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Fusion Techniques in Advanced Endovascular Repair

The performance of increasingly complex endovascular procedures has prompted a need for more eloquent angiographic imaging at the time of the initial procedure The amount of ionizing radiation and contrast media is directly proportional to the complexity of the procedure. To reduce radiation and contrast dose, the intraoperative use of fusion technologies during endovascular aneurysm repair (EVAR) and fenestrated/branched EVAR (f/b-EVAR) was introduced by the Cleveland…

Management of Type II Endoleaks with Ethylene-Vinyl-Alcohol Copolymer Liquid Embolic Agent

Treatment of abdominal aortic aneurysms (AAAs) has evolved significantly during the last two decades, especially with the broader introduction of endovascular aneurysm repair (EVAR) by Parodi et al. in 1991. However, the Achilles’ heel of EVAR remains the endoleak. Many early type II endoleaks are transient and will resolve spontaneously within 6 months with conservative treatment alone. When a type II endoleak is associated with aneurysm sac…

Bridging Devices in Complex Endovascular Aneurysm Repair

Numerous bridging devices have been used in patients undergoing complex endovascular aneurysm repair (EVAR) with involvement of one or more target vessels. In this chapter we highlight the most common bridging devices and outline their strengths and limitations, as used in the Department of Vascular Surgery at St. Franziskus Hospital Münster, Germany. Stainless Steel Balloon-Expandable Covered Stents The Advanta/i-Cast V12 (Maquet) was designed based on the…

Chimney Thoracic Endovascular Technique

Lesions in the aortic arch or descending aorta can be treated using open or endovascular methods. When the lesion is located close to or involves the supra-aortic branches, treatment becomes more difficult, and hybrid approaches may be necessary. In such cases, debranching must be performed to create an adequate landing zone for the thoracic endograft. The requirement for more than one procedure in hybrid cases makes…

Branched Stent-Grafts in the Aortic Arch

The aortic arch is one of the most anatomically complex segments of the thoracoabdominal aorta because of the plurality of supra-aortic branch configurations and highly variable curvature. Endovascular treatment of aortic arch aneurysms using branched stent-grafts was reported initially by Inoue et al. in 1999. Their device consisted of a unibody graft with up to three limbs that were snared and pulled into each of the aortic…

Thoracic Endovascular Aortic Repair

The treatment of thoracic aortic aneurysms depends on the location of the involved segment. Aneurysms of the ascending aorta and the arch are usually still treated by open repair, although endovascular solutions for these pathologies have been introduced in recent years. Ranging from hybrid procedures to parallel grafts and branched devices, treatment of the more proximal aortic segments will continue to evolve. On the other hand,…

Sandwich Endovascular Technique

The sandwich endovascular technique is an option for the total endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique consists of three major steps: (1) deployment of a thoracic stent-graft in a healthy, nonaneurysmal aortic segment of the thoracic aorta; (2) placement of long, self-expanding covered stents in the involved renovisceral vessels; and (3) deployment of abdominal tube endografts between the long, covered stents and the…

Off-the-Shelf Multibranched Endograft

To overcome the delay of custom manufacturing and to offer an off-the-shelf solution for use in urgent conditions, a new device was designed, the t-branch thoracic endograft. This off-the-shelf device has an introduction delivery system that consists of a 22-French (22F) Flexor introducer sheath (7.3-mm inner diameter [ID] and 8.5-mm outer diameter [OD]) and a Captor hemostatic valve (Cook Medical, Bloomington, Indiana, USA). The system has…

Custom-Made Thoracic Endograft

Thoracic aortic aneurysms, which affect the unbranched descending aortic segment between the subclavian and celiac arteries with accompanying sufficient landing zones, can be repaired by standard devices. However, more advanced forms of repair are required when the aneurysm involves the aortic arch or extends to the visceral or infrarenal aorta. These aneurysms can be repaired by entirely endovascular means only if the stent-graft has a branch…

Sizing of Aortic Endografts in Chimney Technique

In the last decade the endovascular treatment of complex aortic disease was revolutionized with the introduction of the chimney technique, an alternative approach to create an adequate proximal/distal landing zone in the event of an insufficient aneurysm neck. The main issue that determines a successful outcome with the chimney technique is the degree of main endograft oversizing in relation to the parallel grafts. A correct oversizing…

Use of Contrast-Enhanced Ultrasound in Follow-up of Endovascular Aneurysm Repair

Acknowledgment We would like to express our deepest appreciation to Ms. Angelica Pecchioli, who has helped us to coordinate the entire EVAR follow-up since 1999, and who embraced with the same enthusiasm and passion the CEUS project at our Vascular Unit. The optimal protocol for imaging and timing of endovascular aortic aneurysm repair (EVAR) follow-up is still being developed. Various follow-up modalities are employed to measure…

Use of EndoAnchors in Endovascular Treatment of Aneurysms with Short Neck

Endovascular aneurysm repair (EVAR) with standard devices can be challenging in cases with “hostile” aortic necks. Several studies have confirmed a close relationship between proximal neck morphology and complications such as type I endoleak. Most authors define a “hostile neck” as one with marked angulation, short length, complex shape, or the presence of calcification or thrombus. A challenging aortic neck represents one of the most significant…

The Standard Endovascular Aneurysm Repair Procedure

Since the first publication of endovascular aneurysm repair (EVAR) by Volodos et al. and Parodi et al., a remarkable evolution in device design, components, and delivery systems has ushered in the applicability of EVAR to challenging anatomies. The main goals remain the optimization of the apposition of the proximal stent-graft to the aortic wall and the improvement of the system’s ability to track through hostile iliac anatomies, as…

The Percutaneous Approach of Endovascular Aortic Aneurysm Repair

The endovascular treatment of aortic aneurysms is based on stent-graft delivery through the common femoral artery (CFA). The procedure has evolved over the years. Since the development of the percutaneous approach in the late 1990s, several surveys have been performed and have promoted the advantages of this technique. The percutaneous approach was associated with a shorter time to ambulation and fewer complications compared with an open…