Intraoperative positioning system-guided antegrade in situ laser fenestration in an aortic model

Fenestrated endovascular aneurysm repair (fEVAR) is routinely being used for visceral vessel incorporation in complex aneurysmal pathology; however, it is associated with prolonged procedure times, high radiation exposure, high contrast use, and multiple staged procedures. To combat these limitations, Centerline Biomedical developed the three-dimensional surgical navigation and visualization technology: intraoperative positioning system (IOPS). We previously presented our IOPS-guided antegrade in situ laser fenestration in a standard aortic model. This case report details our experience using IOPS guidance during a fEVAR procedure in a representative thoracoabdominal aortic aneurysm phantom model.

A silicone thoracoabdominal aortic segment was three-dimensional printed based on high-resolution computed tomography angiogram imaging of a patient with thoracoabdominal aortic aneurysm. An experimental fEVAR procedure was performed on the phantom through simulated vascular entry points in a heated water bath to simulate ambient body temperature. A thoracic endograft was deployed within the phantom, followed by in situ laser fenestrations using intraoperative positioning system guidance for each visceral vessel. Bridging stents were placed through the created fenestrations into the respective visceral vessels. Except for cannulation confirmation and completion images, there was minimal to no radiation used.

Stent deployment was confirmed via a single shot radiograph. Cannulation times were 45 seconds for right renal artery, 96 seconds for the celiac artery, 51 seconds for the superior mesenteric artery, and 687 seconds for the left renal artery. Completion angiogram demonstrated widely patent renal arteries, celiac artery, superior mesenteric artery, and inferior mesenteric artery with accurately aligned stent grafts.

This benchtop phantom model demonstrates early feasibility of IOPS-guided in situ laser fenestration as a promising radiation-sparing technique with the added benefit of obviating a prestenting procedure and expediting fEVAR procedure times. However, research should be conducted to further evaluate the safety and efficacy of IOPS application in fEVAR in humans.