Three-dimensional printing-guided fenestrated endovascular aortic aneurysm repair using open source software and physician-modified devices

Abstract

Fenestrated endovascular aneurysm repair is frequently used for juxtarenal and pararenal aortic aneurysms. In urgent cases, however, the use of premanufactured patient-specific devices is not an option. Physician-modified endografts may be used to treat these patients but require experience and a steep learning curve for accurate planning to position fenestrations and to perform the graft modifications. Despite experience, a margin of error in placing fenestrations always exists, and a mismatch possibility between the fenestration and vessel ostium can lead to increased cannulation time and stent complications, including target vessel loss. Aortic three-dimensional printing has been widely described in medicine for simulation, training, and surgical planning. Commercial software is currently under investigation for planning of fenestrated endovascular aneurysm repair at high costs. We describe an effective and inexpensive technique using free computer-aided design software to create a real 1:1 aortic 3D model that can easily be printed and quickly sterilized. This aortic model can be used to create a physician-modified endograft and to place fenestrations in an accurate way, with potential for shorter and more precise procedures and better long-term results. Two cases are presented to illustrate the technique, demonstrating that 3D printing is a valuable tool to plan, design, and create fenestrated devices more accurately.

Surgeon-modified fenestrated stent graft deployment in type B aortic dissection

“…This aortic model can be used for training to achieve or facilitate the precise location of fenestrations for a faster and more efficient procedure and better long-term results. [ 6 ]…”

“…This aortic model can be used for training to achieve or facilitate the precise location of fenestrations for a faster and more efficient procedure and better long-term results. [6] Fenestrated stent graft technology requires preoperative accurate measurements to ensure precise matching of the native vessel and endograft fenestration. In this method, proper patient selection is the key to success.…”

Utility of 3D printed abdominal aortic aneurysm phantoms: a systematic review

“…Since Winder et al, device selection has remained a key application for these phantoms, with a wide variety of stent grafts appraised in the literature, including the Zenith Flex, 6,8,14,15,17,18 Gore C3 (Gore Medical, Newark, DE, USA), 13 Bolton Treo and Bolton Relay (Bolton Medical, Sunrise, FLA, USA), 18 Endurant (Medtronic, Minneapolis, MN, USA), 7,21,24,26 Anaconda (Terumo, Inchinnan, UK) 4,22 and Aorfix (Lombard Medical, Didcot, UK) 4 devices. For example, a 3DP AAA led to a Medtronic Endurant being selected over an Aorfix device in a case report by Tam et al 4 This was due to a 90 o angulation of the aortic neck when regarding the physical model, which was less apparent with centreline analysis, which suggested an angulation of >75 o .…”

“…11,20,26 3DP is most applicable in complex EVAR cases such as fenestrated and branched grafts, or hybrid thoracoabdominal debranching procedures. However, most work to date has been case reports demonstrating how phantoms have aided presurgical planning and device selection, 4,[6][7][8][9][10]13,15,16,21 with larger scale prospective studies yet to be performed. There are currently no clinical trials investigating if 3DP models improve patient outcomes in endovascular intervention.…”

Surgeon-modified Stentgrafts für komplexe Aortenrekonstruktionen – was ist möglich?

“…Dabei wird auf Basis der Planungs-CTA die Aorta 3-dimensional rekonstruiert und mithilfe eines 3-D-Druckers ein transparentes, innen hohles Modell hergestellt [13]. Die Datei zur Herstellung des 3-D-Modells kann mithilfe kommerzieller Softwares generiert werden, alternativ stehen mittlerweile auch Open-Source-Algorithmen zur Verfügung, die diese Technik noch zugänglicher machen könnten [14]. Das 3-D-Aortenmodell besteht beispielsweise aus Dental-Resin, einem biokompatiblen und sterilisierbaren Material.…”