Structural implications of fenestrated stent graft misalignment

Background: Endovascular aneurysm repair is a minimally-invasive method for the treatment of abdominal aortic aneurysms. For aneurysms that involve the visceral arteries, a custom-made stent graft with fenestrations for the branch arteries is required. The purpose of the current study is to evaluate the structural impact of misaligned fenestrations with respect to luminal patency and proximal aortic neck apposition in an in vitro model. Methods: A custom apparatus was used to evaluate seven Anaconda and three Zenith fenestrated stent grafts. All stent grafts were evaluated at 10 degrees increments of stent/fenestration misalignment up to 80 degrees. Images were captured at each interval and the luminal cross-sectional area and wall apposition were measured. Results: The Anaconda stent graft, which has an unsupported main body, demonstrated a linear reduction in luminal patency at increasing angles of misalignment (P < 0.0001). Stent/fenestration misalignments of 20 degrees and 80 degrees resulted in decreases in mean luminal patency of 14% and 54% respectively. The Zenith stent graft demonstrated a similar decrease in luminal patency, starting at misalignments of >= 40 degrees (P < 0.0001). However, with stent/fenestration misalignments of >= 30 degrees, apposition between the Zenith stent graft and the simulated aortic neck was compromised suggesting the creation of a type Ia endoleak. Conclusions: Both the Anaconda and Zenith devices behave adversely at extreme angles of misalignment with luminal narrowing in the Anaconda device and loss of wall apposition in the Zenith device; however, both stent grafts appear to be equivalent at low angles of misalignment. (C) 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.