A novel cautery instrument for on-site fenestration of aortic stent-grafts: A feasibility study of 18 patients

摘要

The article by Stephen and colleagues1 shows a novel cautery instrument for on-site fenes-tration of Dacron endografts, but we believe that fenestration techniques may be applied to polytetrafluoroethylene (PTFE) endografts as well. Our group has developed a new technique using a physician-customized fen-estrated C3 Excluder (W.L Gore & Associates, Flagstaff, AZ, USA) to treat aortic aneurysms with unsuitable necks. On a back table, the bifurcated Excluder is released until the contralateral leg is entirely liberated (Figure, A). Five-millimeter fenestrations are constructed with a circular object cutter (punch). The edges of the fenestrations are reinforced with a radiopaque wire from a snare (Covi-dien, Mansfield, MA, USA); the wire is anchored to the graft with CV6 PTFE suture (W.L. Gore & Associates). Next, the fenestrations are pre-cannulated with 0.018-inch guidewires. After that, the opened main body and contralateral leg of the endograft are manually constricted and re-sheathed into a 22-F tube segment detached from a 22-F Dryseal introducer flow valve (Figure, B and C). This tube segment containing the re-sheathed endoprosthesis is inserted in a 22-F Dryseal sheath. Once delivered to the target site, the Dryseal is partially retracted using a "pin and pull" mechanism until the main body is completely exposed outside the sheath, positioning the fenestration at the level of the visceral vessels. Next, the target visceral arteries are selectively cannulated and balloon-expandable covered stents (Advanta V12; Atrium Medical Corporation, Hudson, NH, USA) are deployed (Figure, D and E).