Preloaded Device for Aortic Therapeutic Optimization and Refinement (PreDATOR)

C. Baeza
Fundación Jiménez Díaz Univeristy Hospital.,
Spain

Keywords: aortic aneurysm, fenestration, FEVAR, misalignment, PMEG, bifurcation

Summary:

Introduction: FEVAR can be a technically demanding procedure, especially when the stent graft and its fenestrations are not aligned precisely with the intended target arteries. Misaligned fenestrations lead to longer procedural and fluoroscopy times; increase of contrast used; and intraoperative target vessel complications or impossibility of cannulation. A further evaluation of the incidence and causes of stent graft misalignment is needed as well as the use of adjunctive technologies and techniques that can improve alignment. In physician modified endograft techniques (PMEG), the use of aortic models manufactured in 3D printers can provide benefit to adjust the location of fenestrations, but this doesn’t assure target vessels canulation. We describe a new technique that achieves this objective by a system of preloaded guides on a PMEG. Methods: The entire procedure is performed coaxially through a single access point. We describe the technique in a series of steps that, in summary, consist of preloading, through each fenestration performed in a PMEG, a modified guidewire in the form of a slipknot and performing a kind of “through&through” maneuver, achieving tension in these guidewires with a catheter inserted into the destination artery. Results: We have tested the technique in anatomical models. The technique allows that, even if the fenestrations are slightly misaligned with the target vessel, the interlocking guide system has already gained the target vessel prior to prosthesis deployment. This technique not only limits its use to cannulation of visceral arteries but could also be used to cannulate vessels of the aortic arch, hypogastric arteries and, in general, any area of arterial bifurcation. Conclusions: We describe a resource technique for urgent cases that require the use of PMEG. It offers several advantages, but mainly it offers a greater security, above all for the surgeon, as it assures the canalization of the target vessels before the release of the graft and that increase the reliability of the procedure as it assures a pathway regardless of the fenestration and the target vessels are aligned or not. We believe that this technique could be standardized by the use off-the-shelf devices.