This document summarizes a study reviewing cases of "impossible" cannulations during fenestrated and branched endograft procedures. The study reviewed 671 patients undergoing fenestrated or branched endografts between 2001-2014. Of the 1712 target vessels, cannulation was impossible in 29 cases (1.7%). 12 vessels were lost, 13 were salvaged with retrograde cannulation (92.3% success). In 4 cases, unstented fenestrations remained patent without endoleak. The conclusion is that target vessel cannulation success rates are high in high-volume centers, and leaving select unstented fenestrations may be possible in rare cases without causing endoleak.

1. “Impossible” cannulations in
fenestrated/branched endografts: can we
leave some fenestrations unstented?
Eric Verhoeven MD, PhD, A. Katsargyris, MD, K. Oikonomou, MD
Department of Vascular and Endovascular Surgery,
Paracelsus Medical University, Nuremberg, Germany

2. Disclosures
• William Cook Europe/Cook Inc.
– Consultant & Research grants
• W.L. Gore & Associates
– Consultant & Research grants
• Atrium
– Consultant
• Siemens
– Consultant

3. Why to stent a
Fenestration/Branch?
• Fenestration
– Achieve better sealing (covered stent)
– Maintain the fenestration in position
• Branch
– Bridging covered stent to seal

4. To answer the Question…
• Review of our database (2001-2014)
– FEVAR for complex AAA
– FEVAR/BEVAR for TAAA

5. Overview
• FEVAR for complex AAA
– 457 pts
• F/B-EVAR for TAAA
– 214 pts
Total target vessels: N=1712*
– Impossible cannulation (antegrade): N=29/1712 (1.7%)
* Scallops excluded

6. Impossible Antegrade Cannulation
(N=29)
• Vessels lost: N= 12/1712 (0.7%)
• Vessels attempted to save by Retrograde Cannulation:
N= 13/1712 (0.8%)
• Patent Vessels (aligned fenestration):
N= 4/1712 (0.2%)

7. Vessels lost (N=12)
• Renal arteries in FEVAR: N= 7/942 (0.7%)
– Occlusion, no endoleak: N=4
– Rupture → Embolisation: N=1
– False bridging with lumbar artery: N=1
– Occlusion with endoleak in RAAA N=1
(Graft for other pt: Endoleak → Cuff + Chimney + Endostaples)

8. RAAA (Graft for other patient)
Unstented LRA Fenestration - Endoleak

9. After 1st cuff After 2nd cuff + RRA chimney After endoanchors
RAAA (Graft for other patient)

10. Vessels lost (N=12)
• Vessels in TAAAB: N= 5/770 (0.6%)
– Celiac Branch: N=1
• Covered with cuff
– Renal Branch: N=1
• Amplatzer plug, Ileorenal bypass
– Untreated lost renals: N=3
• Death within 30 days: N=2
• Complicated postop course: N=1

11. Retrograde Cannulation (N=13)
• Celiac Artery: N=3
– Planning mistake: N=1
– Deployment mistake: N=1
– Catheterization mistake: N=1
• Renal Artery: N=10
Technical Success: 12/13 (92.3%)

12. Retrograde Cannulation #1
Rule: Flairing of stents: top to bottom

18. Retrograde Cannulation #2
Difficult Angle for LRA

20. Patent Vessels (N=4)
Aligned Fenestration
• No Endoleak: N=3
• Endoleak: N=1
– Fenestration stented
secondarily from above
F#183

21. Conclusion
• Target Vessel Cannulation
– ↑Technical success in high volume centers
• Primary: 1683/1712 (98.3%)
• Assisted: 1695/1712 (99.1%)
• Patent: 1699/1712 (99.2%)
– Unstentable Fenestrations
• Rare scenario
• 4 remained open w/ο endoleak