A pigtail

catheter was advanced through the femoral access, allowing for angiogram and pertinent measurements to be obtained. After securing 10-Fr Prostar XL devices (Abbott Vascular, Santa Clara, CA) in the common femoral arteries bilaterally, 18-Fr and 12-Fr sheathes were placed into the left and right common femoral arteries, respectively. The main body C3 Excluder device (28 x 14 x 12 cm) was advanced through the left femoral access and partially deployed 5 cm distal to the right renal artery. The contralateral gate was then cannulated using a Bern catheter (Boston Scientific, Natick, MA), Glidewire, and ultimately an 8-Fr www.selleckchem.com/CDK.html sheath, with angiographic confirmation. Using a transseptal BRK™ needle (St. Inhibitors,research,lifescience,medical Jude Medical, Inc., St. Paul, Inhibitors,research,lifescience,medical Minnesota), in situ fenestration was performed 2 cm below the top of the graft while it was positioned well within the aneurysm sac to ensure that no aortic injury occurred (Figure 2). A .014” wire was then advanced across the aneurysm sac into the left renal artery, followed by a Quick-Cross® catheter (Spectranetics, Colorado Inhibitors,research,lifescience,medical Springs, CO). The .014” wire was exchanged for a .018”, and a total of four angioplasties were performed using cutting balloons to dilate the fenestration (Figure 3). We then

exchanged the .018” for a Rosen wire (Cook Medical, Bloomington, IN) and brought up a 6 mm iCast™ stent (Atrium Medical Corporation, Hudson, NH) while simultaneously moving the main body of the device proximally Inhibitors,research,lifescience,medical into position in the infrarenal aorta. After fully deploying the main body, the renal stent was deployed (Figure 4), followed by ipsilateral limb deployment and extension into the common iliac with a 14 mm x 12 cm extension. The contralateral limb was then deployed using a 20 mm x 10 cm extension into the iliac artery. Figure 2 (A) Fluoroscopic image of BRK transseptal needle puncturing Inhibitors,research,lifescience,medical side wall of constrained Gore C3 stent graft. (B) Bench-top model of transseptal

needle puncturing through stent-graft. Figure 3 (A) Fluoroscopic image of cutting balloon enlarging fenestration in stent graft. (B) Bench-top model of cutting balloon expanded through fenestration. Figure Ribonucleotide reductase 4 (A) Fluoroscopic image of iCast stent positioned in left renal artery. (B) Bench-top model of iCast stent deployed through fenestration. (C) Porcine aorta with bare-metal stent deployed into renal artery. Upon completion aortogram, a type I endoleak was noted. Repeat ballooning in the main device with Coda® balloon (Cook Medical, Bloomington, IN) as well as ballooning of the left renal stent did not resolve the endoleak (Figure 5). Therefore, the device was extended proximally with an aortic cuff, and a 6 mm Viabahn® stent (W.L. Gore & Associates, Inc., Flagstaff, AZ) was advanced into the iCast in the left renal artery (Figure 4).