Jasper W. van Keulen, MD, Frans L. Moll, MD, PhD, Joost A

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Presentation transcript:

Tips and techniques for optimal stent graft placement in angulated aneurysm necks Jasper W. van Keulen, MD, Frans L. Moll, MD, PhD, Joost A. van Herwaarden, MD, PhD Journal of Vascular Surgery Volume 52, Issue 4, Pages 1081-1086 (October 2010) DOI: 10.1016/j.jvs.2010.02.024 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 The yellow lines in the aneurysm neck are lumen lines. The center lumen line is projected in the middle, a lumen line in the inner curvature of the aneurysm neck is on the right, and a lumen line in the outer curvature of the neck is on the left. The center lumen line length indicates the true length of the neck, but will probably not be the functional neck. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 A, A symmetrically deployed stent graft is shown in a straight aneurysm neck. B, An example of an asymmetrically positioned stent graft is shown in an angulated aneurysm neck. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 This is an enlargement of the aneurysm neck that is shown in Fig 2, B. The stent graft is placed asymmetrically compared with the aneurysm neck. The asymmetric placement of stent grafts may have serious consequences. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 Drawings show the consequences of asymmetric stent graft placement. The radius/diameter of a plane not perpendicular to aorta increases the more oblique it is placed to the perpendicular plane, thereby influencing the degree of oversizing. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 The green lines are expected guidewire routes. Left, A guidewire is introduced in the right groin. Right, A guidewire is introduced in the left groin. The access site for the guidewire influences the route of the guidewire. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 6 Inaccurate positioning of the C-arm underestimates the length of the abdominal aortic aneurysm (AAA) neck. Panel 1, A neutral position of the C-arm is shown in the images on the top. Although the stent graft position seems visually right, the stent graft position is suboptimal, and the entire neck is not used for stent graft fixation and sealing. Panel 2, A C-arm position orthogonal to the aortic angulation (cranial-caudally angulated) is shown. The entire AAA neck is used. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 7 Inaccurate positioning of the C-arm underestimates the length of the abdominal aortic aneurysm (AAA) neck. Panel 1, A C-arm position in neutral position is shown. Again, the stent graft position seems visually optimal. Panel 2, Lateral angulation of the C-arm provides a view orthogonal to the clock position of the renal arteries. This view allows the entire use of the AAA neck for stent graft fixation and sealing. Journal of Vascular Surgery 2010 52, 1081-1086DOI: (10.1016/j.jvs.2010.02.024) Copyright © 2010 Society for Vascular Surgery Terms and Conditions