Fig. 2

Steps involved in the modification of the Zenith Flex AAA bifurcated main body. The device is deployed on a sterile back table and one of the 3 nitinol wires is withdrawn from the inner cannula (A). Fenestrations are created using an ophthalmologic cautery and reinforced with a radiopaque snare using 4–0 Ethibond locking sutures (B). The nitinol wire is redirected through and through the fabric and the device is constrained every Z stent using the nitinol wire for support and two non-locking polypropylene loops prior to being resheathed (C). Completion angiography showing exclusion of the aneurysm and patency of all target vessels (D). 3D CTA obtained 24 months post-operatively showing continued patency of target vessels and aneurysm exclusion (E). Rationale for device selection: In a contained rupture JRAA amenable to 3 vessel PMEG, this two piece repair is ideal since, in case of frank rupture during implantation, the gate can be rapidly cannulated and contralateral limb placed, excluding the aneurysm prior to cannulating and bridging fenestrations. However, to avoid malalignment, we recommend bridging at least one fenestration (usually the SMA) prior to removing the diameter reducing tie. Provided sizing was accurate, one should still be able to cannulate and bridge renal artery fenestrations after the aneurysm is excluded