Fig. 4

A-H. Steps of modification of the Zenith Alpha thoracic stent graft. The device is deployed on a sterile back Table (A). The bottom stent is cut with an ophthalmologic cautery to ensure adequate length to the flow divider of the failed stent graft. Fenestrations are created and reinforced as described in Fig. 1B (B). The device is posteriorly constrained at every Z stent (D), collapsed with a silastic loop (E), and resheathed (F). Completion angiography (G) and 3D post-operative CTA (H) show exclusion of the aneurysm, perfusion of target vessels, and no endoleak. Rationale for device selection: The existing stent graft was 24 mm in diameter, the visceral aorta measured 27 mm and the distance from the bottom of the celiac artery to the flow divider was 92 mm. Furthermore, iliac arteries were small and diseased. For this reason, the low profile Alpha thoracic stent graft ZTA-PT-30-26-108-W was the perfect fit for this 3 vessel repair after removal of the distal Z stent. Resheathing of this device requires removal of laser cut barbs, a process that is straightforward