Relining Of Infrarenal Stent-graft With Preloaded Modified Gore Excluder For Occult Endoleak With Sac Expansion
Aleem K. Mirza, MD, Jesse Manunga, MD
Minneapolis Heart Institute, Minneapolis, MN, USA.
Introduction Endoleaks remain one of the most common indications for reintervention after endovascular aortic repair (EVAR). Occasionally, aneurysm sac expansion occurs in the absence of visible endoleak or due to endotension. We desbribe a case of continued sac expansion without an identifiable endoleak after EVAR. Case presentation A 86-year old male presented with continued aneurysm sac expansion after prior EVAR with occlusion of the right hypogastric artery for a 5.5-cm infrarenal aneurysm. He subsequently required inferior mesenteric artery embolization for type II endoleak with sac growth. The aneurysm continued to expand despite absence of any endoleak on multiple delayed-phase computed tomography angiography (CTA) and transfemoral arteriograms. On most recent presentation, it had expanded to 10.4cm with an 7-mm increase over a 6-month period. We elected to re-line the stent-graft with a Gore Excluder to treat a likely occult endoleak/endotension. There were several technical challenges, including the distance from the lowest renal artery to the flow divider, and the metal artifact that would hinder contralateral gate cannulation. We utilized a previously reported technique of partial extracorporeal device deployment to overcome these challenges. A 22-F sheath was positioned at the level of the renal arteries. A 31-mm Gore Excluder was partially advanced in to the sheath with the contralateral gate still external. The first trigger wire was released, deploying the distal 3-cm of the gate outside the sheath. The gate was cut by 2-cm, shortening the renal-gate distance to 6-cm. A 5F sheath was placed into the contralateral gate, facilitating passage of a 0.018 preloaded wire. The 5F sheath was withdrawn, and the stent-graft was advanced with the preloaded wire to the lowest renal artery. The large sheath was withdrawn over the stent-graft to deploy the device. The “snare-ride” technique was then used, as previously reported to cannulate the gate easily, in the presence of significant metal artifact. Iliac limbs were used to raise the bifurcation. Completion angiogram showed no endoleak and the aneurysm measured 5.3-cm at one month follow-up. Conclusions Preloading the contralateral gate during EVAR has multiple applications, including re-lining of a prior stent-graft where metal artifact makes visualization challenging. This technique also allows for shortening of the contralateral gate with short distances between the renal arteries and the flow divider.
Back to 2021 Abstracts