FET Repair With the Cook FET-FEN Device

The FET-FEN device (Cook Medical, Bloomington, IN, USA) is unique because it is the sole frozen elephant trunk (FET) graft incorporating a fenestration to ensure a reliable and reproducible stenting of the left subclavian artery (LSA). The device may accommodate revascularizing the LSA during most FET procedures. In the authors’ experience, relative contraindications are the presence of a chronically dissected LSA, a very tortuous LSA, or an aneurysmal LSA greater than 15 mm. The device is based on the Zenith Alpha Thoracic Endovascular Graft (Cook Medical) with a distal stented portion (usually between 8 and 12 cm) and a proximal nonstented portion (usually 4 to 5 cm), which includes the 8 mm or 10 mm fenestration (Supplemental Fig. 1). The device is loaded within a clear sheath, allowing for excellent visibility of the fenestration. A handle facilitates traction during the deployment using a simple “pusher rod” mechanism (Supplemental Fig. 2). To enhance precision during deployment and avoid graft foreshortening, the distal end of the graft remains collapsed during the initial deployment phase through a “trifold” suture retention linking the distal end of the graft to the nosecone (Supplemental Fig. 3). The graft may be customized according to patient anatomy and disease, hence adapting the stent design to the patient’s need. Distal graft tapering, use of distal low radial stents, and a 5 mm segment of unstented graft distally are features that minimize the risks of late stent graft-induced complications.

Surgical steps are performed according to the following principles (Supplemental Video). Under circulatory arrest with antegrade cerebral perfusion, the arch is usually transected in zone 1. Although not a prerequisite, the device is usually introduced over a guidewire with the fenestration aligned with the ostium of the LSA. The graft is deployed by retracting the clear sheath while maintaining the fenestration at the level of the LSA. Once the graft is fully deployed, the unstented portion is unfolded and the alignment of the fenestration to the LSA ostium evaluated. Because the graft is still captured at the distal tip, slight displacement of the graft is still possible. Once alignment is optimal, the trifold mechanism is released, pulling back the black releasing tie knob. The nosecone will usually sit in the middle of the distal graft and may be easily retracted through the arch while the guidewire is retrieved through the femoral introducer. The bridging stent, which is sized according to the diameter of the proximal LSA and the distance to the left vertebral takeoff, is premounted on a Rosen guidewire (Cook Medical). Given its excellent tracking capabilities, the Rosen catheter is easily advanced 20 to 30 cm within the LSA. The bridging stent is subsequently advanced through the fenestration within the LSA with 1 cm sitting proximal to the fenestration. Following stent expansion, the proximal portion of the stent is flared with a balloon sized 2 mm larger than the nominal stent diameter. Distal arch anastomosis may be performed according to the surgeon’s preference using either a straight Dacron tube with a reperfusion branch (if an initial arch debranching strategy was performed) or a 4-branch arch graft with exclusion of the LSA branch. The distal anastomosis is completed by running a 3-0 Prolene incorporating the polyester graft of the FET-FEN device, the aortic wall, and the Dacron graft.

Supplemental Material

sj-png-1-inv-10.1177_15569845251344285 – Supplemental material for FET Repair With the Cook FET-FEN Device

Supplemental material, sj-png-1-inv-10.1177_15569845251344285 for FET Repair With the Cook FET-FEN Device by François Dagenais and Kevin Wilger in Innovations

Supplemental Material

sj-png-2-inv-10.1177_15569845251344285 – Supplemental material for FET Repair With the Cook FET-FEN Device

Supplemental material, sj-png-2-inv-10.1177_15569845251344285 for FET Repair With the Cook FET-FEN Device by François Dagenais and Kevin Wilger in Innovations

Supplemental Material

sj-png-3-inv-10.1177_15569845251344285 – Supplemental material for FET Repair With the Cook FET-FEN Device

Supplemental material, sj-png-3-inv-10.1177_15569845251344285 for FET Repair With the Cook FET-FEN Device by François Dagenais and Kevin Wilger in Innovations