ARTERIAL DILATIVE

MEDTRONIC ENDURANT II

Introduction

Last updated: apr 5, 2023

Over the past 20 years the availability of aortic stent-grafts has allowed a major step change in the management of abdominal aortic aneurysms (AAA). Prior to this open surgical resection, first described by Charles Dubost in 1950, was the mainstay of AAA management. For elective cases open surgical repair has now largely been superseded by the deployment of a covered stent (stent-graft) through minimal surgical access in the common femoral arteries. Over the past few years there have been significant developments in stent-graft technology and an improved understanding of how best to utilise stent-grafts when treating aortic disease. Despite this, their role in the management of a patient with an AAA is still, at times, debatable.

 

Indications

Infrarenal or Juxtarenal Abdominal Aorta of Aorto-Iliac Aneurysm

Proximal Neck:

  • Diameter ranging from 19 to 32 mm
  • Length of ≥ 10 mm
  • Length of ≥ 4 mm and < 10 mm when combined with the Heli-FX EndoAnchor system, with insignificant calcification or thrombus, ≤ 60° infrarenal and ≤ 45° suprarenal angulation, and a vessel diameter approximately 10-20% smaller than the Endurant II/Endurant IIs stent graft diameter.
  • Length of ≥ 15 mm with insignificant calcification or thrombus, ≤ 75° infrarenal and ≤ 60° suprarenal angulation, and a vessel diameter approximately 10-20% smaller than the Endurant II/Endurant IIs stent graft diameter.

Iliac Arteries:
  • Adequate iliac or femoral access morphology
  • Angle between the long axis of the aneurysm and the iliac axis < 60°
  • Iliac lumen diameters ranging from 8 to 25 mm
  • Iliac distal fixation length of ≥ 15 mm

Supplement for Juxtarenal Abdominal Aorta or Aorto-Iliac Aneurysm Using Parallel Graft Technique:
  • Aortic neck diameter ranging from 19 to 30 mm
  • Infrarenal proximal neck length of ≥ 2 mm and total available proximal sealing length > 15 mm with a balloon-expandable covered stent deployed in a parallel graft technique for 1 or 2 renal arteries, with insignificant calcifications or thrombus, ≤ 60° infrarenal, ≤ 45° suprarenal, and ≤ 45° supramesenteric angulation, with an aortic diameter approximately 20-30% smaller than the Endurant II/Endurant IIs stent graft diameter.
  • Adequate brachial or axillary access compatible with vascular access techniques
  • Sufficient renal fixation length
  • Renal take-off angulation < 90° relative to the aorta's centerline

 

Contra indications

Absolute

  • Patients with abdominal aortic or aortoiliac aneurysms having morphology not suitable for endovascular repair
  • Patients with known sensitivities or allergies to nitinol, polyester, polypropylene, gold, PTFE, nylon, or urethane
  • Patients with a systemic infection who may be at increased risk of endovascular graft infection

Relative

 

Pre procedural

  • 2000 mg Kefzol
  • Check anticoagulation
  • Check allergies
  • Imaging and EVAR measurement on wall/monitor
  • Check ordered grafts tents
  • Intravenous line

 

Materials

Essentials

  • Chlorhexidine
  • Standard angiography set
  • Lidocaine 10 ml x 2
  • Bupivacaine 10 ml x 2
  • Contrast
  • Heparinized saline and flushing syringes
  • 6F Introducer x 2
  • 0.035" Terumo Stiff guidewire (260 cm)
  • 0.035" Compatible radiopaque tip 5 F angiographic pigtail catheter
  • 0.035" Lunderquist guidewire (260 cm) x 2
  • 20 ml syringe for integrated balloon inflation
  • Exchange catheters and shaped catheters for contralateral gate cannulation
  • Graftstent including all measured and ordered parts
  • Non-compliant balloons (for leg/limb overlap) Compliant aortic balloon
  • Manta 14F (up to 14F)
  • Manta 18F (15-20F)

Non-Essentials

 

Positioning the patient

  • Head first
  • Supine

 

The procedure in steps

Preparation

  • TOP
  • Imaging and EVAR measurements displayed on monitor
  • Check prostheses
  • Positioning the patient: table tilted cranially, left arm along the body, peripheral pulses monitored
  • Covering according to protocol
  • Pressure tubing connected to syringe pump and flushed

Access:
  • Infiltration with lidocaine and bupivacaine
  • Ultrasound-guided puncture
  • Measure and note Manta (in format x +1)
  • Insert 6F sheaths as needed
  • On the main body side: insert angiography catheter over flexible guidewire (Terumo) to the aortic arch
  • Replace flexible guidewire with stiff guidewire (Lunderquist), marking the length with a sticker on the table
  • Remove angiography catheter
  • On the branch side: insert angiography catheter over flexible guidewire to the level of the renal arteries
  • Remove flexible guidewire, flush with heparin saline, connect to the pump
  • Administer 5000 IU heparin IV
Placement and Deployment of the Graft Body:
  • Adjust arch at the origin of the renal arteries with correct inclination and rotation, with 1-2 magnifications
  • Remove sheath
  • Insert main body just above the renal arteries, orienting with the position marker of the contralateral branch
  • Perform angiography (20cc, 10cc/sec, 3 images/sec)
  • Position and deploy the endograft until the branch is released
  • Potentially reposition the endograft
  • Fully deploy the top by turning the small wheel to avoid misalignment later
Placement of Contralateral Branch Graft:
  • Withdraw angiography catheter to the bifurcation
  • Engage the branch
  • Insert stiff guidewire (Lunderquist)
  • Measure catheter on the wire
  • Set for AII imaging
  • Perform blowback angiography on the branch side
  • Mark the upper limit of AII on the screen
  • Fluoroscopy
  • Measure the branch (from flow divider to marking on screen)
  • Remove sheath
  • Insert thicker sheath
  • Place the branch
  • Retrieve delivery device
Placement of Ipsilateral Branch Graft:
  • Deploy last stents in the ipsilateral branch
  • Retrieve top: slightly elevate the device cranially while rotating counterclockwise, then screw down the top and remove it
  • Insert large sheath
  • Calibrated catheter over stiff guidewire
  • Set for AII imaging
  • Perform blowback angiography at the iliac bifurcation via sheath (fill sheath with 7.5cc/7.5cc and then flush with saline)
  • Mark the iliac bifurcation
  • Measure for the branch
  • Place the branch
  • Retrieve delivery device
  • Completion:
  • Balloon-expand the first covered stent body and both branches over stiff guidewires
  • Perform angiography with syringe pump (20cc, 10cc/sec, 3 images/sec) with aspiration sheaths using two empty 20 cc syringes, long series due to endoleak
Closure:
  • Achieve hemostasis with Manta device as needed
  • Sign Out Procedure

My Image
 

Complications

Endoleaks

  • Occurrence rates of 8-45%
  • 40-67% managed conservatively
  • Aneurysm growth < 5% occurs in 1% of ruptures
  • Two lumbar arteries at the L3 or L4 level or IMA correlate with the risk of endoleak; IMA > lumbar (diameter > 2 mm has a 46-67% chance)
1 2

Sac regression

Sac regression is correlated to improved survival and a reduced rate of secondary interventions and EVAR-related complications. The prognostic significance of sac regression should be considered in surveillance strategies. Intensified surveillance should be applied in patients who fail to achieve sac regression following EVAR.

TLA Technique:

Embolization of the sac versus sac and branches shows no difference in outcomes.
3

Laser-Assisted Transgraft Embolization

Successful embolization was achieved with aneurysmal sac regression demonstrated on 1-year follow-up CT angiography.

Martini Pre-EVAR Embolization Criteria:

  • IMA ≥ 2.5 mm
  • IMA open AND one or more lumbar arteries ≥ 2 mm at origin
  • IMA open and an AAA of aorta AND AIC

  1. O'Connor, P. J., & Lookstein, R. A. (2015, September). Predictive factors for the development of type 2 endoleak following endovascular aneurysm repair. Seminars in interventional radiology. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540615/

  2. Aoki, A., Maruta, K., Hosaka, N., Omoto, T., Masuda, T., & Gokan, T. (2017, December 25). Evaluation and coil embolization of the aortic side branches for prevention of type II endoleak after endovascular repair of abdominal aortic aneurysm. Annals of vascular diseases. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835439/

  3. Yu, H., Al-Roubaie, M., Desai, H., Isaacson, A., & Burke, C. (2017). Comparison of type II endoleak embolizations: Embolization of Endoleak Nidus only versus embolization of endoleak nidus and branch vessels. Journal of Vascular and Interventional Radiology, 28(2). https://doi.org/10.1016/j.jvir.2016.12.1019

 

Post-op

  • 4 hours bedrest
  • 2000 mg Kefzol 8 and 16 h after the procedure

 

Follow-up

Pre-Discharge and Follow-Up Plan

  • Pre-discharge CTA (CT angiography)
  • 6-week follow-up with the operating surgeon, including a CTA, to be discussed in the vascular meeting
  • Annual follow-up CTA
Management of Endoleaks and Complications
  • Type 1 or 3 endoleak on first postoperative CTA → Refer to vascular meeting and plan reintervention
  • Type 2 endoleak without aneurysm growth → Conservative management
  • Type 2 endoleak with aneurysm growth (≥5 mm in 1 year) → Refer to vascular meeting and plan reintervention
  • Target vessel occlusion or stenosis → Refer to vascular meeting
Medication Check and Secondary Prevention
  • Verify if the patient is on antiplatelet therapy or anticoagulation and a statin
  • If not prescribed, initiate:
  • Clopidogrel 75 mg once daily
  • Atorvastatin 40 mg once daily

 

Report

TOP. AB profylaxe. Huiddesinfectie en steriel afdekken. Locale anesthesie met levobupivacaine 0,5% en lidocaine 1%. Beiderzijds echogeleide punctie AFC, meten voor Manta device, plaatsen 7Fr sheaths. 5000E heparine.

Via rechts inbrengen 260 cm Lunderquist via terumo/pigtail waarna inbrengen main body (ESBF-32-14-103). Via links inbrengen angiocatheter. Angiogram en aftekenen nierarteriën. Ontplooien mainbody tot en met contralaterale pootje, controle angiogram, ontplooien top-cap. Aanhaken contralaterale poot vanuit links, controle positie in de endograft door de pigtail te roteren. Inbrengen 260 cm Lunderquist via terumo/pigtail . Blow-back angiogram links en aftekenen AII. Inbrengen contralaterale poot (ETLW-16-16-156), ontplooien waarbij we landen in de AIC net boven de origo AII. Verwijderen delivery device en plaatsen 12Fr sheath.

Verder ontplooien main body tot en met de ipsilaterale poot, ophalen topcap en verwijderen delivery device. Inbrengen 16Fr sheath. Blowback angiogram en aftekenen AII rechts. Inbrengen en ontplooien ipsilaterale poot (ETLW-16-16-156) tot in de AIC net boven de origo AII. Naballoneren.

Controle angiogram: fraaie positie endograft, geen endoleak. Nierarteriën en AII bdz doorgankelijk.

Hemostase met Manta device bdz. SOP.

Conclusie: Uitschakeling AAA percutane EVAR.

 

Literature

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