Fenestrated Graft Expands Possibilities for Aortic Aneurysm Treatment Minimally Invasive Technique Ideal for Patients at High Surgical Risk
With the development of the fenestrated aortic graft, patients with aneurysms near the renal arteries have a minimally invasive, endovascular option for their aneurysm repair. The fenestrations, or openings, in the aortic graft align with the arteries that branch off the aorta. Led by vascular surgeon Mounir Haurani, MD, Ohio State’s fenestrated graft team has performed more than 30 fenestrated graft procedures since 2013. Ohio State is one of only three centers in Ohio to perform the procedure and the only one in central Ohio.
Who is a Candidate for a Fenestrated Graft?
Patients with pararenal and juxtarenal aneurysms who have intermediate to high risk for open surgery are the primary candidates for the fenestrated aortic graft. In particular, those who are frail, elderly or ill are most likely to benefit because they avoid potential complications of an open procedure. “We can also use the fenestrated graft for people with a failed aneurysm repair,” Haurani says. “With good CT imaging and 3-D views, we can convert an old endograft without doing an open repair.” For younger patients in their 50s or 60s, an open procedure may be the treatment of choice because of a proven record of long-term reliability, Haurani says, noting that this may change with continued improvement and growing evidence of the success of the fenestrated graft.
For now, he says. “Endografts may dislodge or leak over time and need secondary procedures to reseal the aneurysm or do a bypass around it. The endografts are easier upfront but need lifelong follow-up. With the open procedure, we can sew a polyester or Gortex graft in place, and the material is good for life.” Haurani is optimistic about the future. “As the technology emerges in the next 10 to 15 years, we may not need open aneurysm procedures,” he says.
Preparation and Procedure
Preparation before the procedure is critical to its success. Advanced imaging capabilities at Ohio State enable radiologists to capture precise, 2mm slices during a CT scan that can be processed and transformed into 3-D images of the aorta.
“The openings for the kidneys and intestinal arteries are often only 6mm, so we need fine cuts to pin down precise locations of the holes,” Haurani says. It takes about four weeks to manufacture a custom graft according to specifications, so the procedure cannot be performed emergently. The procedure is technically demanding, requiring three to six hours to ensure precise placement of the graft. Placement of less complex endografts typically takes about one to two hours. Haurani works with the same team of surgical techs, radiology techs and anesthesiologists to optimize procedure outcomes.
“You need a team who really understands the device; there are up to 23 markers on the graft to aid alignment,” he says. “It can be disorienting if you don’t have a good knowledge of the graft design.” The surgeon enters through the femoral artery, similar to a catheterization, and threads the catheter carrying the graft through the iliac arteries and to the proper position in the aorta. Once positioned, the fenestrated graft stays in place through the outward force of the graft pressing against the aorta. The graft gains further stability from its columnar strength and hooks that are above the graft fabric. After the procedure, patients receive care from a dedicated vascular nursing team in the Ross Heart Hospital and are discharged in two to four days.
Advantages of Fenestrated Graft Procedure
For patients who are not strong candidates for an open surgical procedure, the fenestrated graft offers a safer option to prolong length and quality of life. Notable advantages include:
- Minimal blood loss
- No cutting into chest wall muscles, making it easier to breathe postoperatively, which is especially important for people with chronic obstructive pulmonary disease (COPD)
- Less hemodynamic stress, because the aorta is not clamped
- Less stress to the kidneys, because circulation is cut off for only a very short time
- Shorter hospitalization of two to four days versus seven to 10 days with an open vascular procedure
- Shorter recovery time of two to four weeks versus eight to 10 weeks
To date, Ohio State has been able to deploy all attempted grafts and preserve all target vessels. Patients have experienced no further aneurysm growth, and cases that involve leaking have shown no risk of rupture. Haurani is enthusiastic about the next step, still in clinical trials, which uses a branched graft that has applications even higher in the thoracic aorta.
After the procedure, Ohio State physicians see the patient at one month, six months and annually for follow-up CT scans. If a patient’s kidney function isn’t strong, the vascular lab team monitors the graft long term. Physicians maintain close contact with the referring physician via operative reports and communication about post-operative visits. Case managers work closely with patients to ensure they have appropriate care for their recovery and long-term success. Ohio State enrolls all patients in a Vascular Quality Initiative Registry of the Society for Vascular Surgery to measure long-term success and document how long patients are living with the graft.
Make a Referral
At Ohio State’s Aortic Center of Excellence, a team of surgeons, anesthesiologists and radiologists holds regular conferences to discuss cases and develop an optimal treatment plan for each patient. Even if you think your patient may not be suitable for a fenestrated graft, the multidisciplinary team can offer minimally invasive options, hybrid procedures and open aneurysm repair.
To make a referral, call 614-293-8536 or contact the Aortic Center of Excellence at 855-204-1200.
After hours, you can call 614-293-8000 and ask the hospital operator to page the vascular surgery physician on call.
For urgent matters, contact our transfer center at 614-293-4444.