Balloon-Expandable Covered Stents скачать в хорошем качестве

Balloon-Expandable Covered Stents

Technical success of these procedures is contingent upon detailed preoperative planning using centerline analysis on a dedicated workstation. Although the details of case planning are beyond the scope of this brief report, the steps have been well standardized and enable the measurement of the exact coordinate locations of the target vessels to reflect the way in which the endograft is predicted to lie within the aorta due to any associated tortuosity. The stent graft fenestration is performed on the back table by several members of the operating team during the induction of anesthesia and while other members of the team gain vascular access. We typically obtain open surgical access of one common femoral artery to allow delivery of the large bore PMEG delivery system, while percutaneous access of the contralateral femoral vessel is obtained using a “pre-close” technique. Further, we prefer to introduce the branch stents antegrade, which is usually done via open surgical access of the infraclavicular left axillary artery. This access site allows the patient to be positioned with both arms at the side and gives more room for the operators positioned at the patient’s left shoulder to deliver the branch stents. The fenestration holes are created in the stent graft using an ophthalmic cautery device and reinforced with a running locked 5-0 braided polyester suture incorporating a highly radiopaque gold gooseneck snare device wire. Once the PMEG has been fully modified and re-sheathed, the device orientation with regards to the location of the fenestrations is checked under fluoroscopy and the device then partially deployed in the patient’s aorta down to the level of the celiac fenestration. The celiac fenestration is cannulated from above, and the device is then serially deployed to expose each fenestration for cannulation, adjusting the alignment of the PMEG device as needed to optimize target vessel alignment. This technique greatly simplifies the cannulation of the fenestrations and branch vessels. Likewise, the use of fusion imaging allows the patient’s preoperative CTA imaging to be overlaid on the fluoroscopic image during the procedure, creating a three-dimensional map of the visceral vessel locations to assist with their cannulation and thereby minimizing contrast administration and fluoroscopy time. Once all four visceral vessels have been cannulated, the PMEG device is fully deployed and the target vessels stented using balloon-expandable covered stents with the proximal ends of the branch stents post-dilated to flare them and prevent type III endoleak. When this is complete, the seal zones of the PMEG device are post-dilated and the abdominal endografts, if they are being utilized, are then deployed using standard endovascular abdominal aortic repair techniques. Completion angiography is then performed to assess the patency of the visceral branches and rule out any endoleak. In summary, endovascular repair is rapidly evolving to now becoming the first line option for most patients with atherosclerotic/degenerative TAAA outside of the connective tissue population. The technique has been demonstrated to be safe and effective and is transforming, for the better, the way TAAA is treated in the majority of patients.