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Toshifumi Kudo, MD, PhD, Kenneth K. Kao, BA, Scott D

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1 Laparoscopic aortic reinforcement and endovascular graft placement in swine: A new external wrap 
Toshifumi Kudo, MD, PhD, Kenneth K. Kao, BA, Scott D. Nelson, MD, Todd D. Reil, MD, Bradley T. Haas, Samuel S. Ahn, MD  Journal of Vascular Surgery  Volume 41, Issue 6, Pages (June 2005) DOI: /j.jvs Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

2 Fig 1 An external aortic wrap (Aneuwrap). A, The Aneuwrap is made of two nylon cable-tie straps (102 mm in length, 3 mm in width, and 1 mm in depth) and Dacron fabric (38 or 44 mm in circumaortic length, 20 mm in width). The strap has a tooth and pawl design and a buckle (open arrow) for maximum engagement and fine adjustment. A stainless steel radio-opaque wire at each edge of the Dacron fabric is placed between the fabric and the strap and is slightly seen in between them (arrowheads). B, The Aneuwrap is positioned in a collapsed form (arrow) in the delivery system, which is a plastic cylinder (10 mm in outer diameter, 25 cm in length) that could be inserted through a trocar. One centimeter of straps (arrowhead) tied in parallel with a silk tie remains outside of the tube. A plunger (open arrow) is placed behind the Aneuwrap. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

3 Fig 2 Laparoscopic view of Aneuwrap placement surgery with retroperitoneal approach. A, Approximately 2-cm of the infrarenal aorta was dissected circumferentially. The bilateral renal arteries (arrow) and the lumbar arteries (arrowheads) were identified and preserved. (The right renal artery is not seen in the figure.) B, The Aneuwrap was inserted within a delivery system (star) via a trocar. The straps (arrow) were then pushed out posterior to the aorta. C, A right-angle grasper (arrow) picked up and guided the straps (arrowheads) on the posterior surface of the aorta. D, The Aneuwrap (arrows) was completely pushed out of the delivery system, self-expanded from its collapsed form, and was placed around the aorta. E, Each of the two straps (arrow) was fed into their respective buckles (arrowhead). F, Both straps were pulled tight, and each strap was fine tuned and locked. The excess strapping was cut at the buckles (arrows) using endoshears. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

4 Fig 3 Aortogram 1 week after the Aneuwrap implantation. A, Two radio-opaque wire bands (arrows) are shown demarcating the proximal and distal ends of the Aneuwrap just below the renal arteries. B, Aortogram after stent-graft placement. Note that there is no increase in the aortic diameter at the wrapped segment, (arrow) in contrast to slight increase of the aortic diameter below the Aneuwrap (arrowheads) in response to balloon angioplasty. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

5 Fig 4 A specimen of the aorta 5 weeks after the Aneuwrap implantation and 4 weeks after the stent-graft placement. A, Gross examination shows the Aneuwrap (arrows) is totally incorporated into the adventitia with quite extensive fibrosis around it. The stent-graft inside is expanding against the aortic wall distal to the Aneuwrap. B, The stent-graft is well incorporated into the intima. The Aneuwrap (arrows) is covered with fibrous tissue. C, Histologic examination of sections taken from beneath the Aneuwrap reveals band-like necrosis in the media and the adventitia, as evidenced by the lack of nuclear staining in the middle and left portion. The intima is viable with dark staining nuclei present (intima present at lower right portion) (hematoxylin-eosin, original magnification ×200.) D, Sections taken from directly beneath the Aneuwrap show the intima, media, and adventitia layers with focal calcification (arrow) and no signs of necrosis (lumen at lower left) (hematoxylin-eosin, original magnification ×100.) Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

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