Prolene encircling reducing ties combined with through-and-through wire: An additional technique for physician-modified EndoGraft in challenging anatomy

PurposeTo describe the endovascular treatment of symptomatic pararenal abdominal aortic aneurysm (PAAA) with severe infrarenal angulation using a combination of Prolene Encircling Reducing Ties (PERT), through-and-through wire, and a physician-modified 4-fenestrated endograft (PMEG).TechniqueA 73-year-old male presented with symptomatic PAAA with a 105-degree infrarenal angulation. A right common femoral artery (CFA) to right axillary artery through-and-through wire (0.035 soft hydrophilic wire) was placed, and a modified Valiant Captivia stent graft was advanced through the right CFA. The modified stent graft was deployed until the superior mesenteric artery (SMA) fenestration was opened. The SMA fenestration was then adjusted to the correct position, then the free-flow bare stent was opened. Sequential deployment of the modified stent graft was performed. After successful cannulation of three visceral arteries (SMA and renal arteries) from axillary approach, a 7 Fr sheath was advanced into the SMA, and the modified stent graft was fully deployed. Following removal of the delivery system, the stent graft was fully opened by compliance balloon inflation, which ruptured the 6-0 Prolene ties. The SMA and both renal arteries were then stented and flared. A modified bifurcated Endurant stent graft (without free-flow bare stent) was deployed approximately 1 cm below the lowest renal fenestration, and the iliac limbs were deployed to complete the procedure. 6-month follow-up computed tomography angiography (CTA) demonstrated complete exclusion of the aneurysm without endoleak.ConclusionA combination of PERT, through-and-through wire, and PMEG for the treatment of symptomatic PAAA with severe infrarenal angulation demonstrated acceptable early results.