title: Back-table modification of a bifurcated infrarenal stent-graft to aortomonoiliac for emergencies.
abstract: OBJECTIVE
  To describe a simple and quick technique for converting a Zenith bifurcated stent-graft to an aortouni-iliac device for emergency treatment of hemorrhage when a suitable marketed stent-graft is not readily available.
  
  
  METHODS
  The technique is described in an emergent case involving a 72-year-old man presenting with an aortoduodenal fistula and acute gastrointestinal bleeding. The Zenith device was prepared and flushed in the typical fashion. An extra stiff Lunderquist wire was advanced through the graft for better stability during the modification. The peel-away sheath was advanced beyond the hemostatic valve to allow partial release of the graft from the back then the grey positioner was retracted while the sheath was held firmly on the table, partially deploying the iliac limbs from the back side of the sheath. An occluding non-absorbable braided suture was placed at the short limb of the bifurcated graft close to the middle of the contralateral limb stent, through the webbing connecting both limbs below the flow divider of the bifurcated Zenith device. The graft was then resheathed using manual pinching of the graft or compression with umbilical tape. In the illustrated case, the stent-graft was intentionally deployed with the uncovered stents below the renal arteries to facilitate easier explantation later on.
  
  
  CONCLUSIONS
  Back-table modification of stent-grafts is feasible in emergencies for operators familiar with all technical aspects and potential risks of the modifications.
authors.affiliation: Department of Vascular Medicine, University Heart Center, Hamburg, Germany.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Tsilimparis
authors.forename: Christina
authors.initials: C
authors.lastname: Lohrenz
authors.forename: Axel
authors.initials: A
authors.lastname: Pflugradt
authors.forename: Sabine
authors.initials: S
authors.lastname: Wipper
authors.forename: Sebastian
authors.initials: S
authors.lastname: Debus
authors.forename: Tilo
authors.initials: T
authors.lastname: Kölbel
mesh_terms: D000368:Aged; D001018:Aortic Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods; D004378:Duodenal Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D004630:Emergencies; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D007412:Intestinal Fistula / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D008026:Ligation; D008297:Male; D011474:Prosthesis Design; D015607:Stents; D013536:Suture Techniques; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000150:complications / Q000175:diagnosis / Q000601:surgery*