Branched Thoracic Endovascular Grafts for the Treatment of Thoraco-abdominal Aortic

A physician modified branched thoracic endograft is a commercially available, off-the-shelf
endograft that has been altered at the time of the procedure by creating reinforced
fenestrations in the graft through which covered stent grafts can be deployed to preserve
blood flow into visceral branch vessels. The graft is deployed on a sterile working table in
the operating room. The locations of the fenestrations are marked on the graft according to
the pre-procedure measurements. The graft fabric is cut and simultaneously heat sealed using
thermal Cautery. These fenestrations/cuffs are marked with medical grade metal markers to
facilitate fluoroscopic visualization during the procedure. Furthermore, the fenestrations
are reinforced with a short ring of PTFE. This added material is essential as it strengthens
the fenestration and creates a ring within which the branch grafts can seal. After the
fenestrations have been created, marked, and reinforced, additional metal radio-opaque
markers are sewn to the graft to assist in device orientation under fluoroscopy. Additional
sutures may be used at that time to constrain the endograft, either in a temporary or
permanent fashion to facilitate subsequent deployment. The device is the re-constrained and
re-sheathed within the original Zenith® TX2® delivery sheath.

The modified stent graft is then deployed to reline the peri-visceral abdominal aorta.
Proximal and distal fixation and seal can be achieved using the modified TX2® device,
additional unmodified TX2® devices and/or the Cook Zenith® Flex® device depending on the
aortic anatomy.

Once the aortic stent grafts are deployed, the branches are then created. Wires and catheters
are used to cross through the reinforced fenestrations into the target visceral arteries.
Covered stents are then deployed to extend from the modified aortic graft to the target
vessel. The branch stents must create a hemostatic seal with the main endograft as these
branches will be constructed within the aneurysm sac. Single or multiple stents may be
required for any given branch.

Inclusion Criteria:

All patients must meet all of the following inclusion criteria to be eligible for
enrollment into this study:

1. Patient is > 18 years of age

2. Patients who are male or non-pregnant female (females of child bearing potential must
have a negative pregnancy test prior to enrollment into the study)

3. Patient or Legally Authorized Representative has signed an Institutional Review Board
(IRB) approved Informed Consent Form

4. Patient is considered by the treating physician to be at high risk of open surgical
repair due to one or more major medical co-morbidities (i.e. CAD, CHF, COPD, CRI,
advanced age, generalized deconditioning, or other.) with ASA of 3 or more.

5. The patient has a life expectancy of greater than 1 year.

6. The patient has a thoraco-abdominal aortic aneurysm where necessary visceral branch
vessels (i.e. the celiac, superior mesenteric, inferior mesenteric, renal and/or
dominant spinal arteries) arise from the aneurysm or seal zones necessary for on-label
thoracic endovascular repair

7. Patient has a thoraco-abdominal aortic aneurysm that meets at least one of the
following:

- aneurysm > 5.5 cm in diameter

- aneurysm has increased in size by 0.5 cm in last 6 months

- aneurysm is believed to be causing symptoms

8. Patient has sufficient arterial access (femoral and/or iliac) that will allow delivery
of the endovascular device with or without the use of a surgical conduit.

9. Patient has suitable proximal (aorta) and distal (aorta or iliac) arteries to allow
for adequate fixation and seal:

A. Non-aneurysmal proximal aortic seal zone:

1. with a length of 25 mm of proximal seal in non-aneurysmal aorta, with or without
coverage of the left subclavian artery,

2. with an outer wall diameter of no less than 20 mm and no greater 38mm, and

B. Non-aneurysmal distal aortic or iliac landing zone:

3. With a length of at least 15 mm,

4. Aortic seal zone no less than 15 mm and no greater than 38 mm or Iliac seal zone with
an outer wall diameter of no less than 8 mm and no greater than 23 mm.

10. The patient has no more than 5 necessary visceral arteries that require flow
preservation.

11. All target visceral artery seal zones are > 4 mm in diameter. 12. Patient must be
willing to comply with all required follow-up exams.

Exclusion Criteria:

Patients that meet ANY of the following are not eligible for enrollment into the study:

1. Patient has an active systemic infection

2. Patient has a mycotic aneurysm.

3. Patient has a known hypersensitivity to contrast media that is not amenable to
pre-treatment.

4. Patient has an absolute contra-indication to anticoagulation

5. Patient has a known allergy or intolerance to stainless steel, nickel, or gold

6. Patient has a body habitus that would inhibit adequate X-ray visualization of the
aorta

7. Patient has a dominant artery to the spinal cord arising from an area of stent graft
coverage that is not amenable to preservation using an endovascular branch

8. Patient is currently participating in another investigational device or drug clinical
trial

9. Patient has other medical, social or psychological conditions that, in the opinion of
the investigator, preclude them from receiving the pre-treatment, required treatment,
and post-treatment procedures and evaluations.

10. Patient has a freely ruptured TAAA with hemodynamic instability

11. Patient has unstable angina (defined as angina with a progressive increase in
symptoms, new onset at rest or nocturnal angina, or onset of prolonged angina)

12. Patient has had a major surgical or interventional procedure unrelated to the
treatment of the aneurysm planned within 30 days of the TAAA repair. Adjunctive
procedures for treatment of the TAAA (i.e. carotid-subclavian bypass or iliac conduit)
are acceptable.

13. Patient has a history of connective tissue disease (e.g. Marfan or Ehlers Danlos
syndromes)