# Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms

## TL;DR

A new hybrid surgical technique using modified endovascular grafts and thoracoscope-assisted fixation is proposed for treating complex aortic aneurysms in high-risk patients.

## Contribution

A novel urgent hybrid procedure combining surgeon-modified fenestrated grafts and thoracoscope-assisted fixation is introduced for thoracoabdominal aortic aneurysms.

## Key findings

- The hybrid procedure successfully treated a high-risk patient with extent III thoracoabdominal aortic aneurysm.
- Thoracoscope-assisted fixation helped secure the endograft in the proximal descending aorta.
- Fenestrated endografts were aligned with target arteries using radiopaque markers for precise deployment.

## Abstract

Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma.

A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery.

Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.