种新颖的解决方案，即使用双腔、吻接分支技术来使用市售的ZFEN装置。
确定那些在EVAR或OR术后因近端失败而接受开窗修复的患者。将ZFEN装置部署在先前移植物分流器上方。一旦固定好内脏分支，就使用吻接分支与先前的移植物分支相连。标准ZFEN的远端直径为24毫米，根据公式2πD = πD + 2D可容纳两个20毫米的组件。
在2012年至2021年期间，在单一机构接受ZFEN修复的235例患者中，有28例因先前修复的近端失败而接受治疗，其中13例采用双腔技术治疗（8例EVAR，5例OR）。从分流器到最低肾动脉的距离为67±24.4毫米（范围为39 - 128毫米），到肠系膜上动脉（SMA）的距离为87±30.5毫米（范围为60 - 164毫米）。技术成功率为100%。7例患者采用标准ZFEN构建（2例肾小开窗，SMA大开窗/扇贝形开窗）。容纳标准ZFEN构建的到最低肾动脉和SMA的最小距离分别为56毫米和60毫米。4例患者需要辅助通气管移植物，2例需要激光开窗。2例患者在1个月时出现沟漏，自行缓解；1例患者发生晚期1a型内漏。1年、2年和3年的无再次干预率分别为90%、72%和48%。
这种双腔技术可使市售ZFEN装置远端密封到先前的开放性或血管腔内修复中，技术成功率良好。长期结果仍有待量化。
