The Standard Endovascular Aneurysm Repair Procedure

Procedural Steps

The Endurant stent-graft system (Medtronic, Santa Rosa, California, USA) was designed to overcome anatomic limitations, expanding the EVAR population suitable for endovascular repair. The Endurant device is the primary abdominal endograft for infrarenal abdominal aortic aneurysms (AAAs) in Münster, Germany, centers. The short, proximal M-shaped stents, the absence of a longitudinal bar, and the hydrophilic coating of the delivery system represent notable features of this latest-generation endograft. The device received Conformité Européenne (CE) mark approval in July 2008.

The EVAR procedure consists of five steps:

• 1.

  After bilateral puncture of the common femoral artery, 8-French (8F) sheaths are inserted in each groin with the Seldinger technique; 5000 units of heparin is administered. In addition, bilateral femoral placement of the Prostar system allows percutaneous access and closure (see Chapter 1 ).

• 2.

  The Terumo wire is inserted in the descending aorta and a pigtail catheter advanced over the aortic arch and into the ascending aorta. This is followed by insertion of the Lunderquist double-curved stiff wire into the ascending aorta. The contralateral side will be used for angiography, and therefore a pigtail catheter will be placed at the origin of the renal arteries for administration of contrast.

• 3.

  The bifurcated endograft is evaluated, especially the position of the contralateral limb extracorporeally by fluoroscopy. The main body will be advanced over the Lunderquist wire at the level of the renal arteries. After repeated angiographic scans to identify the exact origin of the lowest renal artery, the endograft is deployed. It is important to minimize the parallax effect of the endograft markers by craniocaudal movement of the C-arm.

• 4.

  The pigtail catheter is removed and the contralateral limb cannulated with a stiff Terumo wire. Alternative catheters for a successful cannulation of the contralateral limb include the Headhunter Shepherd Hook. The next step is testing of the correct position of the pigtail catheter in the endovascular limb of the endoprosthesis. After this, the contralateral limb will be deployed exactly at the iliac bifurcation, preserving the flow to the hypogastric artery.

• 5.

  Lastly, the top cap is removed. After deployment of the limb of the bifurcated endograft is completed, a graduated pigtail catheter is advanced and can be helpful to estimate the exact length of the ipsilateral iliac limb. After this step, the iliac limb is deployed just above the iliac bifurcation.

Procedural Issues