Failure modes of thoracic endografts: Prevention and management

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Presentation transcript:

Failure modes of thoracic endografts: Prevention and management W. Anthony Lee, MD Journal of Vascular Surgery Volume 49, Issue 3, Pages 792-799 (March 2009) DOI: 10.1016/j.jvs.2008.12.068 Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 1 Severe aortic tandem tortuosity is partially corrected using a “buddy” dilator inserted over a superstiff Lunderquist guidewire (Cook Medical, Bloomington, Ind) from a contralateral femoral access. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 2 In the transbrachiofemoral wire technique, a guidewire is introduced from the right brachial artery over a long guide catheter or sheath and snared from a femoral approach. The thoracic endograft is advanced over the guidewire, applying firm tension at both ends. The long guide sheath can be used to inject contrast for control angiography during the deployment. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 3 The Valiant thoracic endograft (Medtronic, Santa Rosa, Calif) has a deployment handle that rotates in a counterclockwise manner to unsheathe the endograft. This significantly helps to overcome the high frictional forces required to deploy this endograft using standard pin-pull mechanism. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 4 The crowns of the proximal bare stent of the Valiant thoracic endograft (Medtronic, Santa Rosa, CA) are everted along the inner curve of the arch as the device is pushed against the outer curve by the delivery system. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 5 The tip-capture mechanism of the Relay thoracic endograft (Bolton Medical, Sunrise, Fla). The tips of the proximal bare stent in this device remain constrained (“captured”) until the rest of the endograft is fully deployed. It is released by a separate mechanism as the final step of the deployment sequence. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 6 Left, A partially deployed TAG endograft (W. L. Gore and Assoc, Flagstaff, Ariz) is shown with its proximal end still constrained on the delivery catheter. Right, A 12-mm angioplasty balloon was used to forcibly break the constraining expanded polytetrafluoroethylene suture. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 7 Examples of (A, B) proximal and (C) middle thoracic endograft infolding are shown secondary to excessive oversizing. Note the severe infolding of the proximal segment, which almost bisects the flow lumen into two halves. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 8 Malapposition of an endograft along a tight inner curve of the arch is shown. Note how the device has completely lifted off the aortic wall (yellow dotted line) and can become a source of a type IA endoleak. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 9 The top two panels illustrate selection of an ideal landing zone either (top left) proximal or (top right) distal to the apex of the arch. The bottom panels illustrate deployment near the apex resulting in malapposition of the endograft along the inner curve. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 10 Complete collapse of the TAG endograft (W. L. Gore and Assoc, Flagstaff, Ariz) at the proximal attachment site. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 11 Component separation. Left, At the predischarge computed tomography scan, a three-stent overlap was noted between the proximal and distal components. Middle, At 12-months, the separation has started to occur, leaving only a two-stent overlap. Right, This patient underwent elective revision with a bridging endograft after his 24-month follow-up showed further separation with less than one-stent overlap but without an endoleak. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 12 Longitudinal bar fracture in the first-generation TAG device (W. L. Gore and Assoc, Flagstaff, Ariz). This feature has been eliminated from the subsequent modification of the endograft. Journal of Vascular Surgery 2009 49, 792-799DOI: (10.1016/j.jvs.2008.12.068) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions