Endovascular Abdominal Aortic Aneurysm Repair with on Excluder for Proximal Neck Angulation / 日本心臓血管外科学会雑誌

ABSTRACT

The results of endovascular abdominal aortic aneurysm repair (EVAR) for severe neck angulation with an Excluder were evaluated. We performed EVAR in 51 patients, using an Excluder, from September 2007 to September 2011. The angle between proximal neck and the aneurysm (Angle) was less than 61° in 31 patients (Group I), 61-90° in 13 patients (Group II) and more than 90° in 7 patients (Group III). In Groups I and II, the angled proximal neck was straightened with a stiff guide wire and a Trunkipsilateral device was deployed slowly (aortic modification technique). In Group III, the device modification technique was applied. In this technique, the stiff guide wire was inserted in the aortic root. The Trunkipsilateral device was bent to the contra lateral limb side and was inserted into the aorta. The stiff guide wire was pushed in with a fulcrum at the aortic valve. This procedure resulted in bending of the wire and the trunk-ipsilteral device became parallel to the proximal neck. The renal artery position was confirmed on angiographys and the main body was deployed slowly. We performed angiography after planned device deployment to evaluated Type Ia endoleak, and if it was observed, an additional procedure such as Aortic Extender or Palmaz XL stent deployment was performed and the Type Ia endoleak was evaluated during the procedure by completion angiography. The Angle change was measured by enhanced CT at 7 days and 6 month after EVAR. The Angle were 97-137° in Group III. The frequency of Type Ia endoleak after planned device deployment (35% in Group I, 55% in Group II and 17% in Group III), additional procedure for Type Ia endoleak (29% in Group I, 23% in Group II and 14% in Group III) and Type Ia endoleak by completion angiography (0% in Group I, 8% in Group II and 14% in Group III) did not differ significantly between the 3 groups. When Group I was sub divided into those with Angle less than 41° (Group Ia, 15 patients) and those with an Angle from 41 to 60° (Group Ib, 16 patients), Type Ia endoleak after planned device deployment (18% in Group Ia, 63% in Group Ib) was significantly more frequent in Group Ib and the additional procedure for Type Ia endoleak (7% in Group Ia, 50% in Group Ib) was more frequent in Group Ib. The Angle significantly decreased 7 days after EVAR and did not change thereafter in all 3 groups. EVAR with an Excluder for severe neck angulation was feasible by device modification with the bending technique. This technique might be useful for patients with an Angle of more than 41°.