Novel application of custom-made stent-grafts with inner branches for secondary treatment after stent-graft migration of previous infrarenal endovascular aortic repair

Purpose We present a novel application of custom-made stent-grafts (CMSGs) with inner branches to incorporate target vessels (TVs) as an alternative to fenestrations or directional branches for secondary treatment after stent-graft migration of previous infrarenal endovascular aortic repair (EVAR). Case report Two consecutive patients with stent-graft migration of previous EVAR were electively treated at our institution from January 1, 2018 through December 31, 2018. Stent-graft migration was defined as radiologic evidence of stent-graft displacement >10mm. In both cases, a proximal type I endoleak was noted and the residual infrarenal aorta above the previous endograft was unsuitable as proximal landing zone for a non-fenestrated cuff. Repair was planned by means of a CMSG with four inner branches. The procedures were conducted in two-stage fashion to minimize the risk of spinal cord ischemia. The procedures were technically successful with a total of eight TVs stented. Both patients did not suffer from any early (i.e. up to 30 days) major adverse events and no access-site complications were noted. At one-year follow-up, computed tomography angiography (CTA) showed regular placement of the CMSGs, widely patent TVs, absence of any type I or III endoleak, and stable sac size. No late reinterventions were recorded. Conclusion Secondary treatment of stent-graft migration after previous EVAR is safe and feasible using CSMGs with four inner branches. This technique is effective as showed by stable sac size and 100% freedom from TVI at mid-term imaging follow-up. Larger cohorts and longer follow-up are needed to confirm the preliminary results.