Reverse slider technique using the Endurant stent graft for accurate proximal sealing in hostile neck endovascular aneurysm repair Noriyasu Morikage,

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Presentation transcript:

Reverse slider technique using the Endurant stent graft for accurate proximal sealing in hostile neck endovascular aneurysm repair Noriyasu Morikage, MD, PhD, Junichi Nishimura, MD, PhD, Takahiro Mizoguchi, MD, Yuriko Takeuchi, MD, PhD, Takashi Nagase, MD, Makoto Samura, MD, PhD, Takasuke Harada, MD, PhD, Kenichiro Aga, MD, PhD, Munetaka Masuda, MD, PhD, Kimikazu Hamano, MD, PhD Journal of Vascular Surgery Cases and Innovative Techniques Volume 5, Issue 3, Pages 332-337 (September 2019) DOI: 10.1016/j.jvscit.2019.03.012 Copyright © 2019 The Author(s) Terms and Conditions

Fig 1 Movement of the proximal edge of the stent graft. A, If the delivery system touches only one side of the aortic wall in the proximal neck, the other side is kept away from the aortic wall. B, It is difficult to forecast the point at which to touch on the other side when deploying the main body without unfastening the suprarenal stent. C, When the main body and suprarenal stent are expanded slightly and alternately, the top edge of the graft fabric expands to fill the gap in the contralateral side of the aortic wall. D, Performing the reverse slider technique repeatedly will increasingly expand the top edge of the graft fabric. The top edge of the graft fabric on both sides can touch the aortic wall without unfastening the suprarenal stent. Black dashed arrows, Expected point at which to touch the aortic wall on the contralateral side; black arrows, external slider rotating in the right direction; white arrows, backend wheel rotating in the right direction; black-and-white striped arrow, external slider rotating in reverse. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 332-337DOI: (10.1016/j.jvscit.2019.03.012) Copyright © 2019 The Author(s) Terms and Conditions

Fig 2 Deployment of the Endurant stent graft with the reverse slider technique in the angulated neck case (case 1). A and B, Preoperative three-dimensional computed tomography images show a severely angulated neck at 130 degrees with neck length of 25 mm. C, Angiography during the procedure. The Endurant delivery system runs on a shortcut. It touches the lower left renal artery in the lesser curvature side. D, A series of photographs until the suprarenal stent release. The top edge of the graft fabric on the greater curvature side is deployed and kept in the upper position. The open circles indicate the e mark stitched on the graft fabric edge. Each open square indicates the o mark stitched on the contralateral side of the e mark. As the top edge of the graft fabric expands, the e mark on the greater curvature side rises upward to a proximal position. The line between the e and o marks leans upward to the aortic axial. White arrow, right renal artery; black arrow, left renal artery. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 332-337DOI: (10.1016/j.jvscit.2019.03.012) Copyright © 2019 The Author(s) Terms and Conditions

Fig 3 Short and angulated neck (case 2). An 86-year-old man with chronic kidney disease stage 3a. Preoperative three-dimensional computed tomography image (A) and planning schema (B) show short neck under accessory renal arteries (arrows) and severe angulation under the neck. RA, Renal artery. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 332-337DOI: (10.1016/j.jvscit.2019.03.012) Copyright © 2019 The Author(s) Terms and Conditions

Fig 4 Deployment of the Endurant stent graft using the reverse slider technique (case 2). A, After deployment of the first stent, rotate the external slider in reverse, and the top edge of the graft fabric expands slightly. B, Deploy until the second stent, loosen the backend wheel slightly, and the graft fabric edge expands a little more. C, Rotate the external slider in reverse, and the top edge of the graft fabric expands more. D, Deploy until half of the third stent and loosen the backend wheel slightly. E, Rotate the external slider in reverse, and the top edge of the graft fabric expands more and touches the aortic wall upward on the greater curvature side. F, The first and second stents touch the aortic wall completely without unfastening the suprarenal stent. Therefore, the top edge of the graft fabric on the greater curvature side can be placed accurately in the upper position. G, Thereafter, release the suprarenal stent. H, Deploy the rest of the main body slowly using push-up technique so that it tracks with conformability. Journal of Vascular Surgery Cases and Innovative Techniques 2019 5, 332-337DOI: (10.1016/j.jvscit.2019.03.012) Copyright © 2019 The Author(s) Terms and Conditions