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Napkin Ring Technique-Off The Shelf Endovascular Approach To Complex Aortic Repair
Nicholas Russo, MD, Tigran Divanyan, MD, Jeffrey Hnath, MD, R Clement Darling III, MD.
Albany Medical Center / Albany Medical College, Albany, NY, USA.

OBJECTIVES: Aortic neck anatomy outside the indications for use (IFU) in high-risk aneurysm patients is a difficult clinical situation. Symptomatic patients often cannot wait for custom device manufacturing and asymptomatic patients may not be anatomically suitable for fenestrated devices. The napkin ring technique is an alternative repair utilizing off the shelf components for endovascular repair of abdominal aortic aneurysms. METHODS: A retrospective review of a single prospectively maintained vascular groupís database was queried for all endovascular repairs of infrarenal aortic aneurysms performed with napkin ring technique from January 2017 to October 2019. A standard aortic cuff is deployed 2-3 cm beneath the renal arteries. A thoracic endograft is deployed through the cuff and allowed to flower proximally to seal the neck while the distal end is constrained for docking a standard bifurcated infra-renal device. Then standard endovascular infra-renal repair is completed. RESULTS: 12 patients were identified; 83% male (10/12), mean age 76 (58-94 years). 67% (8/12) symptomatic, 33% (4/12) were elective but outside IFU for fenestrated. Risk factors: hypertension 92% (11/12), diabetes 33% (4/12), coronary disease 75% (9/12), tobacco 67% (8/12), COPD 67% (8/12), hyperlipidemia 75% (9/12), renal insufficiency 8% (1/12), cancer 33% (4/12), congestive heart failure 42% (5/12). Mean abdominal aortic aneurysm size 6.15cm (5-7.8cm). Estimated blood loss 133mL (50-500mL), fluoroscopy time 20.6 minutes (10-54 min), contrast 133mL (50-235mL), operative time 107 minutes (53-238mins), ASA classification 3.5 (3-4 ASA), 17% (2/12) required ICU post-operatively, 100% (12/12) of cases were technically successful, without type 1 endoleak at the completion of the case. 1 required trans-lumbar coil embolization at 3 months for a persistent type 2 endoleak, and 1 required endograft explantation. 30 day mortality was 83% (10/12) with 2 patients lost to follow-up. Median follow up time 5.5 months (1-27 months). Median survival post-op was 8 months (1-33 months). 42% (5/12) were confirmed to be deceased at most recent review. CONCLUSIONS: Endovascular technology is rapidly evolving, however symptomatic and poor anatomy patients have limited options. The Napkin Ring technique offers a viable off the shelf alternative for abdominal aortic aneurysm repair.


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