Physician-Modified Endograft Using Three-Dimensional Model-Assisted Planning

• Published in: Journal of vascular surgery cases and innovative techniques 2022-12, Vol.8 (4), p.794-801
• Main Authors: Mitsuoka, Hiroshi, M.D. Ph.D, Terai, Yasuhiko, M.D, Miyano, Yuta, M.D
• Format: Article
• Language: English
• Subjects: Abdominal aortic aneurysm; Fenestrated endovascular aneurysm repair; Innovations in clinical care; Juxtarenal; Paravisceral; Simulation; Surgery
• ISSN: 2468-4287; 2468-4287
• DOI: 10.1016/j.jvscit.2022.10.012

ABSTRACTObjectiveCase-specific and true-to-scale three-dimensional models have become increasingly useful tools for physician-modified endovascular grafting. This study aimed to validate the use of three-dimensional model-assisted planning for fenestration design. MethodsThirty-two consecutive patients (2019–2021) presenting with para-/juxta-renal abdominal aortic aneurysm (n=16), para-visceral abdominal and Crawford’s extent IV thoracoabdominal aortic aneurysm (n=12), and type-1 endoleak after endovascular repair (n=4) were retrospectively analyzed. All cases were manually planned with a standard method using curved planar reconstruction stretch images and multi-planar images perpendicular to the centerlines. The design was finalized by intraoperative three-dimensional model-assisted planning. Inter-method agreements were assessed for geometrical relationships (separation heights and angles) between the superior mesenteric and renal arteries. The datasets from 55 double measurements of the entire cohort in this series were used to assess measurement discrepancies (≥ 3 mm separation height or ≥ 15° angle difference) and fenestration mismatches (≥ 3 mm separation between the manually planned and three-dimensional model-assisted-planned renal arterial centers on the device surface) between manual and three-dimensional model-assisted planning. Statistical analyses were performed to test the impact of anatomical factors on the discrepancies and mismatches. The imposition accuracy of three-dimensional model-assisted planning and short-term clinical results of the 32 cases were also evaluated. ResultsFourteen fenestration measurement discrepancies were detected. The size of the stent-graft (P=0.0381), the aortic angle (P=0.0008), and the prior existence of stent-graft (P=0.0123) were found to have a statistically significant impact on the measurement discrepancy, using single-logistic and Fisher’s Exact test. Twelve fenestration mismatches were observed and found to be significantly affected (P=0.0039) by aortic angle. A cut-off value for fenestration mismatch was found to be 36.5 o, with a sensitivity and specificity of 69.2% and 80.5% respectively, using receiver operating characteristic analysis (area under the curve: 0.782 ± 0.081, P=0.0023). A high level of branch preservation (100%) was achieved. During the observation period (1.3 years on average; range, 0.5–2.5 years), no patient experienced complications related to fenestration. ConclusionsThe differenc