Clinical Outcomes and Radiation Safety After Endovascular Repair of Complex AAAs Using Fenestrated- Branched Devices

General Inclusion Criteria

A patient is deemed suitable for inclusion in the study if the patient has at least one of the following:

1. Juxtarenal or suprarenal AAA, type I-IV thoracoabdominal aortic aneurysms or aortic arch aneurysms or dissections with a diameter ≥5.0 cm in diameter or 2 times the normal aortic diameter
2. Aneurysm with a history of growth ≥0.5 cm/year
3. Saccular aneurysm with an aortic diameter greater than 1.5 times the normal aortic diameter that is deemed to be at risk for rupture based upon physician interpretation.
4. Patients who are not eligible for treatment with commercially available endografts.
5. Presence of concomitant thoracoabdominal and aortic arch aneurysm meeting one of the above-mentioned criteria.

General Exclusion Criteria

A patient must be excluded from the clinical investigation if any of the following are true:

1. Age <18 years
2. Life expectancy <2 years
3. Pregnant, breastfeeding, or planning on becoming pregnant within 60 months;
4. Inability or refusal to give informed consent by the patient or a legally authorized representative;
5. Unwilling or unable to comply with the follow-up schedule
6. Prior surgical or interventional procedure within 30 days of the anticipated date of the fenestrated procedure, except for planned staged procedures to provide access for repair (e.g. staged iliac conduit, thoracic endovascular aortic aneurysm repair for proximal aneurysms, elephant trunk repair), to facilitate the procedure by allowing open reparation of a target artery not amenable to revascularization with the investigational device, such us an internal iliac artery, subclavian artery or visceral artery with early bifurcation, tortuosity or occlusive disease preventing successful placement and alignment side stents, or to treat proximal aortic aneurysms.
7. Participation in another clinical or device trial, except observational studies, participation in another investigational endovascular endograft protocol, percutaneous aortic valve protocol, or concomitant clinical trials designed to evaluate medical therapy strategies to reduce perioperative risk during fenestrated-branched endovascular repair, including risks of renal dysfunction, contrast-induced nephropathy, neurologic, spinal cord or cardiac complications, and/or use of advanced imaging to reduce radiation exposure during implantation of these devices. Participation in investigational device trials not encompassed by the IDE protocol should be performed remotely from the fenestrated/branched repair (>30 days). Participation in a medical therapy trial or advanced imaging trial designed to improve peri-operative outcomes or to reduce radiation exposure of fenestrated/branched endografts may be concurrent with the IDE study. Examples include therapy directed to reduce rates of spinal cord injury, stroke, and contrast-induced nephropathy associated with implantation of fenestrated-branched stent-grafts or advanced imaging trials designed to reduce radiation exposure during repair.
8. Patients with ruptured aortic aneurysm requiring urgent or emergent repair, except patients with contained, stable ruptures with anatomy suitable for an off-the-shelf design.
9. Patients who meet anatomical criteria for commercially available aortic stent-grafts according to the proposed instructions for use of these devices.

Medical Exclusion Criteria

Patients must be excluded from the study if any of the following conditions are true:

1. Known sensitivities or allergies to stainless steel, nitinol, polyester, solder (tin, silver), polypropylene, urethane, or gold
2. History of anaphylactic reaction to contrast material that cannot be adequately pre-medicated
3. Leaking or ruptured aneurysm associated with hypotension
4. Uncorrectable coagulopathy
5. Mycotic aneurysm or patients with evidence of active systemic infection.
6. History of connective tissue disorder (e.g. vascular Ehlers Danlos, Marfan syndrome), except those patients who had prior open surgical aortic replacement or endovascular repair, where a surgical graft or an endograft would serve as landing zone for the investigational endograft, those who are deemed prohibitive risk for open repair or connective tissue disorders with no vascular effects (e.g. non-vascular types of Ehlers Danlos).
7. Body habitus that would inhibit x-ray visualization of the aorta and its branches.

Anatomical Exclusion Criteria

Patient must be excluded from the study if any of the following are true:

1. Inadequate femoral or iliac access compatible with the requirements of the required delivery system.
2. Inability to perform a temporary or permanent open surgical or endovascular iliac conduit for patients with inadequate femoral/iliac access.
3. Absence of a landing aortic segment in the distal thoracic aorta above the diaphragmatic hiatus with:
4. A diameter measured from the outer wall greater than 42 mm or less than 19 mm
5. Parallel aortic wall with >20% diameter change and with significant calcification and/or thrombus in the selected area of the seal zone.
6. Visceral anatomy not compatible with the investigational device due to excessive occlusive disease or small size not amenable to stent graft placement.
7. Unsuitable distal iliac arterial fixation site and anatomy:
8. Common iliac artery fixation site diameter measured outer wall to outer wall on a section image (CT)< 8.0 mm, with inability to perform surgical conduit.
9. Iliac artery diameter measured outer wall to outer wall on a sectional image (CT) > 21 mm at the distal fixation site, with inability to perform open internal iliac artery revascularization or iliac branch stent graft or custom iliac extension with fenestration.
10. Iliac artery distal fixation site <10 mm in length.
11. Inability to preserve at least one hypogastric artery.

For patients in the type I-III TAAA cohort, the intended use criteria are the same for both the fenestrated/branched CMD vs the off-the-shelf device. The CMD will preferably be used, unless an urgent repair is indicated or the waiting period for design or manufacturing of the CMD is considered unacceptable.

Additional anatomical inclusion criteria for aortic arch devices

1. Proximal aortic fixation zone:
2. Native aorta or surgical graft
3. Diameter: 20-42mm
4. Proximal neck length ≥ 20mm
5. Ascending aortic length ≥50mm
6. Must occur distal to coronary arteries and any coronary artery bypass grafts that are considered patent and necessary for proper cardiac perfusion
7. Distal aortic fixation zone:
8. Native aorta or surgical graft
9. Diameter: 20-42mm
10. Distal neck length ≥20mm
11. Distal fixation will be obtained with stent-grafts in a staged repair
12. Supra-aortic trunk (brachiocephalic) vessels
13. The arch branch device will typically have two or three branches with additional modifications to the design that allow for a single branch or a combination of branch and scallop if a customized version is required. An extra-anatomic bypass graft may be done in conjunction (or in a staged fashion) with the procedure, as required. For the two-branch design, the vessels most commonly incorporated will be the innominate artery and the left common carotid artery. However, the innominate artery may be coupled with the left subclavian artery in the setting of a bovine arch, whereby the flow to the left carotid would come from a left subclavian to carotid bypass. Similarly, the left carotid and subclavian artery may be branched, or simply one vessel branched, should specific anatomic limitations exist. In such a situation, multiple extra-anatomic bypasses may be necessary. A design with a single subclavian retrograde branch and scallop to the left carotid artery may be used to extend the landing zone to Zone 1. Finally, a design with two antegrade inner branches for the innominate and left common carotid, and one retrograde inner branch for the left subclavian artery may be used in select cases. Thus, the inclusion criteria are defined for each artery, yet any combination of arteries may be used for a repair.
14. Innominate artery
15. Native vessel or surgical graft
16. Diameter: 8-22mm
17. Length of sealing zone ≥10mm
18. Acceptable tortuosity ii. Left (or right) common carotid artery
19. Native vessel or surgical graft
20. Diameter 6-16mm
21. Length of sealing zone ≥10mm
22. Acceptable tortuosity iii. Left (or right) subclavian artery
23. Native vessel or surgical graft
24. Diameter: 5-20mm
25. Length of sealing zone ≥10mm
26. Acceptable tortuosity
27. In the setting of an aortic dissection, the following criteria must exist:
28. Access into the true lumen from the groin and at least one supra-aortic trunk vessel
29. A sealing zone in the target aorta (or surgical graft) that is proximal to the primary dissection, such that a stent-graft would be anticipated to seal off the dissection lumen
30. A sealing zone in the target supra-aortic trunk vessels that is distal to the dissection, anticipated to seal off the dissection lumen, or surgically created
31. A true lumen size large enough to deploy the device and still gain access into the target branches
32. In the setting of more distal disease, the repair may be coupled with a thoracoabdominal branched device, infrarenal device, and/or internal iliac branch device.
33. Iliac anatomy must allow for the delivery of the arch branch device, which is loaded within a 20F-24F sheath. Conduits to the iliac vessels or aorta may be used if deemed necessary.