Systems, Instruments, and Methods for Connecting an Artificial Implant to a Fenestrated Body - Patent application

Abstract

Devices, systems, and methods for coupling a prosthetic implant to a fenestrated body and branched stent grafts using the same are provided. A branch stent graft (830) may include an engagement portion for engaging an opening (865) in a fenestrated body (860), such as a vessel wall or an aortic stent graft. The engagement portion (868) of the branch stent graft may be coupled to the fenestrated body such that the branch stent graft may move, rotate or be displaced relative to the fenestrated body, but axial movement of the branch stent graft is limited and / or prevented.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to and the benefit of U.S. Provisional Patent Application No. 62 / 369,978, filed August 2, 2016, entitled "Systems, Devices, and Methods for Coupling a Prosthetic Implant to a Fenestrated Body," the disclosure of which is incorporated herein by reference in its entirety.

[0002] FIELD OF THE DISCLOSURE The embodiments described herein relate generally to prosthetic implants, and more particularly to devices and methods for engaging a prosthetic implant, such as, for example, a branch vessel stent graft, within a fenestration of a second prosthetic implant, such as, for example, an aortic stent graft. [Background technology]

[0003] Prostheses are often implanted in lesions, for example, to repair, support, widen, and / or otherwise aid in the proper functioning of the lesion in a patient. In some cases, prostheses such as stent grafts can be used to repair lesions in a patient's vasculature. For example, an aneurysm in a patient's vasculature generally involves an abnormal swelling or dilation of a blood vessel, such as an artery, which generally weakens the vessel's wall and makes it more susceptible to rupture. Abdominal aortic aneurysms (AAAs) are common aneurysms that pose serious health threats. A common method of treating AAAs and other types of aneurysms is to place an endovascular stent graft in the affected vessel such that the stent graft spans (e.g., crosses) and extends beyond the proximal and distal ends of the lesion in the vasculature. Thus, the stent graft relines the diseased vasculature to form an alternative blood conduit that isolates the aneurysm from high pressure blood flow, thereby reducing or eliminating the risk of rupture. In other cases, the prosthesis may be an implant and / or mechanism that may structurally or functionally support a lesion and / or defect in the body. However, in some cases, placement of the anatomical structure may present challenges when attempting to place and / or secure the prosthesis (including stent grafts, etc.). Such challenges may result in slippage and / or suboptimal morphology of the prosthesis within the anatomical structure.

[0004] Minimally invasive endovascular repair using stent grafts is often chosen to avoid the risks associated with traditional open surgical repair. However, these stent grafts can only be used if the graft can be placed in a stable position without covering the major branch vessels. In the case of pararenal abdominal aneurysms, where the dilated portion extends but does not involve the renal arteries, the proximal part of the stent graft needs to be fixed to the aortic wall above the renal arteries, thus occluding the opening to the renal arteries. Therefore, patients with pararenal abdominal aneurysms, which represent a significant proportion of abdominal aortic aneurysm cases, are generally excluded from endovascular treatment.

[0005] To allow for endovascular repair of a wider range of cases, surgeons may also create openings in the stent graft body to accommodate the origin of a particular branch vessel (a process known as "fenestration"). Thus, for example, in treating a pararenal abdominal aneurysm in a procedure known as fenestrated endovascular aortic repair ("FEVAR"), the fenestrations or openings in the aortic stent graft must be aligned with the branch vessels. Additional stent grafts (e.g., renal artery stents) may then be placed in the branch vessels and secured to the main stent graft (e.g., aortic stent graft) to limit movement of the main stent graft within the anatomy to ensure proper blood flow. In addition, in some cases, endovascular stent grafts may be placed in one or more particular branch vessels to further treat the aneurysm and / or reinforce the branch vessels in the region of the aneurysm. Summary of the Invention [Problem to be solved by the invention]

[0006] Disclosed herein are devices, systems and methods for coupling a prosthetic implant to a fenestrated body. In some embodiments, a branch stent graft is provided. The branch stent graft may include an engagement portion for engaging a vessel wall or an opening of a fenestrated body, such as an aortic stent graft. The engagement portion of the branch stent graft may be coupled to the fenestrated body such that the branch stent graft may be rotated or displaced relative to the fenestrated body, but axial movement of the branch stent graft is limited and / or prevented. [Brief description of the drawings]

[0007] [Figure 1] FIG. 1 illustrates a diseased abdominal aorta according to one embodiment. [Figure 2A] FIG. 2 shows a portion of a stent graft according to one embodiment immediately after being placed within the diseased abdominal aorta of FIG. 1. [Figure 2B] 2B is a view of a portion of the stent graft of FIG. 2A after it has been placed within the diseased abdominal aorta of FIG. 1 for a period of time. [Diagram 3]FIG. 1 shows at least a portion of a fenestrated stent graft according to one embodiment. [Figure 4] For example, FIG. 4 shows a portion of the fenestrated stent graft of FIG. 3 placed within a portion of a diseased abdominal aorta. [Figure 5A] FIG. 2 is a schematic front view of a fenestrated body according to one embodiment. [Figure 5B] FIG. 1 is a schematic side view of a system according to a first embodiment of the present invention. [Figure 5C] FIG. 2 is a schematic side view of a system in a second configuration according to an embodiment. [Figure 5D] FIG. 13 is a schematic side view of a system according to a third embodiment of the present invention. [Figure 6] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 7] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 8] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 9] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 10] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 11A] FIG. 1 is a schematic cross-sectional side view of a first configuration of a system according to an embodiment. [Figure 11B] FIG. 2 is a schematic cross-sectional side view of a second configuration of the system according to one embodiment. [Figure 11C] FIG. 13 is a schematic cross-sectional side view of a third configuration of the system according to one embodiment. [Figure 12] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 13A] FIG. 2 is a schematic cross-sectional side view of a system in a first configuration, according to one embodiment. [Figure 13B] FIG. 13B is a schematic cross-sectional side view of the system of FIG. 13A in a second configuration. [Figure 14] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 15] FIG. 1 is a schematic cross-sectional side view of a system according to one embodiment. [Figure 16A] FIG. 2 is a schematic cross-sectional side view of a system in a first configuration, according to one embodiment. [Figure 16B] FIG. 16B is a schematic cross-sectional side view of the system of FIG. 16A in a second configuration. [Figure 16C] FIG. 16B is a schematic cross-sectional side view of the system of FIG. 16A in a third configuration. [Figure 16D] FIG. 16B is a schematic cross-sectional side view of the system of FIG. 16A in a fourth configuration. [Figure 16E] FIG. 16E is a schematic diagram of the inner wall of the system of FIG. 16D in a second configuration. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0008] Disclosed herein are instruments, systems, and methods for coupling a prosthetic implant to a fenestrated body. In some embodiments, the fenestrated body includes a flexible engagement portion. The prosthetic implant may be configured to engage the flexible engagement portion such that the prosthetic implant may maintain a perpendicular angle between a central longitudinal axis of the prosthetic implant and a plane of the flexible engagement portion while rotating relative to the fenestrated body.

[0009] In some embodiments, a branch stent graft is provided. The branch stent graft may include an engagement portion for engaging an opening in a vessel wall or a fenestrated body, such as an aortic stent graft. The engagement portion of the branch stent graft may be coupled to the fenestrated body such that the branch stent graft may be rotated or displaced relative to the fenestrated body, but axial movement of the branch stent graft is limited and / or prevented.

[0010] As used herein, the singular forms "a," "an," and "an" include plural referents unless the context clearly indicates otherwise. Thus, for example, the term "an element" shall refer to a single element or combination of elements, and "a material" shall refer to one or more materials or combinations thereof.

[0011] As used herein, the terms "proximal" and "distal" refer to directions toward and away from an operator (e.g., of a medical device), respectively. Thus, for example, the end of a medical device that contacts a patient's body would be the distal end of the medical device, and the end opposite the distal end would be the proximal end of the medical device. Similarly, when a device such as an endovascular stent graft is positioned within a portion of a patient's body, the end of the device that is closer to the patient's heart would be the proximal end, and the end opposite the proximal end would be the distal end. That is, the proximal end of the device may be upstream of the distal end of the device.

[0012] The embodiments described herein may be formed or constructed of one or more biocompatible materials. Examples of suitable biocompatible materials include metals, ceramics, or polymers. Examples of suitable metals include pharmaceutical grade stainless steel, gold, titanium, tungsten, nickel, iron, platinum, tin, chromium, copper, and / or alloys thereof. Examples of polymers include nylon, polyester, polycarbonate, polyacrylates, ethylene vinyl acetate and other acyl-substituted cellulose acetates, non-degradable polyurethanes, polystyrene, polyvinyl chloride, polyvinyl fluoride, poly(vinylimidazole), chlorosulfonated polyolefins, polyethylene oxide, polyethylene terephthalate (PET), polytetrafluoroethylene (PTFE), urethanes, and / or mixtures and copolymers thereof.

[0013] The embodiments and methods described herein may be used to form a patient-specific prosthesis and / or to facilitate the function and / or integration of a prosthesis within a portion of a patient. For example, in some embodiments, the devices and / or methods shown herein may be used in conjunction with and / or otherwise included in an endovascular repair using a stent graft. Although the embodiments are illustrated and described herein as being used to facilitate an endovascular repair, for example, in other embodiments, any of the devices and / or methods described herein may be used to facilitate the treatment of any portion of a patient. For example, the devices and methods described herein may form and / or facilitate the integration of any suitable implant, prosthesis, device, mechanism, machine, etc. within a portion of a patient's body (e.g., the patient's vascular system, nervous system, musculoskeletal tissue, etc.). Thus, although some embodiments are illustrated and described herein as being used for endovascular repair of abdominal aortic aneurysms, these embodiments are shown by way of example and not by way of limitation.

[0014] Some of the devices and / or methods described herein may be used in minimally invasive treatment techniques, such as endovascular repair using stent grafts. Such repair techniques are generally more desirable than traditional open surgical repairs and often result in less morbidity or mortality. However, in some cases, the location of the diseased vasculature may require a portion of the stent graft to be modified before the stent graft is inserted into the body. For example, in endovascular repair of abdominal aortic aneurysms, the aneurysm may be located adjacent to and / or just distal to a normally functioning vessel that branches off from a portion of the aorta. To reline an aneurysm using a stent graft, the surgeon often creates an opening in the stent graft fabric to accommodate the origin of a particular branch vessel (a process known as "fenestration"). Specifically, for example, as shown in FIG. 1, when treating a pararenal abdominal aneurysm and / or when treating other aneurysms, the fenestrations or openings of the stent graft may correspond to the size, shape, and / or relative position of the renal arteries, the superior mesenteric artery (SMA), and / or the celiac artery (not shown in FIG. 1), among others.

[0015] Typically, the fenestration process involves measurements based on medical images (such as CT scans) of the vessel origin. For example, in some cases, the longitudinal distance of the branch vessels may be measured and the relative angular positions of the branch vessels may be estimated and / or calculated from a reference point. Based on these measurements and / or calculations, the surgeon or manufacturer may mark and cut the stent fabric of the stent graft to define one or more fenestrations. The fenestrated stent graft may then be positioned (e.g., by endovascular surgery) within the diseased vasculature and oriented to substantially align the fenestrations with the openings of the corresponding branch vessels.

[0016] In some cases, the fenestrations in the fenestrated body (e.g., fenestrated stent graft or vessel wall) described herein may be created and / or otherwise formed based on medical image data of a lesion (e.g., abdominal aortic aneurysm) in a patient's vasculature. For example, an electronic device, such as a personal computer, workstation, laptop, etc., may receive the image data and calculate and / or otherwise define a digital representation of the image data. Based on the digital representation, the electronic device may define one or more templates, process plans, instructions, data sets, etc. associated with and / or representing a desired set of fenestration locations along the body (e.g., stent graft). In some cases, the electronic device may output maps, plans, and / or templates, which may then be used by a physician, surgeon, technician, and / or manufacturer to form the fenestrated body (e.g., fenestrated stent graft). For example, in some embodiments, such templates and the like may be substantially similar to those described in U.S. Patent Application Publication No. 2013 / 0296998, filed May 1, 2013, entitled "Fenestration Template for Endovascular Repair of Aortic Aneurysms" (the "'998 Publication"), and / or U.S. Patent Application No. 15 / 163,255, filed May 24, 2016, entitled "Devices and Methods for Anatomic Mapping for Prosthetic Implants" (the "'255 Application"), the entire contents of which are incorporated herein by reference.

[0017] In other cases, the fenestrations in the fenestrated body (e.g., fenestrated stent graft or vessel wall) may be formed without the use of such a template. For example, in some embodiments, the electronic device may output instructions and / or code (e.g., machine code such as G-code, etc.) to a computer numerical control (CNC) device and / or computer aided manufacturing (CAM) device, which may perform one or more manufacturing processes, etc. associated with forming and / or otherwise marking fenestration locations along the patient-specific prosthesis (e.g., stent graft). Formation of the patient-specific prosthesis may be performed by a manual process or an at least partially automated process. Additionally, changes in the position of some of the anatomical structures caused by the insertion and / or placement of a prosthesis may be determined and / or calculated using the devices and / or methods described in International Application No. PCT / US2016 / 041355, filed July 7, 2016, entitled "Devices and Methods for Anatomic Mapping for Prosthetic Implants" (the "'355 Application"), the entire disclosure of which is incorporated herein by reference.

[0018] 1-2B show a diseased portion of a patient's abdominal aorta 10. A portion of the abdominal aorta 10 is described below, but the description of the abdominal aorta 10 is not exhaustive; rather, the following description refers to relevant anatomical structures. Additionally, descriptions of anatomical structures (e.g., of the abdominal aorta 10) refer to the location, orientation, etc. of the structure relative to a patient, and not the location, orientation, etc., as viewed by an observer (e.g., a physician). For example, when referring to an anatomical structure located on or near the "left" side of a patient, "left" refers to the location relative to and / or from the patient's perspective when looking in an anterior (e.g., forward) direction.

[0019] The abdominal aorta 10 (also referred to herein as the "aorta") has a proximal end 11 that receives blood flow from the descending aorta (not shown) and a distal end 12 that supplies blood flow to the lower extremities. As shown in FIG. 1, at or near the proximal end 11, the aorta 10 supplies blood flow to the right and left renal arteries 13, 14, which supply blood to the right and left kidneys (not shown), respectively. Although not shown in FIG. 1, the proximal end 11 of the aorta 10 also supplies blood flow to the superior mesenteric artery (SMA) and the celiac artery. The distal end 12 of the aorta 10 forms an iliac bifurcation 20 through which the aorta 10 supplies blood to the right and left common iliac arteries 15, 16, which supply blood to the right and left lower extremities, respectively. As shown in Figure 1, a patient has an abdominal aortic aneurysm (AAA) 17 located distal to the renal arteries 13, 14 and proximal to the iliac bifurcation 20. More specifically, the AAA 17 is located in a position where it is not possible to attach the proximal end of a stent graft between the renal arteries 13, 14 and the AAA 17, and therefore a fenestrated stent graft 160 (see, e.g., Figures 2A and 2B) is used for endovascular repair of the AAA 17.

[0020] In some cases, endovascular repair of the AAA 17 includes scanning and / or otherwise capturing anatomical image data related to the patient's aorta 10. For example, the imaging device may be an x-ray device, a computed tomography (CT) device, a computed axial tomography (CAT) device, a magnetic resonance imaging device (MRI), a magnetic resonance angiography (MRA) device, a positron emission tomography (PET), a single photon emission computed tomography (SPECT) device, an ultrasound device, and / or any other suitable device for imaging a portion of a patient, and / or a combination thereof (e.g., a CT / MRA device, a PET / CT device, a SPECT / CT device, etc.). Thus, the image data captured by the imaging device may be used to determine salient features of the patient's aorta 10 (e.g., branch vessels in fluid communication with the aorta 10). For example, a physician, surgeon, engineer, manufacturer, etc. may use the image data to determine and / or calculate the size, shape, location, and / or orientation of the aorta 10, branch vascular structures (e.g., renal arteries 13, 14) in fluid communication with the aorta 10, and / or any other suitable vascular or anatomical structures. In some cases, the physician, surgeon, engineer, manufacturer, etc. may form and / or define one or more fenestrations 165 in the stent graft 160 associated with the determined and / or calculated characteristics of at least the renal arteries 13, 14, as described in the above-referenced '998 Application, the '255 Application, and / or the '355 Application.

[0021] As shown in FIG. 2A, the stent graft 160 may be positioned within a portion of the patient's abdominal aorta 10 by endovascular surgery. For example, the stent graft 160 may be placed within a delivery catheter (e.g., in a collapsed, compressed, constrained, and / or otherwise undeployed configuration) that is inserted, for example, into the femoral artery (not shown). The delivery catheter may be advanced through the artery and into the abdominal aorta 10. After the delivery catheter has been advanced to a desired location within the abdominal aorta 10, it may be withdrawn relative to the stent graft 160. As the delivery catheter is retracted and / or withdrawn, the stent graft 160 changes from the collapsed configuration to an expanded or deployed configuration, thereby widening the portion of the abdominal aorta 10.

[0022] Stent graft 160 includes a proximal end 161 and a distal end 162 and defines a lumen 163 therethrough. Stent graft 160 may be any suitable stent graft. For example, stent graft 160 may be formed from a resilient biocompatible material as described above. For example, the stent graft may include a stent or scaffold having a graft material attached thereto. In some embodiments, the stent (i.e., the scaffold) may be constructed from, for example, a metal or metal alloy such as nickel titanium (nitinol), and the graft material may be constructed from, for example, a woven polymer or fabric such as polytetrafluoroethylene (PTFE) or polyethylene terephthalate (PET or Dacron®). In some embodiments, the graft material or fabric may be woven over the stent and / or attached to the stent in any other suitable manner to form the stent graft (e.g., stent graft 160).

[0023] The stent graft 160 further includes a set of stiffening members 164 disposed about the stent graft 160. The stiffening members 164 may be any suitable structure capable of being biased against the stent graft 160, for example, in an open configuration, thereby providing structural support to the stent graft material ("stent fabric" or "graft fabric"). In some embodiments, the stiffening members 164 may be formed from a metal or metal alloy, for example, as described above. In some embodiments, such metals or metal alloys are, for example, radiopaque and / or otherwise coated with a radiopaque material configured to be visible, for example, by fluoroscopy. The stiffening members 164 may be transitioned from a constrained or deformed delivery configuration (e.g., when disposed within a delivery catheter) to an expanded and / or biased deployed configuration as shown in FIG. 2A.

[0024] In this embodiment, the stent graft 160 defines a set of fenestrations 165, as described above. As shown herein, the location of the fenestrations 165 along the stent graft 160 may be based on anatomical image data and / or one or more digital representations of the patient's anatomy. A physician, surgeon, engineer, and / or manufacturer may then use the image data and / or digital representations to define the fenestrations 165 in the graft fabric. As shown, in this example, the fenestrations 165 are aligned with and may have a size, shape, and / or configuration associated with the corresponding renal artery 13 or renal artery 14, respectively. In this manner, the fenestrations 165 may allow blood to flow from the aorta 10 to the right renal artery 13 and the left renal artery 14 through the fenestrations 165. Although not shown in FIG. 2A, the stent graft 160 may define one or more fenestrations associated with other branch vessels emanating from the aorta 10 (e.g., the superior mesenteric artery (SMA), the celiac artery, etc.).

[0025] As shown in FIG. 2B, the insertion and / or placement of the stent graft 160 within the aorta 10 may, for example, reposition, displace, rotate, deform, and / or otherwise reconfigure the patient's aorta 10. As a result, the openings of the renal arteries 13, 14 are displaced relative to the fenestration 165 defined by the stent graft 160. In some cases, the displacement of the aorta 10 relative to the stent graft 160 results in at least a partial occlusion of the renal arteries 13, 14, as shown in FIG. 2B. For example, in some cases, the openings of the renal arteries 13, 14 may be between about 4 millimeters (mm) and about 7 mm, and the displacement and / or repositioning of the aorta 10 may result in a displacement of the openings of the renal arteries 13, 14 relative to the fenestration 165 of about 1 mm, about 2 mm, about 3 mm, about 4 mm, about 5 mm, about 6 mm, about 7 mm, or more (or fractions of a mm). Thus, even if fenestrations 165 are defined at desired locations along the stent graft 160 based on image data, displacement of the aorta 10 due to the insertion and / or placement of the stent graft 160 may result in occlusion of the renal arteries 13, 14. In some cases, displacement of the aorta 10 may result in about 1%, 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% (or any percentage or fraction of a percent) of occlusion of the renal arteries 13, 14. Although not shown in FIGS. 2A-B, displacement of the aorta 10 may result in similar misalignment of any branch vessels relative to the corresponding fenestrations in the stent graft 160. In some embodiments, the electronic device may be configured to determine and / or calculate a displacement in an anatomical structure resulting from the insertion and / or placement of a prosthesis (e.g., a stent graft) and may define one or more digital representations of the displaced anatomical structure. Based on the calculated displacement, one or more fenestrations may be formed in the stent graft (e.g., stent graft 160), as described in the above-referenced '998 Application, the '255 Application, and / or the '355 Application.

[0026] 3 illustrates at least a portion of a fenestrated stent graft 260 in one embodiment. As discussed above, the stent graft may define one or more fenestrations configured to accommodate one or more branch vessels when deployed within the aorta. Specifically, in this embodiment, the fenestrated stent graft 260 includes a proximal end 261 and a distal end 262 and defines a lumen 263 and a set of fenestrations 265. The fenestrated stent graft 260 may be any suitable stent graft and / or prosthesis. For example, in some embodiments, the fenestrated stent graft 260 may be a commercially available stent graft. In other embodiments, the fenestrated stent graft 260 may be a patient-specific stent graft having a size, shape, and / or configuration corresponding to the patient's anatomy.

[0027] Fenestrated stent graft 260 (also referred to herein as "stent graft") may have any suitable shape, size, and / or configuration. For example, in some embodiments, stent graft 260 may have a size related to the size of the lumen defined by the aorta. In other embodiments, fenestrated stent graft 260 may have a size related to the adjusted or calculated size of the lumen defined by the aorta as a result of endovascular placement of stent graft 260. Additionally, stent graft 260 may have any suitable mechanical properties such as, for example, strength, stiffness, etc.

[0028] As shown in FIG. 3, in some embodiments, the stent graft 260 includes a stent 264 and a graft fabric 266. The stent 264 may be any suitable stent and / or scaffold configured, for example, to increase the stiffness of the stent graft 260 and / or to provide structural support to the stent graft 260. As discussed above, the stent 264 may be formed from any suitable metal or metal alloy, such as Nitinol. In some embodiments, the stent 264 may be configured to transition between a first expanded and / or implanted configuration and a second collapsed and / or delivery configuration. Additionally, in some cases, the stent 264 may be biased such that the stent 264 is in a first configuration until a force is applied to the stent 264 (e.g., when positioned in a delivery cannula, etc.) to transition the stent 264 from the first configuration to the second configuration.

[0029] The graft fabric 266 may be formed from any suitable polymer or fabric, such as, for example, Dacron®, or the like. In some embodiments, the graft fabric 266 may be woven around and / or through the stent 264. In other embodiments, the graft fabric 266 may be joined to the stent 264 by sutures, an interference fit, or an adhesive, and / or may encapsulate the stent 264 between at least two layers of the graft fabric 266. As shown in FIG. 3, the graft fabric 266 defines a fenestration 265 that may be positioned relative to the stent 264 such that the fenestration 265 does not overlap the stent 264. That is, the fenestration 265 may be positioned along the stent graft 260 such that one or more portions of the stent 264 do not span and / or otherwise cross the fenestration 265. In other embodiments, one or more portions of the stent 264 may span and / or otherwise traverse the fenestrations 265. Additionally, as described in detail above, the fenestrations 265 may be defined at locations along the stent graft 260 by the graft fabric 266 based on updated, estimated, predicted, and / or otherwise calculated digital representations of portions of the patient's vasculature.

[0030] As discussed above, the stent graft 260 may be any suitable stent graft and may be formed by any suitable manufacturing process(es). In some embodiments, the stent graft 260 may be manufactured as a commercially available stent graft and the fenestrations 265 may be formed in the graft material 266 in a subsequent manufacturing process. In other embodiments, the stent graft 260 may be a "custom" or non-commercially available stent graft. Although specific manufacturing methods are described herein, these methods are provided by way of example only and not by way of limitation. Additionally, the manufacturing methods described herein may be performed in one facility and / or manufacturing process, or may be performed in multiple facilities and / or manufacturing processes. In some cases, portions of the manufacturing methods described herein may be performed by an end user, such as a physician, surgeon, technician, nurse, etc. Thus, although the manufacturing of the stent graft 260 is specifically described below, the stent graft 260 may be formed by any suitable manufacturing process(es) and is not limited to the manufacturing processes described herein.

[0031] In some cases, the stent graft 260 may be manufactured with an overall shape, diameter, length, etc., relative to the patient's aorta, for example, based on calculations from anatomical image data of the patient. In other embodiments, the stent graft 260 may have an overall shape, size, and / or configuration relative to an updated model defined by an electronic device, the updated model corresponding to a calculated, estimated, and / or revised configuration of the aorta in response to insertion and deployment of the stent graft 260, for example, as described in detail above. Thus, the stent graft 260 has a generally tubular or cylindrical shape. In some embodiments, the diameter of the lumen 263 is based, at least in part, on the calculated, estimated, and / or revised diameter of the lumen defined by the aorta. Further, as described in the '998 Application, the '255 Application, and / or the '355 Application incorporated by reference above, the stent graft 260 may have stiffness and / or any other suitable mechanical properties related to the expected amount and / or manner of aortic displacement caused by insertion and / or placement of the stent graft 260.

[0032] The fenestrations 265 may be defined along the stent graft 260 such that each fenestration 265 corresponds to a calculated location of a corresponding branch vascular structure (e.g., a renal artery), and each fenestration 265 may be formed in any suitable manner, as described in the '998 Application, the '255 Application, and / or the '355 Application cited by reference above.

[0033] As shown in FIG. 4 , when fenestrations 265 are defined along the stent graft 260, the stent graft 260 may be positioned within a portion of a patient's body by any suitable endovascular procedure. In this embodiment, the stent graft 260 is positioned within the patient's aorta 10. As shown, the stent graft 260 may include a first set of fenestrations 265A coupled to and / or otherwise corresponding to, for example, the right renal artery 13 and the left renal artery 14. Specifically, each of the fenestrations 265A may be aligned with and have a size, shape, and / or configuration associated with the corresponding renal artery 13 or renal artery 14. In some embodiments, the size, shape, and / or location of the fenestrations 265A is associated with and / or substantially corresponds to the adjusted and / or calculated size, shape, and / or location of the corresponding renal artery 13, 14. For example, the placement of the stent graft 260 within the aorta 10 may, for example, alter, displace, rotate, change, and / or otherwise reconfigure the placement of the patient's aorta 10. Thus, by biasing the stent graft 260 based on the updated model, the size, shape, and / or location of the fenestrations 265 defined by the stent graft 260 may correspond to the desired branch vascular structures (right renal artery 13 and / or left renal artery 14). Furthermore, in addition to positioning the stent graft 260 within the patient's aorta 10, the renal arteries 13 and / or 14 may also be stented, for example, through the fenestrations 265A (not shown in FIG. 4). Stenting of the renal arteries may be performed by a second branch stent (not shown in FIG. 4) that engages the fenestrated body of the stent graft 260 at the fenestrations 265A and extends into the branch arteries, such as the renal arteries 13 and / or 14. In this manner, the fenestrations 265A of the stent graft 260 and a second branch stent (not shown) positioned to correspond to the branch artery may assist in axial and / or radial alignment and positioning during deployment of the stent graft 260. Additionally, the fenestrations 265A and the second branch stent (not shown) may assist in maintaining alignment and positioning of the stent graft 260 relative to the patient's aorta 10 after placement of the stent graft 260.

[0034] As shown in Figures 3 and 4, in some embodiments, the stent graft 260 may include a second set of fenestrations 265B that are coupled to and / or otherwise correspond to other branch vessels that may otherwise be occluded by the non-fenestrated portions of the stent graft 260. For example, the fenestrations 265B may be coupled to and / or otherwise correspond to the superior mesenteric artery (SMA) 18 and the celiac artery 19, respectively. In other embodiments, the stent graft 260 may define fenestrations to accommodate more or fewer branch vessels than shown herein. For example, in some embodiments, the stent graft 260 may define fenestrations to accommodate the inferior mesenteric artery (IMA), the internal iliac artery, etc. Thus, the fenestrations 265 defined by the stent graft 260 may allow blood to flow from the aorta 10 to branch vasculature that would otherwise be occluded by the stent graft 260 material.

[0035] In some embodiments, the configuration of the stent graft 260 and / or the patient's aorta may be such that the fenestrations 265 are partially defined by the stent graft 260. For example, as shown, the most proximal fenestration 265B is located at the proximal end of the stent graft 260 and corresponds to the celiac artery 19, which is partially covered by the graft material upon deployment. As such, the fenestration 265B for the celiac artery 19 is partially circular or U-shaped to fit the portion of the celiac artery 19 that would otherwise be occluded by the graft material. In other embodiments, any of the fenestrations 265 may have a non-circular and / or irregular shape.

[0036] In some embodiments, the fenestrations 265 may be marked to facilitate locating the fenestrations 265 during deployment of the stent graft 260 and to facilitate coupling of a branch stent (not shown) to the stent graft 260. For example, the periphery 267A or periphery 267B of the stent graft 260 defining the fenestrations 265A or 265B may be sutured using gold wire and / or other radiopaque material. Similarly, the location of the fenestrations 265 may be marked by one or more radiopaque markers. Such radiopaque wires facilitate fluoroscopic visualization of the fenestrations 265 during the endovascular repair procedure and allow the physician to locate the fenestrations 265 relative to the corresponding branch vessels. In other embodiments, the fenestrations 265 may be sewn and / or otherwise marked using any suitable material that can enhance visibility, for example, when using any suitable imaging device (e.g., MRI scan, CAT scan, PET scan, X-ray scan, ultrasound, etc.) Such markers may be placed and / or sewn in during a manufacturing process that may be combined with the formation of the fenestrations 265 or may be separate from the formation of the fenestrations 265.

[0037] As described above, in some embodiments, the second branch stent may be coupled with a fenestration (e.g., fenestration 265) of the stent graft (e.g., stent graft 260). The relative position of the second branch stent may aid in the axial and radial alignment and / or positioning of the stent graft 260 relative to the patient's aorta 10 during deployment of the stent graft 260. The second stent may be positioned within the branch vessel such that the second stent may help reinforce the branch vessel (e.g., SMA 18) extending from the patient's aorta in the open position during placement of the stent graft. Additionally, the second stent may help maintain the axial and / or radial positioning of the stent graft relative to the patient's aorta (e.g., aorta 10) after placement of the stent graft. The second stent may be movable within and / or relative to the fenestration such that movement of the branch vessel may be accommodated (i.e., vessel tortuosity may be corrected and vessel kinking may be prevented). In some embodiments, a fenestrated body, such as a main stent graft, may include a flexible portion surrounding the fenestration such that a rigid branch stent engaged with the fenestrated body at the fenestration can rotate within the fenestration. For example, FIG. 5A is a schematic front view of a fenestrated body 460. The fenestrated body 460 may be, for example, a main stent graft, such as an aortic stent graft. The fenestrated body 460 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 460 may include an engagement portion 468 that defines and surrounds the fenestration 465. The engagement portion 468 may be flexible and configured to engage the branch stent graft 430 (FIGS. 5B-5D). The branch stent graft 430 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent.

[0038] 5B-5D are schematic side views of the system 400 in a first configuration, a second configuration, and a third configuration, respectively. The system 400 includes a fenestrated body 460 and a branch stent graft 430. The branch stent graft 430 may be rigid or flexible. The engagement portion 468 may be configured such that the plane or front surface of the engagement portion 468 remains perpendicular to the central longitudinal axis of the branch stent graft 430 when the branch stent graft 430 moves relative to the fenestrated body 460 in the configurations shown in FIGS. 5B-5D. As shown in FIG. 5B, the branch stent graft 430 may be positioned in a first configuration in which the central longitudinal axis of the branch stent graft 430 is perpendicular to the wall of the fenestrated body 460. As shown in FIG. 5C, the branch stent graft 430 may be transitioned to a second position (i.e., the second configuration) relative to the branch stent graft 430. As shown in Figure 5D, the branch stent graft 430 may be transitioned to a third position (i.e., a third configuration) relative to the branch stent graft 430. Although the system 400 is shown in Figures 5B-5D as having three configurations for illustrative purposes, the system 400 may have essentially an infinite number of configurations. That is, the engagement portion 468 is sufficiently flexible to maintain the central longitudinal axis of the branch stent graft 460 in alignment with the branch vessel regardless of movement of the fenestrated body 460.

[0039] In some embodiments, the engagement portion 468 may include a flexible locking mechanism (not shown) that may be configured to engage the branch stent graft 430 to maintain engagement thereof at various branch stent graft 430 locations. The flexible locking mechanism may further limit and / or prevent axial movement of the branch stent graft 430 within and / or relative to the fenestrations 465 of the fenestrated body 460.

[0040] In some embodiments, rather than the fenestrated body including a flexible engagement portion, the engagement portion of the fenestrated body may be rigid and the associated branch stent graft may be flexible. For example, FIG. 6 is a schematic cross-sectional side view of a system 500 including a fenestrated body 560 and a flexible branch stent graft 530. The stent graft 530 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 560 may be a primary stent graft, such as, for example, an aortic stent graft. The fenestrated body 560 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 560 may include a rigid engagement portion 568 that defines and surrounds the fenestration 565. The engagement portion 568 may be substantially similar to those described in International Application No. PCT / US2017 / 037157, filed June 13, 2017, entitled “Systems, Devices, and Methods for Marking and / or Reinforcing Fenestrations in Prosthetic Implants” (the “'157 Application”), the entire disclosure of which is incorporated herein by reference.

[0041] The flexible branch stent graft 530 may include a proximal end 535 and a distal end 537. The rigid engagement portion 568 may be securely coupled to the proximal end 535 of the flexible branch stent graft 530. The distal end 537 of the flexible branch stent graft 530 may be free to move due to the flexibility of the branch stent graft 530. Factors that may affect the flexibility of the branch stent graft 530 may include, for example, the pattern of the stent, the thickness of the stent material, the type of stent material, and / or the type of connection between the branch stent graft 530 and another stent. The flexible branch stent graft 530 may be moved from a first position to a second position (shown as flexible branch stent graft 530'). In the second position, the proximal end 535 of the flexible branch stent graft 530 remains fixedly coupled to the rigid engagement portion 568. However, the distal end 537' is now disposed in a second position relative to the second end 537 and the flexible branch stent graft 530' is bent into a different shape than it was in the first position. The fixed attachment of the proximal end 535 of the flexible branch stent graft 530 to the rigid engagement portion 568 prevents the flexible branch stent graft 530 from moving axially relative to the fenestration 565 and fenestrated body 560. The fixed attachment of the proximal end 535 of the flexible branch stent graft 530 to the rigid engagement portion 568 may be achieved by any suitable coupling structure. For example, the flexible branch stent graft 530 may include a flanged ring at the proximal end 535.

[0042] The flange may be positioned against a portion of the rigid engagement portion 568 such that it faces the interior of the fenestrated body 560. In other embodiments, the proximal end 535 of the flexible branch stent graft 530 and the rigid engagement portion 568 may be engaged via a saddle shaped feature, such as saddle shaped engagement portion 1031 as described below.

[0043] In some embodiments, any suitable flexible branch stent graft may be configured to be fixedly coupled to the engagement portion of the fenestrated body. For example, FIG. 7 is a schematic cross-sectional side view of a system 600 including a branch stent graft 630 and a fenestrated body 660. The branch stent graft 630 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 660 may be a main stent graft, such as, for example, an aortic stent graft. The fenestrated body 660 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 660 may include an engagement portion 668 that defines and surrounds the fenestration 665. The engagement portion 668 may be rigid or flexible and may be configured to be fixedly coupled to the branch stent graft 630.

[0044] The branch stent graft 630 includes a first rigid stent section 632 and a second rigid stent section 634. The first rigid stent section 632 and the second rigid stent section 634 are joined by a flexible stent section 636. In other words, the flexible branch stent graft 630 may be formed as a unitary stent having a constant cylindrical outer diameter and may include sections having variable flexibility or stiffness. The flexibility of the flexible stent section 636 allows the branch stent graft 630 to bend and / or rotate relative to the engagement section 668. For example, the branch stent graft 630 may be bent from a first position, where the central axis of the branch stent graft 630 is perpendicular to the plane or surface of the engagement section 668, to a second position, represented by branch stent graft 630', where the branch stent graft 630' has a curved central axis. As shown, the second rigid stent section 634' may be displaced to a second position while the first rigid stent section 632' is fixedly coupled to the engagement portion 668 and remains stationary relative to the engagement portion 668. Furthermore, the fixed engagement of the first rigid stent section 632' with the engagement portion 668 may prevent axial movement of the branch stent graft 630 relative to the fenestrated body 660.

[0045] In some embodiments, the first flexible stent portion and the second flexible stent portion may be joined by a rigid stent portion. For example, FIG. 8 is a schematic cross-sectional side view of a system 1200 including a branch stent graft 1230 and a fenestrated body 1260. The branch stent graft 1230 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1260 may be a main stent graft, such as, for example, an aortic stent graft. The fenestrated body 1260 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1260 may include an engagement portion 1268 that defines and surrounds a fenestration 1265. The engagement portion 1268 may be rigid or flexible and may be configured to be fixedly coupled to the branch stent graft 1230 .

[0046] The branch stent graft 1230 includes a first flexible stent section 1232 and a second flexible stent section 1234. The first flexible stent section 1232 and the second flexible stent section 1234 are joined by a rigid stent section 1236. In other words, the branch stent graft 1230 may be formed as a unitary stent having a constant cylindrical outer diameter and may include sections having variable flexibility or stiffness. The flexibility of the first flexible stent section 1232 and the second flexible stent section 1234 allows the branch stent graft 1230 to bend and / or rotate relative to the engagement portion 1268. For example, the branch stent graft 1230 may be bent from a first position, where the central axis of the branch stent graft 1230 is perpendicular to the plane or surface of the engagement portion 1268, to a second position, represented by the branch stent graft 1230', where the branch stent graft 1230' has a variable central axis (i.e., the central axes of the first flexible stent portion 1232 and the second flexible stent portion 1234 are bent). As shown, the first flexible stent portion 1232' and the second flexible stent portion 1234' may be displaced to a second position, each having a second shape, while the rigid stent portion 1236' maintains the same shape in the second position. Furthermore, the fixed engagement of the first rigid stent portion 1232' with the engagement portion 1268 may prevent axial movement of the branch stent graft 1230 relative to the fenestrated body 1260.

[0047] In some embodiments, the branch stent graft may include two rigid portions connected by a flexible tether. For example, FIG. 9 is a schematic cross-sectional side view of a system 700 including a flexible branch stent graft 730 and a fenestrated body 760. The branch stent graft 730 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 760 may be a main stent graft, such as, for example, an aortic stent graft. The fenestrated body 760 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 760 may include an engagement portion 768 that defines and surrounds the fenestration 765. The engagement portion 768 may be rigid or flexible and may be configured to be fixedly coupled to the branch stent graft 730.

[0048] The flexible branch stent graft 730 includes a first rigid stent section 732 and a second rigid stent section 734. The first rigid stent section 732 and the second rigid stent section 734 are connected by a flexible rod-like tether 736. The first rigid stent section 732 and the second rigid stent section 734 may be the same or different sizes, lengths, and / or shapes. The flexibility of the tether 736 allows the flexible branch stent graft 730 to bend and / or rotate relative to the engagement portion 768. For example, the flexible branch stent graft 730 may be bent from a first position, in which the central axis of the flexible branch stent graft 730 (i.e., the central axis through the first rigid stent section 732 and the second rigid stent section 734) is perpendicular to the plane of the engagement section 768, to a second position, represented by the flexible branch stent graft 730', in which the tether 736' is curved. As illustrated in FIG. 9, the second rigid stent section 734' may be displaced to the second position, while the first rigid stent section 732' is fixedly coupled to and remains motionless relative to the engagement section 768. Furthermore, the fixed engagement of the first rigid stent section 732 and the engagement section 768 may prevent axial movement of the branch stent graft 730 relative to the fenestrated body 760.

[0049] In some embodiments, the branch stent graft may include a rigid portion and a flexible tail. For example, FIG. 10 is a schematic cross-sectional side view of a system 800 including a branch stent graft 830 and a fenestrated body 860. The branch stent graft 830 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 860 may be a main stent graft, such as, for example, an aortic stent graft. The fenestrated body 860 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 860 may include an engagement portion 868 that defines and surrounds the fenestration 865. The engagement portion 868 may be rigid or flexible and may be configured to be fixedly coupled to the branch stent graft 830.

[0050] The flexible branch stent graft 830 includes a rigid stent section 832, a flexible tail 836, and a flexible transition section 833 joining the rigid stent section 832 and the flexible tail 836. Because the flexible transition section 833 may have a lower flexibility than the flexible tail 836, the flexible transition section 833 may relieve tension between the rigid stent section 832 and the flexible tail 836, thus preventing kink points or structural fatigue between the rigid stent section 832 and the flexible tail 836. The flexibility of the flexible tail 836 and the flexible transition section 833 allows the flexible tail 836 to bend and / or rotate relative to the rigid stent section 832 and the engagement section 868. For example, the flexible tail 836 may be bent from a first position where the central axis of the branch stent graft 830 (i.e. the central axis through the rigid stent section 832, the flexible transition section 833 and the flexible tail 836) is perpendicular to the plane of the engagement section 868, to a second position represented by the branch stent graft 830', where the flexible tail 836' is curved. As shown, due to the flexibility of the flexible transition section 833 and the flexible tail 836', the flexible tail 836' may be displaced to the second position, but the first rigid stent section 832' is fixedly coupled to the engagement section 868 and remains stationary relative to the engagement section 868. The flexible tails 836' may be formed of any suitable material, such as, for example, a metal or metal alloy, such as nickel titanium (nitinol), stainless steel, or cobalt chrome, and / or a polymeric weave or fabric, such as, for example, polytetrafluoroethylene (PTFE) or polyethylene terephthalate (PET or Dacron®). Additionally, the fixed engagement of the first rigid stent section 832 with the engagement portion 868 may prevent axial movement of the branch stent graft 830 relative to the fenestrated body 860.

[0051] In some embodiments, the branch stent graft may be configured to movably engage with the engagement portion of the fenestrated body. For example, in some embodiments, the engagement portion of the fenestrated body and the engagement portion of the branch stent graft may both be rigid. The engagement portion of the fenestrated body and the engagement portion of the branch stent graft may engage and / or couple such that the branch stent graft can move and / or rotate relative to the fenestrated body. For example, Figures 11A-11C are schematic cross-sectional side views of a system 900 including a branch stent graft 930 and a fenestrated body 960. The branch stent graft 930 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 960 may be, for example, a main stent graft, such as a vessel wall or aortic stent graft. The fenestrated body 960 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 960 may define a fenestration 965 and include a rigid engagement portion 968 surrounding the fenestration 965. The rigid engagement portion 968 may be configured to be coupled to the branch stent graft 930. In some embodiments, the rigid engagement portion 968 includes reinforcement and / or a marked edge of the wall of the fenestrated body 960 in the region surrounding the fenestration 965. In other embodiments, the rigid engagement portion 968 includes the wall of the fenestrated body 960 in the region surrounding the fenestration 965 and is not reinforced.

[0052] The branch stent graft 930 may include an engagement portion (not shown) configured to movably couple the branch stent graft 930 to an engagement portion 968 of the fenestrated body 960. The branch stent graft 930 is movably coupled to the engagement portion 968 of the fenestrated body 960 such that the branch stent graft 930 can move, pivot, and / or rotate relative to the fenestrated body 960, as shown in Figures 11A-11C. Specifically, as shown in Figure 11A, the branch stent graft 930 may be configured such that in a first position relative to the fenestrated body 960, a central axis of the branch stent graft 930 is perpendicular to a central axis of the fenestrated body 960. As shown in Figure 11B, the branch stent graft 930 may be moved relative to the fenestrated body 960 such that the branch stent graft 930 is in a second position relative to the fenestrated body 960. 11C , the branch stent graft 930 may move relative to the fenestrated body 960 to a third position in which the branch stent graft 930 is relative to the fenestrated body 960. Further, engagement of the engagement portion of the branch stent graft 930 with the engagement portion 968 of the fenestrated body 960 may limit or prevent axial movement of the branch stent graft 930 relative to the fenestrated body 960.

[0053] In some embodiments, the engagement portion of the branch stent graft may be formed in any suitable shape. For example, FIG. 12 is a schematic cross-sectional side view of a system 1000 including a branch stent graft 1030 and a fenestrated body 1060. The branch stent graft 1030 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1060 may be, for example, a primary stent graft, such as a vessel wall or aortic stent graft. The fenestrated body 1060 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1060 may include an engagement portion 1068 that defines and surrounds a fenestration 1065. The engagement portion 1068 may be configured to be coupled to the branch stent graft 1030. In some embodiments, the engagement portion 1068 comprises a reinforced and / or marked edge of the wall of the fenestrated body 1060 in the area surrounding the fenestration 1065. In other embodiments, the engagement portion 1068 comprises the wall of the fenestrated body 1060 in the area surrounding the fenestration 1065 and is not reinforced.

[0054] The branch stent graft 1030 may include a saddle-shaped engaging portion 1031. The saddle-shaped engaging portion 1031 is configured to be movably coupled to an engaging portion 1068 of the fenestrated body 1060. In some embodiments, the branch stent graft 1030 may be self-expanding. For example, the saddle-shaped engaging portion 1031 may have a biased expanded shape such that it is collapsible and can be collapsed for delivery and insertion of the branch stent graft 1030 through the fenestration 1065. The saddle-shaped engaging portion 1031 may be deployed such that when the saddle-shaped engaging portion 1031 is positioned within the fenestration 1065 such that it is aligned with the engaging portion 1068 of the fenestrated body 1060, as shown in FIG. 12, the saddle-shaped engaging portion 1031 automatically assumes an expanded configuration to engage with the engaging portion 1068 of the fenestrated body 1060.

[0055] In other embodiments, the engagement portion 1031 or the entire branch stent graft 1030 is shapeable and radially expandable. A separate expandable member, such as a balloon, may be used to expand and / or shape the branch stent graft 1030 after it has been delivered to a target location relative to the engagement portion 1068 of the fenestrated body 1060. The expandable member may be expanded such that the engagement portion 1031 of the branch stent graft 1030 is shaped by a force that the expandable member applies to the inner surface of the engagement portion 1031 of the branch stent graft 1030. In some embodiments, the expandable member may be pre-shaped such that the unconstrained expanded shape of the expandable member includes two larger diameter portions separated by a smaller diameter portion (e.g., an hourglass shape). The pre-shaped expandable member may apply pressure to the inner surface of the engagement portion 1031 such that the engagement portion 1031 assumes a similar shape. In other embodiments, the expandable member may have an unconstrained cylindrical expanded shape and may be restricted in expansion by the engagement portion 1068 of the fenestrated body 1060 such that the expandable member may only expand on either side of the engagement portion 1068. As a result, the expandable member may only apply an expansion force to the inner surface of the engagement portion 1068 on either side of the engagement portion 1068, causing the engagement portion 1031 of the branch stent graft 1030 to have a shape as shown in Figure 12. The expandable member may be a compliant or non-compliant member.

[0056] In some embodiments, the system 1000 may include a stop feature to allow a user to determine when the engagement portion 1031 of the branch stent graft 1030 and the engagement portion 1068 of the fenestrated body 1060 are properly aligned for deployment and / or expansion of the engagement portion 1031. The stop feature may be located on a delivery instrument used to deliver the branch stent graft 1030, on the engagement portion 1068, and / or on the engagement portion 1031. In some embodiments, the stop feature may be located on an expandable member, such as a balloon, used to expand and / or shape the branch stent graft 1030. For example, when the expandable member is in a first expanded configuration, the stop feature may engage an anatomical feature, such as an aortic wall, to indicate to the user that the expandable member is properly positioned. The expandable member may then be transitioned to a second expanded configuration to apply pressure to an inner surface of the engagement portion 1031 so that the engagement portion 1031 assumes the desired shape. In some embodiments, radiopaque markers, such as bands, may be placed on the branch stent graft 1030 and / or the engagement portion 1068 so that the relative positions of the branch stent graft 1030 and the engagement portion 1068 may be visually confirmed prior to deployment and / or expansion of the engagement portion 1031.

[0057] When the saddle shaped engagement portion 1031 is engaged with the engagement portion 1068 of the fenestrated body 1060, the branch stent graft 1030 can move more pivotally or rotatably relative to the engagement portion 1068 of the fenestrated body 1060. The saddle shaped engagement portion 1031 may include a flared distal end to limit or prevent axial movement of the branch stent graft 1030 while allowing movement (e.g. pivoting, rotational movement, etc.) relative to the fenestrated body 1060.

[0058] In some embodiments, the saddle-shaped engagement portion of the branch stent graft may have any suitable shape. For example, FIG. 13A is a schematic cross-sectional side view of a system 1100 including a branch stent graft 1130 and a fenestrated body 1160. The branch stent graft 1130 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1160 may be, for example, a primary stent graft, such as a vessel wall or aortic stent graft. The fenestrated body 1160 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1160 may include an engagement portion 1168 that defines and surrounds a fenestration 1165. The engagement portion 1168 may be configured to be coupled to the branch stent graft 1130. In some embodiments, the engagement portion 1168 comprises a reinforced and / or marked edge of the wall of the fenestrated body 1160 in the area surrounding the fenestration 1165. In other embodiments, the engagement portion 1168 comprises the wall of the fenestrated body 1160 in the area surrounding the fenestration 1165 and is not reinforced.

[0059] The branch stent graft 1130 may include a saddle-shaped or hourglass-shaped engagement portion 1131. The saddle-shaped engagement portion 1031 is configured to be rotatably coupled to an engagement portion 1168 of the fenestrated body 1160. In such a configuration, the branch stent graft 1130 can move relative to the engagement portion 1168 of the fenestrated body 1160.

[0060] In some embodiments, the engagement portion 1131 may be moldable and an expandable member may be used to shape the engagement portion 1131. As shown in FIG. 13A, the system 1100 may include an expandable member 1140. The expandable member 1140 may be fluidly coupled to a fluid supply mechanism (not shown) that may be controlled during deployment. After the engagement portion 1131 is positioned within the fenestration 1165, the expandable member 1140 may be inserted into the fenestration 1165 to align with the engagement portion 1131 of the branch stent graft 1130 and the engagement portion 1168 of the fenestrated body 1160. The expandable member 1140 may be expanded, for example, using a fluid supply mechanism coupled to the expandable member, such that the force applied by the expandable member 1140 to the inner surface of the engagement portion 1131 shapes the engagement portion 1131 of the branch stent graft 1130.

[0061] In some embodiments, the expandable member 1140 may be pre-shaped such that the unconstrained expanded shape of the expandable member 1140 includes a first portion proximal to the fenestrated body 1160 and a second portion 1144 distal to the fenestrated body 1160. The proximal portion further includes a first larger diameter portion 1141, a second smaller diameter portion 1142 distal to the first larger diameter portion 1141, and a third larger diameter portion 1143 distal to the second smaller diameter portion 1142, as shown in FIG. 13A. The first, second, and third diameter portions of the first proximal portion form a saddle or hourglass shape of the expandable member 1140. The diameter of the first diameter portion 1141 may be the same as the diameter of the third diameter portion 1143, or may be slightly larger or smaller in diameter than the diameter of the third diameter portion 1143. The second reduced diameter portion 1142 forms a valley that engages with an engagement portion 1168 of the fenestrated body 1160 .

[0062] The distal portion 1144 of the expandable member 1140 may be configured to have a smaller diameter than the proximal portion, which includes a saddle shape. Additionally, the distal portion 1140 may be configured to engage the tail 1136 of the branch stent graft 1130 upon expansion by applying an expansion force to the inside of the branch stent graft 1130. Thus, the pre-shaped distal portion 1144 of the expandable member 1140 may force the tail 1136 of the branch stent graft 1130 into a desired shape. Similarly, the proximal portion of the expandable member 1140 may force the branch stent graft 1130 into a desired shape by applying an expansion force to the inner surface of the proximal region of the branch stent graft 1130.

[0063] The proximal portion of the expandable member 1140 (including the first diameter portion 1141, the second diameter portion 1142, and the third diameter portion 1143) and the distal portion 1144 of the expandable member 1140 may be fluidly coupled to one fluid supply mechanism to control expansion upon deployment, or may be separately connected to separate fluid supply mechanisms. The pre-shaped expandable member 1140 may be used to apply pressure to the inner surface of the engagement portion 1131 so that the engagement portion 1131 assumes a similar shape.

[0064] In some embodiments, the expandable member 1140 can be a semi-compliant member. In some embodiments, the proximal portion of the expandable member 1140 (including the first diameter portion 1141, the second diameter portion 1142, and the third diameter portion 1143) that forms a saddle shape can be semi-compliant and the distal portion of the expandable member 1140 can be inextensible. In some embodiments, both the proximal and distal portions of the expandable member 1140 can be compliant and the proximal portion can have a higher extensibility than the distal portion. In some embodiments, the distal portion of the expandable member 1140 can have substantially the same extensibility as the proximal portion or can have a higher extensibility than the proximal portion.

[0065] As discussed above, rather than including a flared proximal end when fully expanded like the saddle shaped engagement portion 1031 shown in Figure 12, the saddle shaped engagement portion 1131 when expanded may include two larger diameter portions connected by a smaller diameter valley portion. The engagement portion 1168 of the fenestrated body 1160 may engage the valleys such that the two larger diameter portions prevent the branch stent graft 1130 from moving axially away from the main stent graft 1160 while still allowing rotational movement relative to the main stent graft 1160.

[0066] In some embodiments, the saddle shaped engagement portion 1131 when expanded may be shaped such that the third diameter portion has a larger diameter than the first diameter portion while the first and third diameter portions have a larger diameter than the second diameter portion which forms a valley for engaging the fenestrated body 1160. In some other embodiments, the third diameter portion has a smaller diameter than the first diameter portion and a larger diameter than the second valley which is also configured to engage the fenestrated body 1160 when expanded to prevent axial movement of the branch stent graft 1130.

[0067] In some other embodiments, the first and third portions of the saddle-shaped engagement portion 1131 may have substantially equal diameters when fully expanded, while the second portion has a smaller diameter and engages the fenestrated body 1160 to prevent axial movement of the branch stent graft 1130 while allowing pivotal or rotational movement of the branch stent graft about the fenestrated body 1160.

[0068] In some embodiments, the saddle shaped engagement portion of the branch stent graft 1130 and the engagement portion 1168 of the fenestrated body 1160 may be configured such that, upon deployment, a distal portion of the branch stent 1130 (e.g., including a third diameter portion of the saddle shaped engagement portion 1131) is located outside the fenestrated body 1160 and a proximal portion of the branch stent (e.g., including a first diameter portion of the saddle shaped engagement portion 1131) is located inside the fenestrated body 1160. Additionally, the intermediate portion (e.g., a second diameter portion of the saddle shaped engagement portion 1131 forming a valley) may be configured to frictionally engage or engage via an interference fit with an opening or fenestration in the engagement portion of the fenestrated body 1160.

[0069] In some embodiments, rather than using an expandable member, the saddle shaped engaging portion 1131 may have a biased expanded shape such that it is collapsible and can be folded for delivery and insertion of the branch stent graft 1130 through the fenestration 1165. Once the saddle shaped engaging portion 1131 is positioned within the fenestration 1165 such that it is aligned with the engaging portion 1168 of the fenestrated body 1160, the saddle shaped engaging portion 1131 may be deployed to assume an expanded configuration (e.g., the configuration shown in FIG. 13B ) and engage with the engaging portion 1168 of the fenestrated body 1160.

[0070] In some embodiments, the system 1100 may include a stop feature to allow a user to determine when the engagement portion 1131 of the branch stent graft 1130 and the engagement portion 1168 of the fenestrated body 1160 are properly aligned for deployment and / or expansion of the engagement portion 1131. The stop feature may be disposed on the delivery instrument used to deliver the branch stent graft 1130, the engagement portion 1168, and / or the engagement portion 1131. In some embodiments, the stop feature may be disposed on the expandable member 1140. For example, when the expandable member 1140 is in a first expanded configuration, the stop feature may engage an anatomical feature such as an aortic wall to indicate to the user that the expandable member 1140 is properly positioned. The expandable member 1140 may then be transitioned to a second expanded configuration to apply pressure to an inner surface of the engagement portion 1131 to induce the engagement portion 1131 into a desired shape. In some embodiments, radiopaque markers, such as bands, may be placed on the branch stent graft 1130 and / or the engagement portion 1168 so that the relative positions of the branch stent graft 1130 and the engagement portion 1168 may be visually confirmed prior to deployment and / or expansion of the engagement portion 1131.

[0071] As mentioned above, the system 1300 of Figure 14 may be substantially similar to other systems described herein. For example, the system 1300 may be similar to the system 500 shown in Figure 6, or the system 600 shown in Figure 7, or the system 800 shown in Figure 10. By way of example, the branch stent graft 1130 may be substantially similar to the branch stent 630, and the fenestrated body 1160 may be substantially similar to the fenestrated body 660. Furthermore, the engagement portion 1131 of the branch stent 1130 may be suitably rigid or flexible to engage with the fenestrated body 1160 at the engagement portion 1168. The engagement portion 1131 of the branch stent 1130 may include a transition portion 1133 and a distal tail 1136 that defines a central longitudinal axis. Furthermore, the branch stent 1130 may have suitable flexibility or rigidity in combination with the fenestrated body 1160 to maintain its central longitudinal axis substantially perpendicular to the plane defined by the openings in the fenestrated body 1160.

[0072] In some embodiments, the branch stent 1130 may include a tail 1136 configured to be more flexible than the engagement portion. For example, the tail may be 25% more flexible than the engagement portion 1131 of the branch stent graft 1130. In some other embodiments, the tail may be as flexible or less flexible than the engagement portion 1131.

[0073] In some embodiments, the tail 1136 of the branch stent graft 1130 may include a covering 1138 made of a suitable material of suitable thickness and having a strain capacity to impart a desired flexibility to the branch stent 1130 to allow the branch stent graft to expand. For example, the covering 1138 may be formed of one or more layers having a suitable microstructure such that the flexibility of the branch stent graft 1130 may be precisely controlled. As an example, the covering 1138 may be configured to have a strain capacity to support expansion of the branch stent from a first diameter size (e.g., about 2 mm) to a second substantially expanded diameter size (e.g., about 4-12 mm) without failure. That is, the strain capacity of the covering 1138 may be designed to withstand expansion of the branch stent in the range of 2 mm-4 mm to 2 mm-12 mm. In some embodiments, the cover can have a strain capacity of at least about 2 times, at least about 3 times, at least about 4 times, or at least about 5 times the diametric expansion of the engagement portion without failure (e.g., tearing, ripping, etc.).

[0074] In some embodiments, the covering 1138 described above may be disposed on the flexible tail 1136, the engagement section 1131, the transition section, or any combination thereof. That is, the covering may be disposed on any individual portion, multiple portions, or the entire branch stent graft 1130. Furthermore, the covering 1138 disposed on the engagement section 1131, the transition section 1133, and / or the tail section 1136 of the branch stent graft 1130 may be configured to impart a desired flexibility to the engagement section, the transition section, and the tail section, respectively, of the branch stent graft 1130. For example, the covering disposed on one or more of the portions described above may be made of any suitable material having a suitable microstructure and may be made in a suitable thickness with a suitable number of layers to achieve a desired flexibility with precise control.

[0075] The transition section of the branch stent 1130 may have suitable flexibility or stiffness to prevent kink formation or structural fatigue between the fenestrated body 1160 and the branch stent 1130. For example, in some embodiments, the transition section 1133 of the branch stent 1130 may have a greater flexibility than the engagement section 1131 of the branch stent 1130 and a lesser flexibility than the flexible tail. That is, the tail 1136 may be configured to have a substantially greater flexibility than the transition section 1133 and the engagement section 1131. For example, the flexibility of the tail 1136 of the branch stent 1130 may be configured such that the branch stent 1130 deflects at least about 1 mm, at least about 2 mm, at least about 3 mm, or at least about 4 mm from the longitudinal axis at a longitudinal distance of 20 mm from the engagement section 1131 of the branch stent when a deflection force of less than 1 N is used. In other words, the flexible tail defines a longitudinal axis in a first unstressed state and is configured to deflect to a second stressed state upon an applied deflection force of less than about 1 N at a longitudinal distance of 20 mm from the engagement portion. When such a deflection force is applied, the flexible tail moves from the first state to the second state by at least about 1 mm, at least about 2 mm, at least about 3 mm, or at least about 4 mm. In some other embodiments, the transition portion 1133 can be configured to have a flexibility that is similar to or less than the flexibility of the engagement portion 1131 and / or tail of the branch stent 1130.

[0076] 14 is a schematic cross-sectional side view of a system 1300 including a branch stent graft 1330 of another shape, according to one embodiment. As shown in FIG. 14, the system 1300 includes a branch stent graft 1330 and a fenestrated body 1360. The branch stent graft 1330 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1360 may be, for example, a primary stent graft, such as a vessel wall or aortic stent graft. The fenestrated body 1360 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1360 may include an engagement portion 1368 that defines and surrounds a fenestration 1365. The engagement portion 1368 may be configured to be coupled to the branch stent graft 1330. In some embodiments, the engagement portion 1368 comprises a reinforcement and / or a marked edge of the wall of the fenestrated body 1360 in the area surrounding the fenestration 1365. In other embodiments, the engagement portion 1368 comprises the wall of the fenestrated body 1360 in the area surrounding the fenestration 1365 and is not reinforced.

[0077] The branch stent graft 1330 may include an engagement portion 1331. The engagement portion 1331 may include a first larger diameter portion 1331A and a second larger diameter portion 1331B. The engagement portion 1331 may be coupled to the engagement portion 1368 of the fenestrated body 1360 such that the engagement portion 1368 of the fenestrated body 1360 is positioned between the first larger diameter portion 1331A and the second larger diameter portion 1331B. Thus, the branch stent graft 1330 can move relative to the engagement portion 1368 of the fenestrated body 1360. The first larger diameter portion 1331A and the second larger diameter portion 1331B may each have a diameter larger than the diameter of the fenestration 1365 defined by the engagement portion 1368 of the fenestrated body 1360, thereby limiting or preventing the branch stent graft 1330 from moving axially relative to the main stent graft 1360, while still allowing rotational and / or pivotal movement relative to the main stent graft 1360. Although the first larger diameter portion 1331A is shown sized smaller than the second larger diameter portion 1331B, in some embodiments the first larger diameter portion 1331A may be the same size as or larger than the second larger diameter portion 1331B.

[0078] 15 is a schematic cross-sectional side view of a system 1400. The system 1400 may include a branch stent graft 1430 having a double-sided engagement portion 1431. The system 1400 further includes a fenestrated body 1460. The branch stent graft 1430 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1460 may be, for example, a primary stent graft, such as a vessel wall or aortic stent graft. The fenestrated body 1460 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1460 may include an engagement portion 1468 that defines and surrounds a fenestration 1465. The engagement portion 1468 may be configured to be coupled to the branch stent graft 1430. In some embodiments, the engagement portion 1468 comprises a reinforced and / or marked edge of the wall of the fenestrated body 1460 in the area surrounding the fenestration 1465. In other embodiments, the engagement portion 1468 comprises a wall of the fenestrated body 1460 in the area surrounding the fenestration 1465 that is not reinforced.

[0079] The double-sided engagement portion 1431 is configured to be movably coupled to an engagement portion 1468 of the fenestrated body 1460. The engagement portion 1431 of the branch stent graft 1430 includes a first engagement feature 1431A and a second engagement feature 1431B. The engagement portion 1431 (and thus the first engagement feature 1431A and the second engagement feature 1431B) may be of any suitable shape that can engage with the engagement portion 1468 from the inside and / or outside of the fenestrated body 1460. For example, in some embodiments the first engagement feature 1431A and the second engagement feature 1431B may be configured and attached to the fenestrated body 1460 similar to a patent foramen ovale (PFO) closure device with a stent attached thereto.

[0080] In some embodiments, the first engagement feature 1431A and the second engagement feature 1431B may each be formed as an expandable ring and disposed on either side of the engagement portion 1468. The first engagement feature 1431A may be positioned on a first side of the engagement portion 1468 (e.g., on the inside of the fenestrated body 1460). The second engagement feature 1431B may be positioned on a second side of the engagement portion 1468 opposite the first side (e.g., on the outside of the fenestrated body 1460). The engagement portion 1431 may be coupled to the engagement portion 1468 of the main stent graft 1460 such that the engagement portion 1468 of the fenestrated body 1460 is movably fixed between the first engagement feature 1431A on the first side and the second engagement feature 1431B on the second side. In such a configuration, the branch stent graft 1430 may rotate and / or displace relative to the engagement portion 1468 of the fenestrated body 1460. The first engagement feature 1431A and the second engagement feature 1431B may have a diameter larger than the diameter of the fenestration defined by the engagement portion 1468, thereby preventing the branch stent graft 1430 from moving axially away from the fenestrated body 1460 while still allowing rotational movement relative to the fenestrated body 1460.

[0081] In some embodiments, the engagement portion 1431 of the branch stent graft 1430 may comprise an X-shaped saddle such that the first engagement feature 1431A comprises a first prong element and a second prong element and the second engagement feature 1431B comprises a third prong element and a fourth prong element. The first and second prong elements may be positioned on a first side of the engagement portion 1468 (e.g., on the inside of the fenestrated body 1460). The third and fourth prong elements may be positioned on a second side opposite the first side of the engagement portion 1468 (e.g., on the outside of the fenestrated body 1460). The engagement portion 1431 may be coupled to the engagement portion 1468 of the main stent graft 1460 such that the engagement portion 1468 of the fenestrated body 1460 is movably fixed between the first and third prong elements on a first side, and between the second and fourth prong elements on a second side. In such a configuration, the branch stent graft 1430 may rotate and / or displace relative to the engagement portion 1468 of the fenestrated body 1460. The distance between the first and second prong elements and the distance between the third and fourth prong elements may be greater than the diameter of the fenestration defined by the engagement portion 1468, thus preventing the branch stent graft 1430 from moving axially away from the fenestrated body 1460 while still allowing rotational movement relative to the fenestrated body 1460.

[0082] In some embodiments, the branch stent graft may include an anchoring member for engaging an inner wall of a main stent graft or a fenestrated body, such as a vessel wall. For example, Figures 16A-16E are schematic diagrams of various scenes and configurations of a system 1500. The system 1500 includes a branch stent graft 1530 including an anchoring member 1550 and a fenestrated body 1560. The branch stent graft 1530 may be any suitable stent, such as, for example, a bridge stent or a FEVAR stent. The fenestrated body 1560 may be, for example, a vessel wall or a main stent graft, such as an aortic stent graft. The fenestrated body 1560 may have the same or similar structure and / or function as any of the other fenestrated bodies or stent grafts described herein, such as, for example, stent graft 160 or stent graft 260. The fenestrated body 1560 defines a fenestration 1565 and may include an engagement portion 1568 surrounding the fenestration 1565. The engagement portion 1568 may be configured to be coupled to the branch stent graft 1530. In some embodiments, the engagement portion 1568 includes reinforcement and / or a marked edge of the wall of the fenestrated body 1560 in the area surrounding the fenestration 1565. In other embodiments, the engagement portion 1568 includes the wall of the fenestrated body 1560 in the area surrounding the fenestration 1565 and is not reinforced.

[0083] The anchoring member 1550 may be in the form of a parachute or may be a flared end of the branch stent graft 1530. The anchoring member 1550 may be movable from a collapsed delivery configuration to an expanded anchoring configuration. As shown in FIG. 16A, a schematic cross-sectional side view of the system 1500 in a first configuration, the anchoring member 1550 may be delivered to the fenestration 1565 in a collapsed delivery configuration. In some embodiments, the anchoring member 1550 may be delivered to the fenestration in a delivery tube (not shown). The anchoring member 1550 may be biased toward the expanded configuration such that the anchoring member 1550 may be compressed within the delivery tube and then automatically transition to the expanded configuration when removed from the delivery tube. As shown in FIG. 16B, a schematic cross-sectional side view of the system 1500 in a second configuration, the anchoring member 1550 may be expanded to an expanded anchoring configuration after being delivered, for example, from the end of a delivery tube. When the anchoring member 1550 is deployed to the expanded anchoring configuration, it may be positioned against the inner surface of the wall of the fenestrated body 1560 such that the anchoring member 1550 is engaged with the engagement portion 1568 of the fenestrated body 1560 (e.g., the anchoring member 1550 abuts the engagement portion 1568), as shown in FIG. 16C. In such a configuration, the branch stent graft 1530 may be positioned to extend through the fenestration 1565 but not move axially relative to the fenestration 1530. When the anchoring member 1550 is positioned in engagement with the engagement portion 1568, as shown in FIG. 16D, the branch stent graft 1530 may be expanded within the fenestration 1565, for example, by an expandable member (e.g., a balloon). FIG. 16E is a schematic illustration of the inner wall of the fenestrated body 1560 with the anchoring member 1550 secured to the engagement portion 1568 of the fenestrated body 1560. In some embodiments, the anchoring member 1550 and branch stent graft 1530 may be attached to the fenestrated body in a manner similar to a stent-mounted patent foramen ovale (PFO) closure device.

[0084] 16A-16E, it is possible that in some embodiments a second anchoring member may be included such that the second anchoring member engages the outer wall of the fenestrated body 1560. For example, self-expanding parachutes may be positioned on the branch stent graft 1530 such that a first self-expanding parachute opens on the inside of the fenestrated body 1560 and a second self-expanding parachute opens on the outside of the fenestrated body 1560 to secure the branch stent graft 1530 to the fenestrated body 1560.

[0085] As discussed above, in use, the branch stent graft 1530 may be delivered to a target location using a deployment device. For example, the branch stent graft 1530 may be delivered over a guidewire that passes through the fenestrated body 1560 and out the fenestrations 1565 of the fenestrated body 1560 and into a branch artery (not shown in Figures 16A-16E). In some embodiments, a delivery tube may be used to position the branch stent graft 1530 so that the anchoring member 1550 is within the lumen of the fenestrated body 1560 and another portion of the branch stent graft 1530 is within the branch artery (similar to the configuration shown in Figure 16A). In this position, the anchoring member 1550 (e.g., a parachute) may be deployed (similar to the configuration shown in Figure 16B). For example, the anchoring member 1550 or the entire branch stent graft 1530 may be pushed out the end of the delivery tube and automatically expanded to the configuration shown in Figure 16B. The anchoring member 1550 may then be pushed towards the fenestration 1530 such that it abuts the area of ​​the fenestrated body surrounding the fenestration (e.g., engagement portion 1568 as shown in FIG. 16C ). Abutment of the anchoring member with the wall and / or engagement portion of the fenestrated body may cause the branch stent graft 1530 to expand axially within the fenestration 1565 and branch artery (as shown in the configuration in FIG. 16D ). For example, an expandable member (e.g., a balloon) may be inserted into the lumen of the branch stent graft 1530 and expanded, allowing the branch stent graft 1530 to expand to a wider diameter configuration than within the fenestration 1565.

[0086] Various embodiments of systems, methods, and apparatus have been described above, which are presented by way of example only and not by way of limitation. While the methods and steps described above show certain events occurring in a particular order, those skilled in the art having the benefit of this disclosure will understand that the ordering of certain steps may be modified, and such modifications are in accordance with variations of the invention. Furthermore, certain steps may be performed simultaneously in a parallel process where possible, and may be performed sequentially as described above. While specific embodiments have been shown and described, it will be understood that various changes in form and details may be made.

[0087] For example, although various embodiments have been described as having certain combinations of features and / or components, other embodiments are possible having any combination or subcombination of any of the features and / or components of any of the embodiments described herein. Additionally, the specific form of the various components may vary. For example, the size and specific shape of the various components may differ from that of the illustrated embodiments while still providing the functionality described herein.

Claims

1. 1. A radially expandable branch stent graft assembly comprising: an engagement portion for engaging an opening of a fenestrated body, said engagement portion comprising: a proximal portion configured to be disposed inside said fenestrated body and having a first diameter, an intermediate portion configured to be disposed outside said fenestrated body and having a third diameter, said second diameter being smaller than said first diameter and said third diameter in an expanded state of said engagement portion, said branch stent graft assembly being configured to pivot and rotate about said opening of said fenestrated body and to limit axial movement of said branch stent graft assembly relative to said fenestrated body; a flexible tail extending from the engagement portion; Equipped with Branched stent graft assembly.

2. the intermediate portion is configured to frictionally engage the opening of the fenestrated body.

10. The branch stent graft assembly of claim 1.

3. The engagement portion is rigid.

10. The branch stent graft assembly of claim 1.

4. The engagement portion is flexible.

10. The branch stent graft assembly of claim 1.

5. The present invention further comprises a flexible transition portion, wherein the engagement portion and the transition portion define a central longitudinal axis, and the engagement portion is configured to maintain the central longitudinal axis substantially perpendicular to a plane defined by the opening in the fenestrated body.

10. The branch stent graft assembly of claim 1.

6. a transition portion between the engagement portion and the flexible tail portion; the transition portion is rigid; 10. The branch stent graft assembly of claim 1.

7. a transition portion between the engagement portion and the flexible tail portion; the transition portion is flexible; 10. The branch stent graft assembly of claim 1.

8. The flexibility of the flexible tail is provided by at least one of the stent pattern, the stent thickness, and the stent material.

10. The branch stent graft assembly of claim 1.

9. At least a portion of the flexible tail has a cover.

10. The branch stent graft assembly of claim 1.

10. the flexibility of the flexible tail is determined by at least one of a thickness of the cover, a material of the cover, a microstructure of the cover, and a number of layers of the cover; A branch stent graft assembly according to claim 9.

11. the cover has a strain capacity of at least about 5 times the diametric expansion of the engagement portion; A branch stent graft assembly according to claim 9.

12. the flexible tail portion is at least about 25% more flexible than the engagement portion; 10. The branch stent graft assembly of claim 1.

13. the flexible tail defines a longitudinal axis in a first state, the flexible tail being configured to deflect from the first state to a second state when an applied deflection force is less than about 1 N.

10. The branch stent graft assembly of claim 1.

14. the flexible tail is configured to move at least about 3 mm at a longitudinal distance of 20 mm from the engagement portion; A branch stent graft assembly according to claim 13.

15. 1. A radially expandable branch stent graft assembly comprising: a saddle-shaped engagement portion for engaging an opening of a fenestrated body, the saddle-shaped engagement portion including a proximal portion disposed inside the fenestrated body and having a first diameter, a distal portion disposed outside the fenestrated body and having a third diameter, and an intermediate portion configured to frictionally engage the opening of the fenestrated body and having a second diameter, wherein in an expanded state, the second diameter is smaller than the first diameter and the third diameter; a flexible tail extending from the saddle-shaped engagement portion; Equipped with The flexibility of the flexible tail is at least 25% greater than that of the saddle-shaped engagement portion; Branched stent graft assembly.

16. In the expanded state, the first diameter is substantially equal to the third diameter.

16. A branch stent graft assembly according to claim 15.

17. the saddle-shaped engagement portion is configured to pivot the branch stent graft assembly about the opening in the fenestrated body.

16. A branch stent graft assembly according to claim 15.

18. the saddle-shaped engagement portion is configured to limit axial movement of the branch stent graft assembly relative to the fenestrated body.

16. A branch stent graft assembly according to claim 15.

19. a transition portion between the engagement portion and the flexible tail portion; the saddle-shaped engagement portion, the transition portion, and the flexible tail portion comprise a covering disposed over the stent structure.

16. A branch stent graft assembly according to claim 15.

20. The characteristics of the cover, at least a portion of the cover, determine the flexibility of the engagement portion, the transition portion, and the flexible tail portion.

20. A branch stent graft assembly according to claim 19.

21. The characteristics include at least one of a thickness of the cover, a material of the cover, a microstructure of the cover, and a number of layers of the cover.

21. A branch stent graft assembly according to claim 20.

22. 1. A system for treating an aneurysm, comprising: a fenestrated stent graft including openings corresponding to branch vessels; a radially expandable branch stent graft assembly configured to be coupled to an opening in the fenestrated stent graft, the branch stent graft assembly including an engagement portion for engaging the opening in the fenestrated stent graft and a flexible tail extending from the engagement portion; an expandable member configured to change the branch stent graft assembly from a collapsed configuration to an expanded configuration, the expandable member including a proximal portion having a first diameter and a distal portion having a second diameter smaller than the first diameter; Equipped with the branch stent graft assembly is configured to pivot and rotate about the opening in the fenestrated stent graft. system.

23. the expandable member is semi-compliant; 23. The system of claim 22.

24. the proximal portion of the expandable member is semi-compliant and the distal portion of the expandable member is inextensible.

23. The system of claim 22.

25. each of the proximal and distal portions of the expandable member is fluidly coupled to a fluid supply mechanism; 23. The system of claim 22.

26. the proximal portion of the expandable member has a first extensibility and the distal portion of the expandable member has a second extensibility, the first extensibility being greater than the second extensibility; 23. The system of claim 22.

27. the expandable member having an hourglass shape in the expanded configuration; 23. The system of claim 22.

28. the expandable member having radiopaque markers configured to align with the openings in the fenestrated stent graft.

23. The system of claim 22.

29. the proximal portion of the expandable member is inextensible and the distal portion of the expandable member is semi-compliant.

23. The system of claim 22.

30. a transition portion between the engagement portion and the flexible tail portion; the transition portion is rigid; 23. The system of claim 22.

31. a transition portion between the engagement portion and the flexible tail portion; the transition portion is flexible; 23. The system of claim 22.

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