Physician-modified fenestrated endovascular repair of type 1A endoleaks from polymer-based low-profile endografts

There have been increasing number of endovascular aortic aneurysm repair performed in hostile necks using newer generation technology including polymer-based proximal sealing devices such as the Ovation system. Unique design features of the device can pose challenges during endovascular salvage of type 1A endoleak. We describe two cases of successful application of physician-modified fenestrated endografting, in order to repair type 1A endoleaks following endovascular aortic aneurysm repair with ovation system.

In both cases, multi-fenestrated endografts were custom-modified using preloaded wire technique on Cook Zenith Alpha thoracic stent grafts at the back table. Under general anesthesia, left brachial cut down and a single percutaneous femoral access were performed. Staggered deployment of fenestrated endograft, accompanied by sequential catheterization of target vessels, facilitated correct alignment of fenestrated endograft. Infolding of fenestrated endograft inside the Ovation main body resulted in leg claudication, and repaired with balloon expandable covered tent. Prophylactic deployment of balloon expandable covered stent was performed in the second case. Both cases showed resolution of type 1A endoleak.

Fenestrated endovascular repair is feasible for proximal failure of Ovation endografts. Careful planning and advanced skill set in complex endovascular aortic repair are required, as well as detailed knowledge of the failed endografts.