Evidence for endovascular aneurysm repair in patients with highly angulated neck anatomy
Patients with highly angulated neck anatomy may account for up to a fifth of all patients treated by endovascular repair. However there is evidence that these patients have worse early and long-term outcomes, including sac expansion. This review explores the evidence supporting the use of endovascular repair in the setting of severe neck angulation, with particular emphasis on new technology with devices that have expanded the anatomical criteria for endovascular aneurysm repair such as the Lombard Aorfix and Medtronic Endurant endografts.
Available from: Moshe Brand
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To describe rapid prototyping or 3-dimensional (3D) printing of aneurysms with complex neck anatomy to facilitate endovascular aneurysm repair (EVAR).
A 75-year-old man had a 6.6-cm infrarenal aortic aneurysm that appeared on computed tomographic angiography to have a sharp neck angulation of ~90°. However, although the computed tomography (CT) data were analyzed using centerline of flow, the true neck length and relations of the ostial origins were difficult to determine. No multidisciplinary consensus could be reached as to which stent-graft to use owing to these borderline features of the neck anatomy. Based on past experience with rapid prototyping technology, a decision was taken to print a model of the aneurysm to aid in visualization of the neck anatomy. The CT data were segmented, processed, and converted into a stereolithographic format representing the lumen as a 3D volume, from which a full-sized replica was printed within 24 hours. The model demonstrated that the neck was adequate for stent-graft repair using the Aorfix device.
Rapid prototyping of aortic aneurysms is feasible and can aid decision making and device delivery. Further work is required to test the value of 3D replicas in planning procedures and their impact on procedure time, radiation dose, and procedure cost.
Available from: PubMed Central
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ABSTRACT: Endovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm. However, hostile proximal aneurysmal neck and tortuosity of access vessels remain challenges in selecting optimal stent-grafts in abdominal aortic aneurysms with difficult anatomy.
A 65-year-old woman complained of intermittent abdominal pain for one week. Computed tomography angiogram demonstrated a tortuous infrarenal abdominal aortic aneurysm with a tapered neck and a 136° of infrarenal angulation. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also showed. Endovascular approach using Endurant stent-graft was attempted at an outside hospital, but failed because of the significant tortuosity of the abdominal aorta and iliac arteries. Since the patient refused to have open aneurysm repair, he was transferred to our hospital for further evaluation and possible EVAR with a different approach. EVAR was performed successfully using Gore Excluder stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA). During the procedure, cannulation of the contralateral limb was unable to be achieved because of the tortuous aortoiliac course. Therefore, a snare was inserted from right radial artery, through the contralateral gate, to grasp the wire from left femoral artery. Two iliac stent-grafts were sequentially deployed with the lower end distal to the opening of the left internal iliac artery. Angiography confirmed complete sealing of the aneurysm with patency of bilateral renal arteries and external iliac arteries. The postoperative courses were uneventful and follow-up computed tomography angiogram at 6 months demonstrated patent bilateral femoral and renal arteries without endoleaks or stent migration.
Although endovascular repair of aortic aneurysm with hostile neck and tortuous access is rather challenging, choosing flexible stent-grafts and suitable techniques is able to achieve an encouraging outcome.
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