1. Usefulness of fenestrated stent graft for thoracic aortic aneurysms
Jichi Medical University,
Saitama Medical Center
Department of Cardiovascular Surgery1
Tokyo Women’s medical university
Department of Cardiovascular Surgery2
Koichi Yuri 1, Yoshihiko Yokoi2, Koichi Adachi1, Hideki Morita1, Atsushi Yamaguchi1 and Hideo Adachi1

2. 【Background 】
The introduction of endovascular stent-graft（SG) technology has ushered in a new era in the therapy for disease of the distal aortic arch and the descending thoracic aorta.
Since Thoracic endovascular aortic repair （ TEVAR ）has been commercially available ,it became into wide use in Japan.
We also introduced TEVAR for the high risk cases of a thoracotomy operation in our medical center and an associated institution since 2006.

3. 【Method】
Patients in whom undergoing single elective Thoracic Aortic Aneurysm repair from January, 2006　through November, 2011 were 350 cases.
Among 68 cases in which TEVAR was performed,
19 cases were treated by fenestrated TEVAR.
Early and mid-term results were analysed retrospectively.

4. 【Patients background】
Average age ± 17　y.o
Gender male：female 16:3
Site of aneurysms
Distal arch 18
Ascending Aorta 1

5. 【Device】
Our TEVAR device was custom made and was constructed with a self expandable Z stent and e-PTFE graft with customized fenestrations strategically adjusted for the patient’s vessel anatomy.

6. 【Design of Stent Graft (SG)】
Fenestration
Before creating a stent graft(SG), it will be
measured specifically using 3D-CT in 0.5 mm
slices.Left subclavian artery was occluded strategically in this case.

7. 【Operation method】
・All patient’s one femoral artery was surgically isolated and a 6 Fr sheath was inserted into the right brachial artery.
・The SG was delivered through the femoral artery with a Fr sheath, using tug of wire technique.
・After delivering the sheath, the SG was deployed from Zone 0（zero）～Zone2. ・

8. 【CASE】

9. 【Post operative CT】
Arch vessels were preserved and no endoleaks were detected. Left subclavian artery was occluded strategically.

10. 【Result】 ・Average operation time 169.5 ± 64.4 minute
・Average bleeding 　139 ±187 ml
・Technical Success rate was 100%
・Initial Success and Early Success rate was 89.4%
(There were one operative death and one transient paraparesis.)
・Mid-TermSuccess was 94.1%
( One case has endoleak“probably Type 2 ”)

11. 【Result】 At a mean follow-up 771days
・3 cases passed away ( non-aortic death.)
　 (Actuarial Survival rate is 83.3%. )
・No secondary interventions.
・No migration were detected in all cases.

12. 【Discussion】 【Conclusion】
The ascending aorta and the aortic arch are challenging sites for endovascular repair because of the anatomical restrictions, such as the proximity to the great vessels and arch tortuosity, and there are no adequate commercially available devices.
Our method uses a custom-made fenestrated SG with a J-shaped long sheath. This method does not require surgical transposition of the arch branches and it is also widely applicable.
【Conclusion】
Endovascular repair of the ascending aorta and the arch with a fenestrated SG can be easily performed, and it seems less invasive than other procedures.
And early and mid term results are acceptable.