Two technical tips for severely angulated infrarenal necks during EVAR

This is a short video with two technical tips for the treatment of severely angulated necks with standard EVAR (Endurant, Medtronic) if an open surgical repair is not indicated. The first tip starts with the release of the top cap before the opening of the contralateral gate and the second tip is a solution to pull safely back the top cap if you have a conflict with the suprarenal stent. However, do not forget that this is an outside the IFU implantation of the device.


    June 3, 2018

    Hi Theo,

    very nice case! By what means you judge the pushing-up manoueuvre of the main body once the struts are opened? I’m sure in your hands this reflects experience, but is it not a quite risky step for some less experienced operators?

    I like a lot the move with the contralateral limb, never thought about this! Very smart indeed!!!

    Best, P

    Dr. Theodosios Bisdas
    June 3, 2018

    Thank you, Philippe, for your comment. Of course, you need experience with this maneuver. The trick here is to ‘cram’ the prosthesis into the angulated neck. I have not seen an upward migration yet, but there is sure a risk for this. Thus, you have to do smooth movements and to use some landmarks of the vertebral bodies for your renal arteries. An important issue is also the oversizing in those cases: we recommend at least 30%.

    Nice information and demonstration. If i get it right, the philoshophy of the “pushing-up”maneuver of the mainbody after the top-cap release (and before the contralateral limb release) is to shrink the fabric between the 1st and 2nd covered stent, thereby reducing the distance between these covered stents and aproximating them in order to achieve the optimal position of these within the infrarenal neck length; therefore, you should start pushing-up the whole device just after the deployment of the 1st stent-top cap release and before the deployment of the 2nd covered stent, so that the latter could actually be positioned as close as it gets to the 1st one, leaving perhaps extra place for the third stent etc., isn’t it?
    Regarding the 2nd excellent tip of yours i.e., engagement of cap with suprarenal stent, an alternative maneuver would be to inflate a Relay molding balloon mildly leaving a pathway through which the top cap could withdraw safely without the aforementioned problem.

    Dr. Theodosios Bisdas
    June 3, 2018

    Exactly Stratos! You could not describe it by a better way. The risk of angulated necks is the poor apposition of the proximal stents on the wall. This is a good solution.
    Your suggestion is also good and works fine. I have tried it in the past. The only advantage of my tip is that you win some time because you do not need to remove the sheath of the contralateral extension.
    After implanting the ETLW you do not remove it but you further open the main body. Then, you connect the top cap and you advance the sheath of contralateral extension at the height of the top cap.
    In any case, both work fine.

    Thanks for sharing your tricks.
    For this maniouver I have used as Pr Efstratios comments a Relliant Ballon partially inflated to straight the neck is much us possible, but also using the contralateral limb sistems works, and probably a long big sheat or anything that could make righter the neck could works…
    Anyway for more 70 angulation we should be careful, my option now for this neck is more Aorfix or even Gore with Aptus, more comfortable grafts.
    The battle stentgrafts VS hostile anatomy will be always won by the anatomy at mid-long term!! Also consider that Endurant suprarrenal stent is totally straight, difference with COOK suprarrenal stent, and in cases with severe angulations I have seen total apposition of the suprarrenal stent one half side and the half of the suprarrenal stent free in the aorta without wall contact…
    Best regards

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