Push-Up Technique and Anatomical Deployment With the Endurant Stent-Graft System for Severely Angulated Aneurysm Necks

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series

Background

Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique.

Method

Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses.

Result

Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient.

Conclusion

MSW technique is a simple and effective technique to modify aortic neck/iliac artery angulation in TEVAR or EVAR procedure.

Long-term Outcomes of the Endurant and Excluder Stent Grafts for Endovascular Aneurysm Repair in a Japanese Cohort

PURPOSE

To compare the long-term outcomes of the most widely used third-generation stent grafts, the Endurant and Excluder stent grafts, in Japanese patients using a multicenter registry.

MATERIALS AND METHODS

A retrospective analysis of endovascular aneurysm repairs for abdominal aortic and iliac artery aneurysms using either the Endurant or the Excluder stent grafts from January 2012 to July 2019 at 10 Japanese hospitals was performed.

RESULTS

A total of 332 and 378 repairs using the Endurant and Excluder stent grafts, respectively, were analyzed. Although the patients' characteristics were generally similar in the two groups, the Endurant group exhibited significantly shorter (Endurant: 31.5±18.6 mm, Excluder: 37.4±21.0 mm; p<0.001), larger (Endurant: 22.4±4.2 mm, Excluder: 21.7±3.8 mm; p=0.029), and more reversed tapered (Endurant: 12.1%, Excluder: 5.8%; p=0.003) proximal necks. The incidence of instructions for use (IFU) violations was similar between the two groups (Endurant: 59.0%, Excluder: 54.5%; p=0.223). However, the Endurant group had significantly more proximal neck-related IFU violations (54.1% and 46.3%, respectively; p=0.039), more access-related IFU violations (8.1% and 4.0%, respectively; p=0.019), and fewer bilateral hypogastric artery embolizations (5.1% and 9.3%, respectively; p=0.035) compared with the Excluder group. The incidence of intraoperative (Endurant: 3.6%, Excluder: 3.7%; p=0.950) and perioperative complications (Endurant: 3.6%, Excluder: 3.4%, p=0.899) was equivalent in the two groups. However, there was a significantly higher incidence of postoperative type II endoleaks in the Excluder group (Endurant: 28%, Excluder: 46.0%, p<0.001). Aneurysm sac regression was more frequent in the Endurant group (Endurant: 40.7%, Excluder: 31.7%, p=0.013). The Endurant group also had significantly higher rates of sac increase (Endurant: 13.0%, Excluder: 7.7%, p=0.020). Kaplan-Meier curve and log-rank analyses revealed no statistical differences in late complications (p=0.868) and overall survival (p=0.926).

CONCLUSIONS

There were no statistically significant differences between the Endurant and the Excluder stent grafts in terms of intraoperative, perioperative, and late complication rates; however, the anatomical characteristics of the patients were significantly different.

Endovascular Aortic Repair with the "Step-by-Step" Deployment of the Endurant Stent-Graft System in Severe Neck Angulation: Technique and Review of the Literature

OBJECTIVES

To describe a new technique based on a different deployment of the Endurant Stent-Graft System (Medtronic Cardiovascular, Santa Rosa, CA) during endovascular aortic aneurysm repair to guarantee a more precise deployment in presence of severe neck angulation (SNA).

TECHNIQUE

The "step-by-step" deployment technique consists of an alternate partial release of the main body and of the free-flow suprarenal stents to approximate the radiopaque markers of the graft fabric to the aortic wall, obtaining a more precise delivery, reducing the possibility of downward dislodgments along the external curve of the infrarenal angle and asymmetrical deployments in presence of SNA.

CONCLUSIONS

The "step-by-step" technique is a simple, safe, and effective graft-deployment method, which allows a very precise release in SNA and possibly achieves better results in the long-term period in such difficult anatomies.

Adjunctive Procedures for Challenging Endovascular Abdominal Aortic Repair: When Needed and How Effective?

Endovascular aneurysm repair (EVAR) is now considered the first choice treatment modality for abdominal aortic aneurysm (AAA) treatment. Advocates for endovascular strategies will try to treat all AAA by EVAR, regardless if the anatomy is conducive for treatment or not. However, the long-term outcomes of EVAR outside the instructions for use (IFU) due to a hostile aneurysmal neck or iliac artery anatomy are known to be poor. The EVAR procedures can be classified according to the technical difficulty, IFU, and need for visceral revascularization: standard, adjunctive, and complex EVAR. The situation required for adjunctive procedures can be classified as the following four steps: a hostile neck (i.e., short or severely angled); large inferior mesenteric or lumbar artery; tough iliac artery anatomy, such as a short common iliac artery and stenotic external iliac artery; and limitations in vascular access. This article will discuss the adjunctive procedures to overcome hostile aneurysm neck and unsuitable iliac artery anatomy.

Reverse slider technique using the Endurant stent graft for accurate proximal sealing in hostile neck endovascular aneurysm repair

This report introduces the reverse slider technique to obtain proximal sealing effectively in endovascular aneurysm repair in short or angulated necks. It is the deployment process of the stent graft main body by repeatedly rotating and reversing the external slider with slight loosening of the suprarenal stent. This method helps obtain accurate placement of the proximal edge and effective sealing on the greater curvature side even in short and angulated necks. It is an effective method of extending the proximal sealing zone. It is gained by changing the deployment process with the Endurant stent graft (Medtronic, Santa Rosa, Calif) as an existing popular device.

Recent Advances and Mid-to-Long Term Results of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysms

Endovascular aneurysm repair (EVAR) has become the standard therapy alongside open surgery repair (OSR) for abdominal aortic aneurysm (AAA) and it is rapidly becoming prevalent. There has been substantial technical progress with respect to EVAR since its introduction. Technical contrivance can be used to manage even inappropriate EVAR cases, including those involving a hostile neck, deficient access route, or aneurysm rupture. However, there are some controversies over reinterventions in relation to long-term outcomes. Although a long-term result has not yet been analyzed in Japan a randomized controlled trial (RCT) held in the West reported that OSR is superior to EVAR for avoiding reinterventions and aneurysm-related death. The RCT involved the use of older devices and proceeded in a different way from the present study; therefore, different results may be obtained for Japanese EVAR outcomes. However, this Western RCT result should be considered as an important warning. Type II endoleak also must be managed in order to improve long term outcomes of EVAR. Efforts to improve both technical methodology and long-term outcomes are necessary to ensure EVAR as a minimally invasive therapy for patients with AAA. (This is a translation of Jpn J Vasc Surg 2018; 27: 405–411.)

Chimney Endovascular Aneurysm Repair Using Endurant Stent-Grafts With Bare Balloon-Expandable Stents for Patients With Juxtarenal Aortic Aneurysms

PURPOSE

To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms.

MATERIALS AND METHODS

Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES.

RESULTS

The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p<0.001 vs preoperative), with an individual mean sac regression of 6.2±5.9 mm. Overall primary chimney stent patency was 100%. One of the 2 cases of intraoperative type Ia endoleak resolved at the 6-month imaging, and no new type Ia endoleaks developed in any cases at follow-up. No additional treatment- or aneurysm-related events were observed.

CONCLUSION

Short-term outcomes of chEVAR using Endurant with uncovered BES have been favorable when covered stents were unavailable, and it can be useful for high-risk patients with juxtarenal aortic aneurysms.