Physician-Modified Cook Zenith Alpha Thoracic Endovascular Graft with Preservation of Active Fixation Barbs: A Step-by-Step Technical Guide

Physician-modified endografts (PMEGs) represent an important treatment option for urgent and semi-urgent complex abdominal aortic aneurysms (cAAAs). The Zenith Alpha Thoracic Endovascular Graft (Cook Medical, Bloomington, IN, USA) is a common choice for PMEGs due to its low strut interference, albeit at the cost of requiring removal of the proximal fixation barbs for resheathing—a process that remains technically challenging. The current article details a step-by-step approach on how to modify an Alpha thoracic endograft without requiring removal of the proximal barbs. The Zenith Alpha Thoracic Endovascular Graft is fully unsheathed on a sterile back-table and completely detached from the delivery system by removing the blue rotational handle. The grey positioner is removed from the introducer sheath. Next, a 0.018-inch guidewire is introduced distally through the inner positioner and retrieved via the exposed grey handle to function as a trigger wire. Following the creation and reinforcement of the fenestrations, circular diameter-reducing ties are constructed and secured using an insertion tool. The endograft is placed back on the delivery system and the guidewire is passed through the endograft fabric at the distal end and through the insertion tool, which is then removed. At the proximal end, the trigger wire is again passed through the endograft fabric, and both the proximal bare alignment stent and the distal end of the endograft are secured to the delivery system using 2-0 Prolene sutures (Ethicon Inc., Somerville, NJ, USA). The endograft is subsequently resheathed through the distal end of the introducer sheath using a tourniquet-assisted resheathing technique and a cut-off tip from an introducer sheath to guide the endograft’s passage through the valve. Using the current standardized modification protocol, a PMEG can be constructed using the Zenith Alpha Thoracic Endovascular Graft while preserving the active fixation barbs for the treatment of cAAAs.