Complex Aortic Aneurysm Repair Using Physician Modified Endografts and Custom Made Devices

Overview

The purpose of this study is to evaluate the safety and efficacy of custom made devices, Zenith t-Branch devices and physician modification of FDA approved off-the-shelf endovascular grafts in the treatment of patients with complex abdominal aneurysms, aortoiliac aneurysms, thoracoabdominal aneurysms and aortic arch aneurysms who (1) have anatomy not suitable for endovascular repair using grafts currently marketed in the United States,(2) are deemed unsafe to wait the required time necessary for commercial endograft manufacturing, and (3) are at high risk for open surgical repair. Amendment to the study has created a cohort open to people with connective tissue diseases such as Marfan, Ehlers-Danlos or Loey-Dietz syndromes to enroll in the trial. An additional amendment to the study allows the use of a custom made device to treat an aneurysm in the aortic arch.

Description

Endovascular repair of complex aortic aneurysms is limited by the need to maintain blood flow to the critical organs that receive blood from the aorta, such as the kidneys, liver and intestines. While there are some commercially available devices that may treat some of these patients these devices may not be suitable or available for a given patient. In this study we will use custom made devices manufactured by Cook, Inc, Zenith t-Branch devices and off-the-shelf, FDA approved devices which are altered by creating fenestrations (holes) in the stent graft that allow additional stents to be inserted into the blood vessels that supply blood to these critical organs.

Determination of which type of endograft to use will be based on the patient's anatomy and the perceived urgency of the need for repair. This decision will be made by the study team and confirmed by a 3rd party reviewer who is not an investigator on the study team. After ensuring that a patient meets inclusion and exclusion criteria for participation in the CARPE-CMD study, the perceived urgency for repair will be evaluated given the 6-8 week required time for manufacture of a CMD device.

If the patient's aneurysm is not symptomatic and if, at the discretion of the treating surgeon, the patient is deemed safe to wait 8 weeks until repair, the patient will be considered non-urgent. Non-urgent patients will undergo repair with a CMD device.

If the patient's aneurysm is symptomatic and if, at the discretion of the treating surgeon, the patient is deemed unsafe to wait 8 weeks until repair, the patient will be considered urgent. Urgent patients will undergo repair with a t-branch device (if anatomy suitable) Urgent patients who do not have anatomy suitable to a t-branch device or patients who are not deemed safe to wait for the device to be obtained, will undergo repair with a physician modified device.

The device is inserted into the body through two small punctures or incisions in the groin. Small stents will be inserted through the stent graft fenestrations into the major blood vessels affected by the aneurysm so that blood flow is maintained to these organs.

Eligibility

Inclusion Criteria:

• A patient may be suitable for inclusion in the study if the patient has at least one of the following:
  1. Aortic or aortoiliac aneurysm with diameter ≥5.5 cm
  2. Aortic or aortoiliac aneurysm with a history of growth ≥1.0 cm per year, or clinical indication for aneurysm repair based on symptoms

     General Inclusion Criteria

  3. Cannot be treated with a currently available non-modified approved device
  4. Symptomatic on presentation and unsafe to wait for the time necessary to obtain a currently available non-modified approved device
  5. At least 18 years of age
  6. Not pregnant or breastfeeding
  7. Willing and able to comply with five years of follow-up
  8. Willing and able to provide informed consent prior to enrollment
  9. No systemic or local infection that may increase the risk of endovascular graft infection
  10. High risk for open surgical repair based on any of the factors below:
      1. Anatomic i. Previous abdominal surgery ii. Previous left-sided thoracotomy (if the proposed open repair would require dissection of the thoracic aorta) iii. Previous aortic surgery b. Physiologic i. ASA Category III or higher ii. Age >70 years iii. Previous myocardial infarction, coronary artery disease, or coronary artery stent iv. Coronary stress test with a reversible perfusion defect v. Congestive heart failure vi. COPD

Exclusion Criteria:

• Exclusion Criteria Medical Exclusion Criteria
  1. Cultural objection to receipt of blood or blood products
  2. Allergy or sensitivity to stainless steel, polyester, polypropylene, solder (tin, silver), gold, or nitinol
  3. Anaphylactic reaction to contrast that cannot be adequately pre-medicated
  4. Uncorrectable coagulopathy
  5. Unstable angina (defined as angina with a progressive increase in symptoms, new onset at rest or nocturnal angina, or onset of prolonged angina)
  6. Patient has active malignancy with life expectancy of less than 2 years
  7. Patient has life expectancy less than two years

Anatomical Exclusion Criteria

1. Significant occlusive disease, tortuosity, or calcification that would prevent endovascular access
2. Proximal neck length ≤25 mm
3. Proximal neck, measured outer wall to outer wall on a sectional image (CT)
   1. For use of Zenith Flex: diameter >32 mm or <18 mm
   2. For use of Zenith TX2: diameter >38 mm or <24 mm (for proximal and distal neck diameter)
4. Proximal neck angulated more than 60 degrees relative to the long axis of the aneurysm
5. Proximal neck diameter change over the length of the proximal seal zone >4 mm
6. Proximal seal site with a circumferential thrombus/atheroma
7. Iliac artery diameter, measured inner wall to inner wall on a sectional image (CT) <7.0 mm at any point along access length (prior to deployment)
8. Ipsilateral iliac artery fixation site diameter, measured inner wall on a sectional image (CT) >21 mm at distal fixation site
9. Iliac artery distal fixation site <10 mm in length
10. Non-bifurcated segment of any artery to be stented < 15 mm in length
11. Artery to be stented with a maximum diameter <3 mm or >10 mm at the vessel ostium
12. Inability to maintain at least one patent hypogastric artery