• Konstantinos Spanos, Nikolaos Tsilimparis, Franziska Heidemann, Fiona Rohlffs, Christian-Alexander Behrendt, Eike Sebastian Debus, and Tilo Kölbel.
• 1 German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany.
• J. Endovasc. Ther. 2018 Feb 1; 25 (1): 16-20.

PurposeTo describe planning and a technique for fenestrated endovascular repair of a large Crawford type IV thoracoabdominal aortic aneurysm after previous 2-fenestration endovascular aneurysm repair (FEVAR).TechniqueThe first FEVAR procedure performed at another center implanted a standard Zenith device with 2 fenestrations and 1 scallop for a juxtarenal abdominal aortic aneurysm. The diameter of the Crawford type IV thoracoabdominal aortic aneurysm had progressed from 68 to 75 mm within a year after the FEVAR. Since the celiac trunk was already occluded, a 3-fenestration 22-×172-mm stent-graft was chosen to extend the existing stent-graft further proximally. A tapered 38/22-×179-mm Zenith custom-made device was designed for the thoracic component. The technique addresses several issues that arise during a FEVAR-in-FEVAR case, such as the orientation of the new stent-graft and its fenestrations, the absence of space between the 2 devices for maneuvers, and the difficulty in catheterizing target vessels with existing bridging stents, for which a bailout "snare-ride" maneuver is described.ConclusionFEVAR after previous FEVAR is a feasible and efficient treatment option. The modified "snare-ride" technique can be used to catheterize target vessels in the absence of an Indy snare.

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