Endovascular Aortic Repair (eBook)

Gustavo S. Oderich, MDDirector of Advanced Endovascular Aortic ProgramDepartment of Vascular SurgeryMayo ClinicRochester, MNUSA

Dedication 5
Foreword 6
Preface 7
About the Illustrator 10
Acknowledgements 12
Abbreviations 17
Contents 13
Contributors 19
Part I: Basic Concepts, Mechanisms of Disease and Pre-­operative Planning 23
1: Historical Aspects and Evolution of Fenestrated and Branched Technology 24
Introduction 24
Development of the Zenith Fenestrated Graft 24
Preservation of Normal Anatomy 27
Directional Branches 28
Iliac Branch Device 29
Thoracoabdominal Multibranch Repair 30
Arch Branch Device 34
Dissemination of the Technique 36
References 37
2: Mechanisms of Disease and Natural History 39
Introduction 39
Most Common Types of Thoracic Aortic Pathology 39
Pathophysiology Involved in the Development of Aortic Aneurysm 40
Ascending and Descending Aortic Aneurysm Are Two Different Diseases 46
Thoracic Aortic Aneurysm Is a Genetic Disease 47
Natural History of Thoracic Aortic Disease 50
How Big Is the Normal Aorta? 50
Where Should We Measure the Aorta? 50
Growth Rate of the Thoracic Aorta 52
Risk of Adverse Events 52
Role of Body Surface Area 55
Mechanical Properties of Thoracic Aorta Underlie Its Natural History 55
How Does Aortic Dissection Pick a Particular Time to Occur? 56
Why Do Some Aortic Dissections Occur at Small Sizes? 57
Thoracic Aortic Disease in the Setting of a Bicuspid Aortic Valve 59
Conclusion 60
References 61
3: Genetic Considerations in Patients with Aortic Disease 64
Introduction 64
Prevalence of Genetically Triggered Aortic Disease 64
Marfan Syndrome 65
Mutations 65
Diagnosis 65
Differential Diagnosis 67
Surgical Management 68
Aortic Root 68
Descending Thoracic and Abdominal Aorta 68
Medical Management 68
Vascular Ehlers-Danlos Syndrome 69
Mutations 69
Diagnosis and Clinical Features 70
Major Diagnostic Criteria 70
Minor Diagnostic Criteria 70
Treatment 70
Loeys-Dietz Syndrome 70
Mutations 71
Diagnosis 72
Clinical Features 72
Differential Diagnosis of LDS 72
Treatment 72
Aneurysms-Osteoarthritis Syndrome 72
Arterial Tortuosity Syndrome 72
Familial Thoracic Aortic Aneurysms and Dissections 73
FTAAD Mutations Affecting the TGF? Pathway 73
TGF?R2 Mutations 73
TGF?2 Mutations 73
SMAD3 Mutations 73
FTAAD Mutations Affecting the Smooth Muscle Cell Contractile Apparatus 73
ACTA2 Mutations 73
MYH11 Mutations 74
MYLK Mutations 74
PRKG1 Mutations 74
Familial Abdominal Aortic Aneurysms 74
Endovascular Repair and Genetically Triggered Aortic Diseases 75
Conclusion 76
References 78
4: Normal Aortic Anatomy and Variations of Its Branches 81
Introduction 81
Aorta and Aortic Arch Branches 81
Mesenteric Branches 83
Renal Branches 86
Iliac Branches 87
References 89
5: Classification Systems Relevant to Complex Endovascular Aortic Repair 90
Introduction 90
Types of Repair 90
Fenestrated and Branched Stent Grafts 90
Parallel Stent Grafts 90
Hybrid Endovascular Repair 91
Spectrum of Aortic Disease 92
Atherosclerotic Aneurysms 92
Inflammatory Aneurysms 93
Genetically Triggered Aortic Diseases 93
Classification of Blunt Aortic Traumatic Injuries 93
Classification of Aortic Coarctation 95
Classification of Aortic Aneurysms 95
Ascending Aorta and Arch 95
Descending Thoracic Aneurysms 95
Thoracoabdominal Aortic Aneurysms 95
Abdominal Aortic Aneurysms 96
Iliac Artery Aneurysms 96
Classification of Aortic Dissections 96
DeBakey’s Classification 98
Stanford Classification 98
Aortic Arch Dissections 98
Endovascular Classification Schemes 98
Aortic Arch Type 101
Ishimura Zones of Implantation 102
Society for Vascular Surgery Zones of Implantation 102
Mayo Clinic Endovascular Complex Abdominal Aneurysm Classification 102
Mayo Clinic Supra-celiac Coverage Classification 104
Conclusion 104
References 109
6: Intravascular Ultrasound to Guide Complex Endovascular Aortic Repair 111
Introduction 111
Intravascular Ultrasound 111
Aortic IVUS 112
IVUS and Fenestrated EVAR 112
References 119
7: The Spinal Cord Collateral Network: Implications for Endovascular Aortic Repair 120
Introduction 120
Background 120
Anatomy 120
Pathophysiology 120
The Impact of the Collateral Network on Endovascular Repair 122
References 127
8: Role of Fusion Cone-Beam Computed Tomography Imaging During Complex Aortic Procedures 128
Introduction 128
Cone-Beam Computed Tomography 128
Fusion Imaging 130
Processing of Preoperative CTA 130
Intraoperative Volume Acquisition: CBCT 130
Registration of Preoperative CTA and CBCT 130
Intraoperative Adjustment 130
CBCT for Intra-procedural Evaluation 135
Conclusion 139
References 139
9: 3D Printing to Create Templates for Patient-Specific Fenestrated Stent Grafts 140
Introduction 140
3D Printing Methodology 140
Clinical Implications 143
Concl usion 144
References 145
10: Preoperative Evaluation and Clinical Risk Assessment 146
Introduction 146
General Assessment 146
American Society of Anesthesiology (ASA) Physical Status Classification [21] 147
Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) Comorbidity Score [24] 147
Cardiac Risk Assessment 149
Active Cardiac Conditions 149
Recommendations on Perioperative Cardiovascular Assessment 149
Cardiac Risk Models 150
Revised Cardiac Risk Index [33] 152
The ACS NSQIP MICA [34] 152
ACS NSQIP Surgical Risk Calculator [38] 152
VSG-CRI Scoring System [36] 152
Biomarkers 153
Hypertension 153
Renal Risk Assessment 154
Pulmonary Risk Assessment 155
ARISCAT 156
The Gupta Calculator 156
Diabetes 157
Addendum 157
Medications 157
Conclusion 160
References 160
11: Computed Tomography/Computed Tomography Angiography for Evaluation, Planning, and Surveillance of Complex Endovascular Repair 163
Introduction 163
Imaging Data 163
Scan Parameters 164
Reconstruction 165
Standardized Protocols 168
Special Protocols 168
Low Radiation 168
Low Contrast 168
Intra-arterial Injection 170
Initial Aortic Assessment 170
Analysis of Disease Extent 170
Aneurysm Size Measurements 172
Assessment of Landing Zones 175
Tortuosity 175
Branch Assessment 175
Branch Vessel Geometry 176
Surveillance Protocols 178
Endoleaks 179
Branch Stenosis, Kink, or Occlusion 182
Solid Organ Embolization 182
Component Separations 182
Stent Infolding 182
Progression of Aortic Disease 184
Device Integrity Issues 202
Conclusion 202
Suggested Reading 202
12: Duplex Ultrasound for Evaluation and Surveillance of Fenestrated, Branched, and Parallel Stent-Grafts 203
Introduction 203
Technique 203
Mesenteric Arteries 207
Renal Arteries 211
Contrast-Enhanced Ultrasound 211
Other Issues 212
Median Arcuate Ligament Compression 212
Conclusion 213
References 213
13: Magnetic Resonance Angiography for the Initial Assessment and Follow-Up of Acute Aortic Syndromes 215
Introduction 215
Overview of Magnetic Resonance Angiographic Techniques 215
Acute Aortic Syndromes 217
Normal Anatomical Variants 217
Aortic Dissections 220
Intramural Hematomas 221
Penetrating Atherosclerotic Ulcers 222
Surgical Planning 223
Entry and Re-entry Tears 223
Distance from Branches 223
False Lumen Flow Assessment 223
Branch Involvement, Static Versus Dynamic Obstructions 224
Surveillance 225
Conclusion 225
References 225
Part II: Building Advanced Endovascular Aortic Programs 227
14: Managing Endovascular Inventory 228
Introduction 228
Endovascular Coordinator 228
Space Management 229
Labeling 229
Specific Ancillary Tools 229
Sheaths 230
Catheters and Guide-Catheters 233
Guide-Wires 235
Balloons 235
Stents 236
Aortic Stent-Graft Components 237
Arch Aneurysms 237
Bolton Medical 238
Cook a-Branch and Fenestrated Platform 239
Gore Thoracic Branch Endoprosthesis (TBE) 239
Medtronic Valiant Mona LSA 241
Najuta Next-Gen Fenestrated TEVAR and Innoue Stent 241
Pararenal and Thoracoabdominal Aneurysms 241
Cook Patient-Specific and Off-the-Shelf Fenestrated and Branched Platforms 241
Gore TAMBE® (Thoracoabdominal Multi-Branch Endoprosthesis) 244
Anaconda Fenestrated 244
Jotec Multi-Branch Thoracoabdominal Device 244
Iliac Aneurysms 244
References 244
15: Integration of Clinical Practice, Research, Innovation, and Education 245
Introduction 245
Dr. Roy Greenberg’s Legacy 245
Investing in Education 245
Early Years 245
Identifying Clinical Need 245
Dissemination of Endovascular Education 250
Focus on Durability 250
Impact on Advanced Endovascular Aortic Programs Worldwide 250
References 255
16: Endovascular Training and Learning Curve for Complex Endovascular Procedures 256
Introduction 256
Training Paradigms 256
Credentialing Process 257
Hospital and Surgeon Volume and Outcomes 257
Failure to Rescue 258
Learning Curve 258
Minimally Invasive Cardiovascular Procedures 258
Standard EVAR 260
Complex EVAR 260
Fenestrated and Branched Stent-Grafts 262
Conclusion 265
References 268
17: Regulatory Pathway for Physician-­Sponsored Studies Evaluating Endovascular Aortic Repair 269
Introduction 269
When Is an IDE Needed? 269
Content of an IDE Application 270
How to Apply for an IDE? 272
Common Mistakes Identified During Review of IDEs 273
What It Takes to Run an IDE 273
Overview of Good Clinical Practices 273
What Do We Mean When We Say GCP? 273
The Sponsor-Investigator and Good Clinical Practice 275
Overview of Sponsor-Investigator Roles and Responsibilities 276
Building Quality Into Sponsor-Investigator Clinical Studies of Medical Devices 277
References 279
Resources/Useful Links 279
18: Developing Physician-Sponsored Investigational Device Exemption Protocols 280
References 283
Part III: Techniques of Implantation and Adjunctive Procedures to Minimize Complications 284
19: Principles of Side Branch Incorporation and “Bail Out” Maneuvers 285
Introduction 285
Pre-procedure Planning 285
Alignment of Fenestrations and Fenestrated-Branches 285
Kinks 287
Vessel Perforation or Dissection 288
Endoleaks 291
Infolding of the Aortic Stent 291
Stenotic Target Vessels 293
Stent Dislodgement 293
Preventing Compression of Side Stents 296
Sheath Advancement 296
Crossing Dissection Flaps 296
Suggested Reading 302
20: Strategies to Minimize Risk of Spinal Cord Injury During Complex Endovascular Aortic Repair 303
Introduction 303
Risk Stratification 303
Mechanisms of Injury 303
Spinal Cord Injury Prevention Protocol 305
Staging 305
Blood Pressure Management 306
Cerebrospinal Fluid Drainage 306
Neuromonitoring 307
Limb Perfusion 309
Intra-operative Maneuvers 312
Peri-operative Management 314
Delayed Neurologic Deficit 314
Results 316
References 318
21: Strategies to Minimize Risk of Acute Kidney Injury During Complex Endovascular Aortic Repair 320
Introduction 320
Renal Outcomes After Complex Endovascular Aneurysm Repair 320
Measurement of Renal Function and Acute Kidney Injury 321
Factors Associated with Acute Kidney Injury 321
Preoperative Measures 321
Intraoperative Measures 323
Postoperative Measures 328
Conclusion 328
References 328
22: Anesthetic Considerations for Complex Endovascular Aortic Repair 330
Introduction 330
Anesthetic Considerations 330
Anesthesia Technique and Patient Setup 330
Cerebrospinal Fluid (CSF) Drainage 331
Vascular Access, Hemodynamic and Neurologic Monitoring 331
Radiation Safety 334
Assessing and Managing the Risk for Contrast-­Induced Nephropathy 335
Spinal Cord Protection 335
Strategies to Augment Spinal Cord Perfusion 337
Strategies to Detect and Manage Spinal Cord Ischemia 337
Induced Hypotension for Precise Graft Deployment 337
Rapid Ventricular Pacing 339
Right Atrial Inflow Occlusion 340
Medications 340
Postoperative Considerations 340
Conclusion 341
References 341
23: Techniques of Iliofemoral Conduit for Endovascular Repair 343
Introduction 343
Adjunctive Maneuvers 343
Conduit Selection 344
Surgical Conduits 344
Temporary Iliofemoral Conduits 344
Permanent Iliofemoral Conduits 348
Endovascular Conduits 348
Axillary Artery Conduits 351
Conclusion 351
Suggested Reading 351
Part IV: Visceral Artery Incorporation 353
24: Current Device Designs to Incorporate Visceral Arteries 354
Introduction 354
Visceral Incorporation 354
Patient-Specific Designs 354
Cook Zenith Fenestrated and Branched Stent Graft 354
Vascutek Fenestrated Anaconda Endograft 355
Jotec Extra Design Multibranch Stent Graft 356
Off-the-Shelf Designs 356
Cook p-Branch 356
Cook t-Branch 356
Endologix Ventana 359
WL Gore Thoracoabdominal Branched Endoprosthesis (TAMBE) 359
References 363
25: Selection of Optimal Bridging Stents for Fenestrations and Branches 364
Introduction 364
The Ideal Stent 364
Balloon-Expandable Stents 364
Maquet Atrium iCast or V12 Covered Stent 365
WL Gore Balloon-Expandable Viabahn (VBX) 366
Bentley BeGraft Stent 366
Self-Expandable Stents 367
WL Gore Viabahn Stent Graft 367
Bard Fluency Plus 368
Boston Scientific Wallgraft 370
Bare-Metal Stents 370
Planning and Selection of Bridging Stents 372
Fenestrations 372
Directional Branches 373
Special Scenarios 374
Small Renal Branches 374
Early Bifurcation Lesions 375
Large Target Vessels 375
Intentional Branch Occlusion 376
Conclusion 376
References 379
26: Sizing and Planning Fenestrated and Multibranched Endovascular Repair 380
Introduction 380
Evidence of Disease Progression 380
Suboptimal Necks Yield Suboptimal Results 380
Neck Dimensions Are Not Stable 381
Rescue Procedures for Failed Necks Are Morbid and Less Effective 381
CTA Protocol and Measuring Techniques 383
Selecting the Seal Zone 383
Selecting the Access Site 384
Selecting the Type of Incorporation 384
Selecting Fenestrations Versus Branches 385
Visceral Artery Triangulation 386
Measuring Location of Fenestrations and Branches 388
Graft Tapering 388
Adjuncts to Facilitate Vessel Catheterization 389
Special Scenarios 389
Staged Repairs 389
Chronic Dissections 390
Type I TAAAs 392
Short Distance to Aortic Bifurcation 392
Conclusion 392
References 398
27: Limitations for Branch Incorporation and Implications on Off-the-Shelf Designs 400
Introduction 400
Factors Affecting Design 400
Proximal Extension of Aortic Disease 400
Renal-Mesenteric Arterial Anatomy 401
Aortic Angulation 402
Other Factors 403
Devices 403
Sealing Between the Celiac and Renal Artery Segment 403
Cook p-Branch® Stent-Graft 404
Endologix Ventana® Stent-Graft 406
Sealing in the Supra-Celiac and Thoracic Aortic Segment 407
Cook T-Branch® Stent-Graft 407
Gore Excluder® TAMBE 408
Results 411
Cook p-branch® Stent-Graft 412
Cook t-Branch® Stent-Graft 413
Future Directions 414
References 415
28: Techniques of Implantation of Fenestrated and Multibranched Stent Grafts for Visceral Artery Incorporation 417
Introduction 417
Definitions 417
Anatomical Review 419
Ancillary Tools 419
Perioperative Measures 419
Contrast Use and Radiation Safety 419
Positioning 421
Arterial Access 421
Techniques 425
Patient-Specific Fenestrated Stent-Grafts 426
Patient-Specific Fenestrated and Branched Stent-Grafts 436
Multibranched Stent-Grafts 437
Staging 442
Preloaded Renal Guide Catheters 442
Preloaded Catheters and Guide-Wire Systems 444
Inverted Limb 445
Conclusion 447
Suggested Reading 452
29: Results of Fenestrated, Branched, and Parallel Stent Grafts for Pararenal and Thoracoabdominal Aortic Aneurysms 453
Introduction 453
Open Conventional Repair 453
Endovascular Repair 453
Fenestrated and Branched Stent Grafts 454
Pararenal Aneurysms 454
Type IV Thoracoabdominal Aortic Aneurysms 456
Type I to III Thoracoabdominal Aortic Aneurysms 457
Spinal Cord Injury 458
Bridging Stent Characteristics 458
Late Results 459
Mayo Clinic Experience 461
Parallel Stent Grafts 463
Conclusion 464
References 464
30: Parallel Graft Techniques to Treat Complex Aortic Aneurysms Involving the Renal and Mesenteric Arteries 467
Introduction 467
Preoperative Imaging 467
Surgical Management 468
Preoperative Planning 468
Positioning 468
Arm Access 469
Single or Double Chimney Procedure 469
Renal/Visceral Cannulation and Sheath Advancement 469
Positioning of Main Body Endograft and Chimney Stent Grafts 470
Sequence of Stent Graft Deployment and Balloon Molding 470
Completion of Distal Components 474
Periscope EVAR/TEVAR 474
Femoral Access for Introduction of Main Body Endograft 474
Contralateral Access and Cannulation of Target Visceral Branch(es) 474
Sheath Advancement and Periscope Stent Graft Positioning 474
Sequence of Deployment and Balloon Molding 478
Octopus Off-the-Shelf Branch Repair 478
Chimney Stage 478
SMA Revascularization 478
Contralateral Gate Positioning and Renal Cannulation 482
Infrarenal Completion 482
“Sandwich” Grafts 482
Postoperative Care and Outcomes 482
Complications 484
References 486
31: Hybrid Repair Using Visceral Debranching and Aortic Stent Grafts to Treat Complex Aortic Aneurysms 487
Introduction 487
Rationale 487
Preoperative Evaluation 487
Clinical Risk Assessment 487
Aortic Imaging and Planning 488
Techniques 489
Exposure 489
Graft Selection and Preparation 491
Proximal Anastomosis 491
Distal Renal and Mesenteric Anastomosis 492
Results 495
Single-Center Experiences 495
Systematic Reviews 495
North American Complex Abdominal Aortic Debranching (NACAAD) Registry 496
Conclusion 500
References 500
Part V: Arch Branch Incorporation 502
32: Current Device Designs to Incorporate Supra-aortic Arch Trunks for Endovascular Repair 503
Introduction 503
Arch Anatomy Requirements 503
Historical Perspective 503
Kawasumi Najuta Fenestrated Endograft 504
Cook Medical 504
Fenestrated Stent Grafts 504
Inner Branches 505
WL Gore Thoracic Branch Endoprosthesis (TBE) 505
Medtronic Mona LSA 506
Bolton Relay Plus Thoracic Arch System 506
Frozen Elephant Trunk Devices 506
References 507
33: Technical Aspects and Results of Branched Endografts for Repair of Aortic Arch Aneurysms 509
Introduction 509
Important Considerations for Endovascular Arch Repair 509
Seal Zone 509
Device Durability 509
Aortic Valve 510
Device Alignment 510
Stroke 510
Mortality 510
Endograft Design 510
Scalloped and Fenestrated Endografts 510
Branched Endografts 510
A-Branch Stent-Graft (Cook Medical) 511
Patient Selection 513
Technique 513
Preparation and Setup 513
Subclavian Artery Revascularization 513
Arterial Access 514
Establishing the Delivery Platform 514
Delivery and Deployment of the Branched Stent-Graft 514
Innominate Artery Bridging Stent 515
Left Common Carotid Artery Bridging Stent 518
Distal Thoracic Extension 518
Special Situations 518
Through-and-Through Wire Technique 518
Modified “Bullet” Nose Tip 519
Thoracic Branch Endoprosthesis® (WL Gore, Flagstaff, AZ) 519
Zone 2 TBE® Implantation Steps 519
Zone 0 TBE® Implantation Steps 527
Early Results 527
References 531
34: Techniques and Results of Endovascular In Situ Arch Fenestrations 532
Introduction 532
Development of In Situ Arch Fenestrations in TEVAR 532
Pathology 532
Anatomic Limitations and Patient Selection 533
Needle Versus Laser In Situ Arch Fenestration 534
Technique 534
Establishing Access 535
Creating the In Situ Fenestration 535
Passage of Guidewire 535
Angioplasty and Stenting 537
Completion Angiogram 537
Complex In Situ Arch Fenestration of the Left Common Carotid 537
Application of New Technologies 539
Outcomes of In Situ Laser Fenestration 539
Conclusion 542
References 542
35: Parallel Stent Graft Techniques to Facilitate Endovascular Repair in the Aortic Arch 543
Introduction 543
Basic Principles 544
Techniques 544
Zone 2 Deployment 544
Zone 1 Deployment 546
Zone 0 Deployment 551
Conclusion 553
References 553
36: Techniques and Results of Aortic Arch Hybrid Repair 555
Introduction 555
Anatomy and Patient Selection 555
Distal Arch Debranching 556
Left Subclavian Artery Revascularization 556
Left Common Carotid Artery Revascularization 557
Proximal Arch Debranching 560
Frozen Elephant Trunk 563
Results 564
References 566
37: Techniques and Results of Hybrid Arch Replacement with Elephant Trunk 567
Introduction 567
Technique 567
Results 568
Modification for Acute Type I Aortic Dissection 571
References 575
Part VI: Internal Iliac Artery Branch Stent-Grafts 576
38: Iliac Branch Device Designs 577
Introduction 577
Device Designs 577
Cook Medical 577
Straight and Helical Branch Devices 578
Bi-Branch Bifurcated-Bifurcated Device 578
Gore Excluder Iliac Branch Endoprosthesis (IBE) 579
Jotec E-liac Stent Graft System 579
39: Preoperative Planning and Sizing for Iliac Branch Devices 581
Introduction 581
CTA Imaging 581
Anatomic Considerations 581
Cook Iliac Branched Devices 581
Gore Excluder Iliac Branch Endoprosthesis 583
Jotec E-liac Branch Stent Graft 583
Pitfalls and Anatomical Challenges 583
Ostial Disease 583
Short Length 584
Narrow Diameter 584
Internal Iliac Artery Aneurysm 584
Dissections 585
Saccular Aneurysms 585
Bilateral Aneurysms 588
Suggested Reading 591
40: Techniques of Endovascular Repair of Aorto-Iliac Aneurysms Using Iliac Branch Devices 592
Introduction 592
Rationale 592
Design Options 592
Ancillary Tools 593
Technique 593
Access 593
Straight and Helical IBDs 594
BB-IBD 595
Gore Excluder IBE 601
Bilateral Aneurysms 605
Internal Iliac Aneurysms 607
Concomitant Fenestrated and Branched Stent-Graft Repair 607
Prior Bifurcated Aortic Stents 607
Common Problems and “Bail Out” Maneuvers 607
Pseudo-Occlusion of the Internal Iliac Artery 607
Difficult Catheterization of the Internal Iliac Artery 609
Kinks 610
Branch Occlusion 610
Perforations and Dissections 612
Integrity Issues 615
Results 615
Lessons Learned 617
Future Considerations 618
Conclusion 619
References 619
41: Results of Iliac Branch Stent-Grafts 620
Introduction 620
Anatomical Feasibility 620
Results of Commercially Available IBGs 621
Indications 621
Technical Success 621
Early Outcomes 621
Mid-Term and Late Outcomes 626
The Perugia Experience 632
Physician-Modified IBGs 633
Results for Bilateral Iliac Aneurysms 634
Conclusion 634
References 635
42: Technical Aspects and Results of Hybrid Iliac Revascularization 638
Introduction 638
Indications 638
Technique 638
Aneurysmal Internal Iliac Artery 640
Iliofemoral Conduit with Internal Iliac Reconstruction 643
External to Internal Iliac Stents with Femoral Crossover Graft 644
Results 645
References 646
43: Off-Label Use of Aortic Devices and Parallel Stent Grafts for Iliac Revascularization 647
Introduction 647
The Perimeter Method for Sizing 648
The Minimum Combined Length of the Perimeters of the Parallel Extensions 649
The Length of the Segment of Apposition Between the Parallel Extensions 649
Possible Shapes 651
The Effect of Angioplasty 653
Conclusion 654
References 657
Part VII: Physician-Modified Endovascular Stent-Grafts 658
44: Clinical Applications and Regulatory Issues for Physician-Modified Endovascular Grafts (PMEGs) 659
Introduction 659
Obtaining an IDE 659
Conducting an IDE Clinical Trial 660
Patient Selection for PMEG 663
Conclusion 664
References 664
45: Techniques of Physician-Modified Endovascular Grafts (PMEGs) for Incorporation of Renal Mesenteric Arteries 665
Introduction 665
Indications 665
Ancillary Tools 665
Preoperative Planning 665
Stent Graft Design 665
Stent Graft Modifications 666
Reinforced Fenestrations 667
Mini-Cuff Reinforced Fenestration 667
Directional Branches 667
Diameter-Reducing Wire 667
Preloaded Guidewires 667
Re-sheathing 667
Orientation Markers 668
Modified Bifurcated Stent Graft 668
Perioperative Measures 668
Techniques of Implantation 669
Four-Vessel Fenestrated Stent Graft 669
Combination of Directional Branches and Fenestrations 670
Mini-Cuffs 672
Preloaded System 672
Postoperative Management 681
Suggested Reading 682
Part VIII: Complications of Complex Endovascular Aortic Repair 683
46: Thromboembolic Complications During Endovascular Repair of Complex Aortic Aneurysms 684
Introduction 684
Clinical Implications 684
Risk Stratification 684
Aortic Wall Thrombus Assessment 684
Study Patients 689
Clinical Events 689
Cases Examples 693
Case 1 693
Case 2 694
Case 3 695
Case 4 697
Conclusion 697
References 699
47: Spinal Cord Injury Prevention and Management 702
Introduction 702
SCI Following Endovascular Aortic Repair 702
Spinal Perfusion 703
Risk Reduction and SCI Management Strategies 703
Current Strategies 708
Preoperative 708
Intraoperatively 708
Postoperatively 710
Conclusion 710
References 710
48: Renal Function Deterioration in Complex Aortic Repair 713
Introduction 713
Definitions and Classification 713
Pathogenesis and Etiology 716
Risk Factors 718
Comparing Different Strategies 719
Renal Protection 720
Conclusion 721
References 722
49: Late Branch-Related Complications and Management 724
Introduction 724
Branch-Related Outcomes 724
Classification of Branch Complications 727
Endoleak 727
Case 1 727
Case 2 727
Case 3 729
Case 4 729
Occlusion and Stenosis 729
Case 5 729
Case 6 729
Case 7 730
Case 8 730
Case 9 732
Case 10 732
Case 11 732
Conclusion 732
References 734
Index 735