Fenestrated and

Branch Devices

Sean P. Lyden, MD FACS

Associate Professor, Cleveland Clinic

College of Medicine at CWRU

Solaci Chile 2011

Disclosures

• Consultant & speaker for Medtronic and

Cook

What Can We Look

Forward To?

• Branch and Fenestrated IDE limited at

present in United States

• Biggest Issue

• Lack of coupling stent graft

What is Happening Now

• Physician off Label

Modification of

Approved Devices

Chimney Grafts

J ENDOVASC THER 2008;15:427–432

Modifications to

Commercial Devices

Courtesy J. Ricotta, MD Mayo ClinicPerspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9

Homemade Iliac Branch

Courtesy J. Ricotta, MD Mayo Clinic

Perspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9

Mating devices

• Viabahn

• ICast

• Fluency

• No ideal device

• No device designed for this use

• Most are using ICast

Fenestrated Devices

Bifurcated Bifurcated

Device

• Built in

hypogastric

branch

Hypogastric Devices

JoMedAtrium

Helical Hypogastric

Branch

• IDE at CCF

• All helical branch

device

• On HL&B introducer

with preloaded

wire through branch

to allow contra-

lateral snare

Cook Preloaded

Fenestrated

Endologix Off the Shelf

Fenestrated

Medtronic Branch

Device

Gore Branch Device

4 Vessel

Branches

• Helical

• Axial

Proximal Thoracic

Fenestrations

• Frequently aneurysms

encroach upon the arch

vessels

• Tortuous aortic

segment

• Cant cover brain flow

Branched & Fenestrated AAA

Devices

• Can be modified to treat the arch

Problems Unique to the

Arch

• Increased pressure and

migration forces

• Coronary Arteries

• Largest Vessels

• 3D spacial relationships

of the arch vessels

• Imaging difficulty

• Dealing with the aortic

valve

• Delivery system

problems

Brachiocephalic Vessel

Orientation

Evolution of Devices

Cook Arch Device

ARCH BRANCHES

ARE BEING DONE

TODAY

ASCENDING GRAFTS

SOON TO COME

Ascending Devices

• Physician

sponsored IDE

• Australia

• Canada

What is the biggest

limitation?

• Merging TEVAR

devices with

Percutaneous

Valve Technology

will be necessary

to treat the entire

ascending aorta

and provide

proximal fixation

Conclusions

• Branch and fenestrated devices are

needed

• Lack of coupling branch device has

delayed development

• Use in IDE and outside US

• ? When in US

• Multiple Companies working on it