Triple In Situ Antegrade Laser Fenestration of Aortic Stent-Graft Extension Using Fusion Imaging for Urgent Treatment of Symptomatic Abdominal Aneurysm with Type 1 Endoleak

The present report describes the management of massive proximal type 1 endoleak with an enlarged symptomatic aneurysmal sac. Urgent treatment was performed using in situ laser fenestration of an aortic proximal extension facing renovisceral ostia. Image fusion was obtained intraoperatively. For each target vessel (superior mesenteric and two renal arteries), an Aptus HeliFX steerable sheath (Medtronic) inserted through femoral access was curved to face the vessel’s ostium marker. A laser catheter (Spectranetics) was used to traverse the stent-graft and insert a 0.014” guidewire in the vessel. The fenestration was enlarged using a 2.5-mm-diameter cutting balloon, followed by a 4-mm-diameter balloon angioplasty and a V12 I Cast/Advanta covered stent implantation. Final angiogram demonstrated aneurysm exclusion and patent target vessels. The postoperative course and 7 months follow-up were uneventful.