Endovascular Repair of Abdominal Aortic Aneurysms
Current Status and Future Directions
John A. Kaufman1,2,
Stuart C. Geller1,
David C. Brewster3,
Chieh-Min Fan1,
Richard P. Cambria3,
Glenn M. LaMuraglia3,
Jonathan P. Gertler3,
William M. Abbott3 and
Arthur C. Waltman1
1
Division of Vascular Radiology, Massachusetts General Hospital, Fruit St.,
Boston, MA 02114.
2
Present address: Dotter Interventional Institute, Oregon Health Sciences
University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97201-3011.
3
Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA
02114.
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Alfred Gray 16th President of ARRS 1915-1916
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Augustus W. Crane 17th President of ARRS 1916-1917
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Fig. 1. —73-year-old man with atherosclerotic abdominal aortic aneurysm.
Coronal maximum intensity projection of contrast-enhanced helical CT angiogram
shows infrarenal abdominal aortic aneurysm. Aneurysm starts well below renal
arteries (curved arrows) and ends at aortic bifurcation. True size of
abdominal aortic aneurysm is indicated by calcification in wall of aorta
(straight arrows) because mural thrombus deposited in abdominal
aortic aneurysm sac results in smaller opacified lumen.
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Fig. 2A. —Surgical repair of abdominal aortic aneurysm. (Reprinted with
permission from [100])
Drawing shows exposure of abdominal aortic aneurysm from anterior approach.
Dashed lines indicate site of incision in sac. Inferior mesenteric artery
(arrow) arises from anterior surface of abdominal aortic
aneurysm.
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Fig. 2B. —Surgical repair of abdominal aortic aneurysm. (Reprinted with
permission from [100])
Drawing shows abdominal aortic aneurysm has been opened and thrombus removed.
Orifices of lumbar arteries (arrow) are oversown to prevent
back-bleeding into sac.
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Fig. 2C. —Surgical repair of abdominal aortic aneurysm. (Reprinted with
permission from [100])
Drawing shows graft material is sutured (arrow) to normal artery
above and below abdominal aortic aneurysm.
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Fig. 3A. —Photographs of sample stent-graft. In this device (AneuRx;
Medtronic, Minneapolis, MN) nitinol metal is outside of graft material.
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Fig. 3B. —Photographs of sample stent-graft. Partially deployed stent-graft.
Constrained device is delivered into body from remote access over guidewire,
after which stent-graft is allowed to reexpand.
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Fig. 4A. —Two commercially available stent-grafts. Photograph of one-piece
bifurcated stent-graft (Ancure; Guidant, Indianapolis, IN). Supporting metal
stents are located inside graft material at ends of device. Note exposed metal
attachment hooks (straight arrows). Radioopaque marker bands
(curved arrow) are visible on surface of graft. (Courtesy of
Guidant)
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Fig. 4B. —Two commercially available stent-grafts. Radiograph of 71-year-old
man with abdominal aortic aneurysm with implanted bifurcated stent-graft
(Ancure; Guidant) shows supporting metal localized to attachment sites
(straight arrows). Location of graft material is indicated by
radioopaque marker bands (curved arrow).
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Fig. 4C. —Two commercially available stent-grafts. Photograph of modular
bifurcated stent-graft (AneuRx; Medtronic, Minneapolis, MN). When assembled,
modular components telescope with sufficient overlap to form hemostatic seal
between components. (Courtesy of Medtronic)
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Fig. 4D. —Two commercially available stent-grafts. Radiograph of 76-year-old
man with abdominal aortic aneurysm with implanted bifurcated stent-graft
(AneuRx; Medtronic). Metal supports entire device.
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Fig. 4E. —Two commercially available stent-grafts. Digital subtraction
angiogram of 74-year-old man shows infrarenal abdominal aortic aneurysm
(arrows).
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Fig. 4F. —Two commercially available stent-grafts. Digital subtraction
angiogram of same patient as E immediately after placement of
bifurcated stent-graft (arrows) shows exclusion of aneurysm.
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Fig. 5A. —Drawings of basic configurations of stent-grafts. Tube
stent-graft.
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Fig. 5B. —Drawings of basic configurations of stent-grafts. Bifurcated
stent-graft.
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Fig. 5C. —Drawings of basic configurations of stent-grafts. Tapered
aortounilateral external iliac artery stent-graft with occluder (solid
straight arrow) in contralateral common iliac artery, embolization coils
in ipsilateral internal iliac artery (open arrow), and surgical
femoral-to-femoral cross-over graft (solid curved arrow). Occluder
and coils prevent retrograde perfusion of aneurysm sac.
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Fig. 6. —Digital subtraction angiogram in 77-year-old man using graduated
pigtail catheter (arrow) shows multiple renal arteries (severe
stenosis in upper right accessory artery) with approximately 4 cm of normal
aorta between lowest renal arteries and aneurysm. Note slight angle between
long axis of normal aorta and aneurysm.
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Fig. 7A. —73-year-old man with abdominal aortic aneurysm and right common
iliac artery aneurysm. Conventional angiogram shows abdominal aortic aneurysm
and right common iliac aneurysm (arrow). Bifurcated stent-graft will
be placed, but it must extend into external iliac artery on right to effect
adequate seal.
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Fig. 7B. —73-year-old man with abdominal aortic aneurysm and right common
iliac artery aneurysm. Angiogram obtained after insertion of bifurcated
stent-graft. Coils were placed in right internal iliac artery (straight
arrow) before insertion of stent-graft to prevent retrograde flow into
common iliac artery aneurysm. Stent-graft extends into external iliac artery
on right (curved arrow). Note patent left internal iliac artery.
(Reprinted with permission from
[101])
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Fig. 8. —Angiogram of 83-year-old man with type I endoleak shows large distal
attachment endoleak (straight arrow) after placement of tube
stent-graft. Note lumbar arteries (curved arrows) providing outflow
for endoleak.
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Fig. 9A. —71-year-old man with type II endoleak. Axial contrast-enhanced CT
scan after placement of bifurcated stent-graft shows opacified inferior
mesenteric artery (open arrow) and contrast material in sac
(solid arrows) outside of stent-graft limbs flowing toward pair of
lumbar arteries.
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Fig. 9B. —71-year-old man with type II endoleak. Late image obtained from
digital subtraction angiogram after superior mesenteric artery injection
confirms retrograde flow from inferior mesenteric artery into aneurysm sac
(arrow) as source of inflow for type II endoleak.
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Fig. 10A. —Large proximal type I endoleak in 75-year-old man.
Shaded—surface display contrast-enhanced CT scan shows severe angulation
between infrarenal aorta (arrow) and aneurysm sac.
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Fig. 10B. —Large proximal type I endoleak in 75-year-old man. Angiogram after
placement of custom stent-graft shows huge proximal attachment leak
(arrow) due to inadequate seal.
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Fig. 11A. —Shrinking abdominal aortic aneurysm in 74-year-old man after
treatment with bifurcated stent-graft. Pretreatment axial contrast-enhanced CT
scan shows abdominal aortic aneurysm (arrows).
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Fig. 11B. —Shrinking abdominal aortic aneurysm in 74-year-old man after
treatment with bifurcated stent-graft. Axial contrast-enhanced CT scan
obtained shortly after placement of bifurcated stent-graft shows no evidence
of endoleak. Abdominal aortic aneurysm (arrows) is unchanged.
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Fig. 11C. —Shrinking abdominal aortic aneurysm in 74-year-old man after
treatment with bifurcated stent-graft. Axial contrast-enhanced CT scan
obtained 12 months later shows marked reduction in diameter of abdominal
aortic aneurysm (arrows).
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Fig. 12A. —Delayed rupture of abdominal aortic aneurysm after treatment with
stent-graft in 83-year-old man. Unenhanced axial CT scan shows abdominal
aortic aneurysm 2 years after treatment with tube stent-graft. No endoleak was
present on contrast-enhanced study (not shown).
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Fig. 12B. —Delayed rupture of abdominal aortic aneurysm after treatment with
stent-graft in 83-year-old man. Unenhanced axial CT scan obtained at same
level as A 3 years after treatment. Note decrease in size of abdominal
aortic aneurysm. No endoleak was present on contrast-enhanced study (not
shown).
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Fig. 12C. —Delayed rupture of abdominal aortic aneurysm after treatment with
stent-graft in 83-year-old man. Axial unenhanced CT scan obtained
approximately 6 weeks after B shows reexpansion and rupture
(arrow) of abdominal aortic aneurysm. Detachment of distal attachment
site was found at surgery.
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Fig. 13A. —Change in graft morphology with decrease in aneurysm size in
74-year-old man. Axial contrast-enhanced CT scan obtained shortly after
placement of bifurcated stent-graft shows no evidence of endoleak. Note
orientation of two limbs of stent-graft.
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Fig. 13B. —Change in graft morphology with decrease in aneurysm size in
74-year-old man. Axial contrast-enhanced CT scan obtained at same level as
A 12 months after treatment shows aneurysm has decreased substantially
in diameter (straight arrows). Note almost 90° rotation in
orientation and slight separation of limbs (curved arrow).
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Fig. 14A. —72-year-old man with stent-graft that requires life-long follow-up.
Axial contrast-enhanced CT scan obtained 1 year after insertion of bifurcated
stent-graft shows no evidence of endoleak. Diameter of abdominal aortic
aneurysm had decreased compared with that seen on pretreatment CT scan (not
shown).
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Fig. 14B. —72-year-old man with stent-graft that requires life-long follow-up.
Axial contrast-enhanced CT scan obtained during subsequent hospitalization for
septic knee joint. Patient complained of abdominal pain. Acute expansion,
perianeurysmal inflammatory changes, and rupture (arrow) of abdominal
aortic aneurysm are present, without opacification of sac. At surgery, pus was
found in sac, but no evidence of endoleak. Organism in sac was same as that in
joint.
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Copyright © 2000 by the American Roentgen Ray Society.
