Treatment of complex abdominal aortic
`aneurysms by a combination of endoluminal
`and extraluminal aortofemoral grafts
`James May, MS, FRACS, FACS, Geoffrey White, FRACS,
`Richard Waugh, MB, BS, DDR, FRACR, Weiyun Yu, MB, BS, BSc, and
`John Harris, MS, FRACS, FACS, Sydney, Australia
`
`Purpose: The purpose of this study was to test the hypothesis that abdominal aortic
`aneurysms (AAA) whose morphology makes them unsuited for repair with an endolu(cid:173)
`minal tube graft can be treated by a combination of a transluminally placed aortofemoral
`graft and a femorofemoral crossover graft. In addition the technique involves either
`ligation or balloon occlusion of the contralateral common iliac and internal iliac arteries
`in such a manner that excludes the AAA from the circulation.
`Methods: We report the use of this technique in three male patients with 6.4 to 7.0 em
`diameter AAA. Two had renal impairment and cardiac function too poor to permit open
`repair, and the third had an unfavorable abdomen caused by previous surgery and the
`presence of a permanent colostomy. Each patient had an individually tailored Dacron tube
`graft constructed on the basis of preoperative arteriograms and computed tomography
`scans. The grafts were delivered transluminally into the aorta through a sheath in the iliac
`arteries and anchored proximally with a stainless steel stent under radiographic control.
`The grafts were then anastomosed distally to the femoral artery.
`Results: Recovery was complicated by a midgraft stenosis corrected by percutaneous
`balloon dilation in one patient, an episode of pulmonary edema in the second and an
`unexplained pyrexia in the third. Follow-up with duplex scanning confirmed normal flow
`through the grafts and the presence of thrombus between the prosthetic graft and the
`aneurysmal sac.
`Conclusions: We conclude that transluminal placement of an aortofemoral graft combined
`with a femorofemoral crossover graft is feasible in patients who are unsuited to repair with
`an endoluminal tube graft. The outcome with this technique is not known and requires
`further careful evaluation. (J VASe SURG 1994;19:924-33.)
`
`Currently there is great interest in endoluminal
`techniques for treatment of abdominal aortic an(cid:173)
`eurysms (AAA). The ideal method seems to be
`transluminal placement of a tube graft into the
`aorta, but variations in morphology of the aortic
`wall, particularly at the bifurcation, and associated
`aneurysms of the iliac arteries make many patients
`unsuitable candidates. We report three patients with
`AAA lacking a distal neck, two of whom had
`common iliac aneurysms in addition, who were
`
`From the Department of Vascular Surgery, Royal Prince Alfred
`Hospital and Department of Surgery, University of Sydney,
`Sydney.
`Reprint requests: James May, MS, FRACS, FACS, Department of
`Surgery, University of Sydney, Sydney, NSW 2006, Australia.
`Copyright © 1994 by The Society for Vascular Surgery and
`International Society for Cardiovascular Surgery, North Ameri(cid:173)
`can Chapter.
`0741-5214/94/$3.00 + 0 24/1/52315
`
`924
`
`treated by a combination of a transluminally placed
`aortofemoral graft and a femorofemoral crossover
`graft.
`There have been several reports of experimental
`endoluminal graftsl-S preceding the first report of
`AAA endoluminal repair in human beings by Parodi
`et al.6 He and his colleagues treated five patients with
`AAA by transfemoral intraluminal Dacron grafts
`anchored by modified stainless steel stents. These
`aneurysms were all of the fusiform variety with a
`discrete proximal neck between the renal arteries and
`the proximal extent of the aneurysm and a distal neck
`between the distal extent of the aneurysm and the
`bifurcation of the aorta. In three of the patients the
`proximal stent was used without a distal stent. In the
`other two patients, both ends of the Dacron graft
`were anchored by stents.
`The three patients in this report were not suitable
`for treatment by an endoluminal tube graft tech-
`
`MEDTRONIC 1120
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`

`JOURNAL OF VASCULAR SURGERY
`Volume 19, Number 5
`
`May et aI. 925
`
`nique, because of the lack of distal neck of the
`aneurysm. The technique described in this report is a
`modification of a method developed by Parodi, 10
`whose experience preceeded the authors'.
`
`PATIENTS AND METHODS
`Endovascular repair of aneurysms with materials
`currently used in vascular surgery is approved by the
`Institutional Review Board. Food and Drug Admin(cid:173)
`istration approval of grafts and stents is not required
`in Australia. Informed consent was obtained from
`each patient. Laboratory and clinical experience in
`the use of intraluminal grafts for subclavian and aortic
`aneurysms has previously been reported by the
`authors. 7-9
`Graft preparation. The graft/stent devices used
`in the treatment of two of these three patients were
`identical except in length. Each device was con(cid:173)
`structed from two Dacron tubes (Fig. 1). The larger
`of the two was 18 mm-diameter knitted Dacron
`(Industrias HA Barone, Buenos Aires, Argentina).
`The proximal 15 mm of this graft was compliant and
`was constructed to allow stretching up to 24 mm in
`diameter. The diameter of the proximal necks of the
`aneurysms had been measured at 19.2 mm and 20.4
`mm, respectively, on preoperative CT scans and
`aortograms. During arteriography a pigtail catheter
`with 1 cm markings was used to accurately calibrate
`the dimensions and avoid errors of parallax and
`magnification. The smaller of the two tubes was a
`woven Dacron graft (Bard Inc., C.R., Murray Hill,
`N.J.). Each graft was cut obliquely and joined with a
`continuous 5/0 Gore-tex suture. * The proximal graft
`measured 9 cm in length, and the smaller diameter
`grafts measured 13 cm and 20 cm, respectively, with
`the crimp fully extended in each. The larger grafts
`were supplied with stainless steel stents, 5.2 mm in
`diameter and 3.5 cm in length, to which they were
`attached by braided sutures at two opposing points
`on the circumference.
`The third graft/stent device consisted of a com(cid:173)
`mercially available bifurcated woven Dacron graft
`(22 mm diameter with 10 mm-diameter limbs)
`(Bard Inc., C.R) and a stainless steel stent similar to
`that used in the previous two cases. The body of the
`graft was attached to the stent in a similar manner to
`the previous two cases. One limb of the graft was
`amputated and the resulting defect in the graft
`repaired with 5/0 Gore-tex suture. The remaining
`limb of the graft was cut to give the whole graft an
`overall length of 30 cm with the crimp fully extended.
`
`*Gore-tex is a trademark ofW.L. Gore & Associates, Elkton, Md.
`
`The diameter of the neck of the aneurysm had been
`measured on preoperative arteriography and CT
`scanning at 22 mm.
`The stents were mounted on a 30-mm-diameter
`balloon catheter (BALT Extrusion, Montmorency,
`France, or William A Cook, Queensland, Australia).
`The graft was furled around the stent and balloon
`catheter in the transverse configuration of the letter S.
`The graft/stent device and the balloon catheter were
`then loaded into a 21F internal diameter Teflon
`sheath (William A Cook) and advanced until the tip
`of the balloon protruded from the opposite end of the
`sheath (Fig. 2).
`Case report 1. A 79-year-old male patient was
`admitted with an infrarenal AAA. It measured 6.4 em
`in maximal diameter on CT scanning and had
`increased in diameter from 5.2 cm on CT scanning
`performed 18 months previously. He had been
`rejected for surgical repair of his aneurysm because of
`poor cardiac function. He had been receiving treat(cid:173)
`ment for congestive heart failure for 4 years. Coro(cid:173)
`nary angiography demonstrated triple vessel disease
`that was technically suitable for bypass grafting. This
`was precluded, however, by severe left ventricular
`dysfunction (gated heart pool ejection fraction less
`than 20%). He was referred for possible endoluminal
`repair of his aneurysm. Investigation revealed that his
`hematologic and biochemical parameters were within
`normal limits, with the exception of his serum
`creatinine, which was 140 mg/dl (Normal range 80
`to 100 mg/dl). Aortography and CT scanning
`demonstrated a 2 cm-Iong neck between the renal
`arteries and the commencement of the aneurysm
`(Fig. 3). Close examination of the calcium within the
`walls of the aneurysm showed that the aneurysm
`extended to and involved the bifurcation of the aorta.
`, The apparent distal neck of the aneurysm seen on the
`aortogram was due to mural thrombus, confirmed by
`CT scanning, just above the bifurcation of the aorta
`(Fig. 4). Endovascular repair of the aneurysm with a
`stent-anchored aortofemoral graft, combined with
`detachable balloon occlusion of contralateral com(cid:173)
`mon iliac artery and femorofemoral crossover graft
`was planned.
`The operation was performed with the patient
`receiving general anesthetic and being placed in the
`supine position on a radiolucent table. The abdomen
`was prepared and draped in addition to the upper
`thighs in the event that access proximal to the
`planned femoral arteriotomy was required.
`A retrograde aortogram was performed via a
`percutaneous approach to the left femoral artery. The
`positions of the renal arteries, the proximal extent of
`
`

`

`926 May et al.
`
`JOURNAL OF VASCULAR SURGERY
`May 1994
`
`Fig. 1. Device consists of two Dacron tube grafts sutured together obliquely and stainless steel
`stent sutured to larger diameter graft.
`
`Fig. 2. Graft/stent device mounted on balloon catheter and packaged in inner 2IF sheath ready
`for delivery into outer sheath.
`
`the AAA, and the bifurcation of the aorta were
`carefully determined and marked with metallic clips
`on the patient's abdomen. A radiopaque ruler be(cid:173)
`neath the patient was also used as an additional
`reference point for these anatomic levels. The com(cid:173)
`mon femoral artery was exposed through a small
`vertical incision in the right groin. An Amplatz extra
`stiff guide wire (Cook, Inc., Bloomington, Ind.) was
`introduced into the right femoral artery and passed
`up to the descending thoracic aorta. An unsuccessful
`attempt was made to pass a 24F internal diameter
`Teflon sheath with its mandrel (William A Cook)
`through a right femoral arteriotomy into the aorta.
`The external iliac artery, which had been measured at
`6.S mm in diameter on the preoperative aortogram
`could not be dilated sufficiently to accommodate the
`sheath, which had an external diameter of 10 mm.
`Access via the iliac artery was then obtained with a
`
`method devised by Parodi. 10 This involved the use of
`a large-diameter Dacron graft as a temporary conduit
`to the common iliac artery. With Parodi's technique
`the graft is oversewn proximally and the excess is
`excised when it is no longer required as a conduit. In
`this case the conduit was retained to allow the
`aortofemoral graft to pass distally to the femoral
`artery. The distal right common iliac artery was
`exposed through an extraperitoneal approach in the
`right iliac fossa. A 14 mm, woven Dacron tube graft
`was sutured to an arteriotomy in the nonaneurysmal
`common iliac artery and delivered to the exterior by
`passing the graft deep to the inguinal ligament and
`out through the wound in the right groin. The 24F
`Teflon sheath and mandrel were then passed without
`difficulty over a guide wire through the Dacron graft
`into the distal aorta. The mandrel was removed and
`replaced with the 21F internal diameter Teflon
`
`

`

`JOURNAL OF VASCULAR SURGERY
`Volume 19, Number 5
`
`May et aI. 927
`
`sheath containing its preloaded balloon catheter ami
`graft stent device. Under radiographic control the
`balloon and graft/stent device were advartced in a
`cephalad direction from the end of the 21F Teflon
`sheath. The stent was deliberately positioned with its
`uncovered upper end overlapping the left renal artery
`origin by 0.5 cm. The stent was deployed by inflating
`the balloon to a diameter of 22 mm. During inflation
`of the balloon the patient's blood pressure was
`maintained at 80 mm Hg systolic by means of a
`nitroprusside infusion. After balloon deflation, the
`guide wire was removed, and aortography was
`performed through the central channel of the balloon
`catheter. This demonstrated a satisfactory seal be(cid:173)
`tween the graft and the neck of the aneurysm without
`escape of contrast into the aneurysmal sac. The 24F
`and 21F sheaths were removed, and the graft was
`extended down to the femoral arteriotomy by sutur(cid:173)
`ing on an additional segment of Dacron graft. The
`left lower limb was revascularized with a crossover
`8 mm Gore-Tex graft from the Dacron graft in the
`right groin to the common femoral artery in the left
`groin. Both common iliac arteries were ligated, the
`left one at its origin and the right one distal to the site
`of attachment of the original 14 mm Dacron access
`graft (Fig. 5). Ligation of both common iliac arteries
`through a small right-sided extraperitoneal approach
`was facilitated by the patient's build but could be
`difficult in an obese patient. The blood loss of 3 L was
`returned to the patient by cell-saver and the operating
`time was 7 hours.
`Outcome. The patient recovered and was extu(cid:173)
`bated in the immediate postoperative period. His
`serum creatinine level rose to 230 mg/dl on the
`second postoperative day before returning to the
`preoperative level of 140 mg/dl on the fourth
`postoperative day.
`The patient's convalescence was complicated by
`an episode of acute ischemia affecting both lower
`limbs on the tenth postoperative day. Urgent aor(cid:173)
`tography was performed via the right brachial artery
`in the cubital fossa. This demonstrated stenosis in the
`composite aortic graft, just distal to the oblique
`suture line. This stenosis was corrected by balloon
`dilation, with a 6 mm balloon catheter followed by a
`10 mm balloon catheter. Postdilation arteriography
`demonstrated restoration of the normal graft lumen.
`The ischemia in both legs rapidly reversed with return
`of ankle-brachial pressure indexes to postoperative
`levels. The patient was discharged 2 days later (the
`thirteenth postoperative day). Follow-up duplex
`
`Fig. 3. Aortogram from case 1. Centimeter markers on
`upper end of catheter for accurate measurement of aneu(cid:173)
`rysm. Calcification in aortic wall (arrows) demonstrate that
`aneurysm extends down to bifurcation.
`
`scanning studies at 4 months confirmed normal
`blood flow through the graft and runoff arteries.
`Isolation of the aneurysm from the circulation and
`obliteration of the aneurysm sac by thrombus around
`the graft was also confirmed.
`Case report 2. A 76-year-old male patient was
`admitted with a 6.5 cm diameter infrarenalAAA. The
`patient had angina and underwent exercise dipyri(cid:173)
`damole thallium scanning, which demonstrated an
`area of redistribution. Coronary angiography dis(cid:173)
`closed triple vessel disease that was technically
`suitable for bypass grafting. Gated heart pool ejection
`fraction was less than 20%. The patient's cardiologist
`considered the combined risk of coronary artery
`bypass grafting and open repair of the AAA to be
`considerable and recommended transluminal repair
`in preference to the two open operations. Hemato(cid:173)
`logic and biochemical parameters were within nor(cid:173)
`mal limits, with the exception of the serum creatinine
`level, which was 176 mg/dl. Aortography demon(cid:173)
`strated that the aneurysm had a neck 2.2 cm in length
`between the renal arteries and the commencement of
`the aneurysm (Fig. 6). Together with a cr scan, it
`also demonstrated that the right common iliac artery
`
`

`

`928 May et aI.
`
`JOURNAL OF VASCULAR SURGERY
`May 1994
`
`Fig. 4. CT scan 0.5 cm above aortic bifurcation from case 1, confirms extent of aneurysm and
`absence of distal neck.
`
`was aneurysmal and the left common iliac artery was
`ectatic.
`The operation was performed with the patient
`receiving general anesthetic and in the supine posi(cid:173)
`tion. Draping and preliminary aortography were
`performed in a similar manner to the preceding case.
`Access to the aorta was gained through the left
`external iliac artery. This artery was exposed through
`a transverse incision below the inguinal ligament.
`Because of extreme tortuosity, the left external iliac
`artery was extensively mobilized in the manner
`devised by Parodi.lo This allowed the excess in length
`of the tortuous artery to be delivered below the
`inguinal ligament and provided a straight passage
`into the aorta for the 24F sheath.
`The graft/stent was delivered into the aorta,
`positioned, and deployed in a similar manner to the
`previous case. After withdrawal of the sheaths, the
`distal end of the aortofemoral graft was left protrud(cid:173)
`ing through the arteriotomy in the left external iliac
`artery. This artery was transected at this point, and an
`additional 3 em of redundant artery distal to this
`point was excised. The distal end of the aortofemoral
`graft was anastomosed end-to-end to the free end of
`
`the common femoral artery, as shown in Fig. 7. There
`was no bleeding between the transected end of the
`left external iliac artery and the Dacron graft, but a
`ligature with minimal tension was applied to secure
`this potential opening. The right limb was revascu(cid:173)
`larized by a femorofemoral crossover graft. The right
`common iliac artery was occluded with a detachable
`balloon (custom made in the Interventional Radiol(cid:173)
`ogy Department, Royal Prince Alfred Hospital,
`Sydney, Australia) passed up the right external iliac
`artery and the left internal. iliac artery was ligated
`extraperitoneally. On table intraoperative angiogra(cid:173)
`phy confirmed the occlusion of the right common
`iliac was complete. The blood loss of 21/2 1 was
`returned to the patient by cell-saver and the operating
`time was 61/2 hours.
`Outcome. The patient recovered well and was
`extubated in the immediate postoperative period.
`The serum creatinine level rose to 357 mgjdl by the
`third postoperative day. At this point the patient had
`an acute episode of pulmonary edema requiring
`ventilation for 24 hours. The patient then made an
`uneventful recovery with his serum creatinine level
`falling to the preoperative level over the next 4 days.
`
`

`

`JOURNAL OF VASCULAR SURGERY
`Volume 19, Number 5
`
`May et at. 929
`
`Fig. 6. From case 2, aortogram demonstrates 6.S cm
`AAA with early aneurysmal disease in common iliac
`arteries.
`
`Fig. 5. From case 1, illustration demonstrates translumi·
`nal placement of aortic graft/stent device via right common
`iliac artery and revascularization of lower limbs with aorto
`right femoral graft and crossover graft. Note that larger
`graft sutured to right common iliac artery as conduit for
`access has been retained to allow aortofemoral graft to pass
`through it.
`
`The patient was discharged from hospital 12 days
`after operation. Follow-up with CT scanning at 1
`month (Fig. 8) and duplex scanning at 2 months
`confirmed normal flow through the graft and the
`presence of thrombus between the prosthetic graft
`and the aneurysmal sac.
`Case report 3. A 70-year-old male patient with a
`7 cm diameter AAA was referred for possible.
`endoluminal repair. He had a permanent colostomy
`on the left side of his abdomen after an abdomino(cid:173)
`perineal excision of the rectum for carcinoma 9
`
`months previously. The AAA had been diagnosed 3
`years previously, when it was 4.9 cms in diameter.
`Investigation revealed that his hematologic and
`biochemical parameters were within normal limits.
`Aortography and CT scanning demonstrated that the
`aneurysm had a neck 3 cm in length between the renal
`arteries and commencement of the aneurysm but
`lacked a distal neck between the aneurysm and the
`aortic bifurcation. The iliac and femoral arteries were
`also shown to be of adequate size (1.2 to 1.5 cm in
`diameter) to accommodate a 24F sheath.
`The operation was performed with the patient
`receiving general anesthetic and in the supine posi(cid:173)
`tion. Draping and preliminary aortography were
`performed in a similar manner to the preceding cases.
`Access to the aorta was gained through a 24F sheath
`introduced through the right common femoral
`artery. The graft/stent was delivered into the aorta,
`positioned, and deployed in a similar manner to the
`
`

`

`930 May et at.
`
`JOURNAL OF VASCULAR SURGERY
`May 1994
`
`Apart from a pyrexia for which no cause could be
`found, the patient had an uneventful recovery and
`was discharged 8 days after operation. Duplex
`scanning at 1 week (Fig. 9) confirmed normal blood
`flow through the graft and thrombus between the
`prosthetic graft and the aneurysmal sac.
`
`DISCUSSION
`There is currently much research into developing
`endoluminal techniques for the treatment of AAA.
`The ideal method seems to be transluminal placement
`of a tube graft into the aorta, but variations in
`morphology of the aortic wall at the bifurcation and
`associated aneurysms in the iliac arteries make this
`technique unsuitable for many patients. Use of a
`bifurcated Dacron graft is an attractive alternative.
`We have attempted this technique in one patient
`unsuccessfully. Successful placement of a bifurcated
`graft in a canine model has been reported. ll
`The three cases reported herein confirm the
`feasibility of an alternative method of endoluminal
`repair by trans luminal placement of an aortofemoral
`graft in the treatment of AAA, which is unsuited to
`treatment with an aortic tube graft. A similar
`technique of aortoiliac endoluminal graft combined
`with a femorofemoral crossover graft was devised by
`Parodi.lO His experience preceded the authors and
`the method varied from that described in this report
`by the use of a stent in the common iliac artery to
`anchor the distal end of an aortoiliac graft.
`These cases also illustrate several issues that
`require further comment. Firstly the selection of
`patients for this procedure. Those, such as the
`patients in this report, whose cardiac function does
`not permit them to have open repair of their
`aneurysms are most in need of the new technology.
`The situation can occur, however, where open
`operation is required to retrieve an inappropriately
`placed graft. This and other risks of the procedure
`need to be carefully explained to the patient before
`operation.
`As pointed out by Parodi,lO detailed preopera(cid:173)
`tive investigation is very important. The exact di(cid:173)
`mensions of the aneurysm and its relationship to the
`renal arteries and bifurcation need to be determined
`on aortography and cr scanning. For the first time
`the anatomy of the mural thrombus within the
`aneurysm takes on a significant role. It is important
`to determine that the distal neck of an aneurysm
`seen in the aortogram is formed by aortic wall and
`not thrombus within the aneurysmal sac. In addi(cid:173)
`tion the course of the lumen within the mural
`thrombus of large aneurysms may be tortuous and
`
`Fig. 7. From case 2, illustration demonstrates translumi(cid:173)
`nal placement of graft/stent device via left external iliac
`artery, which has been transected to allow distal end of
`aortofemoral graft to be anastomosed end-to-end to left
`common femoral artery. Right common iliac artery has
`been occluded with detachable balloon.
`
`previous cases. After withdrawal of the sheaths, the.
`distal end of the aortofemoral graft was left protrud(cid:173)
`ing through the arteriotomy in the right common
`femoral artery. This artery was transected at this
`point, and the distal end of the aortofemoral graft was
`anastomosed end-to-end to the free end of the
`common femoral artery. The remainder of the
`procedure was performed in a similar manner to the
`second case as shown in Fig. 7. The blood loss was
`2 L, and the operating time was 51/2 hours.
`Outcome. The patient recovered well and was
`extubated in the immediate postoperative period.
`
`

`

`JOURNAL OF VASCULAR SURGERY
`Volume 19, Number 5
`
`May et at. 931
`
`Fig. 8. A, From case 2, CT scan with contrast shows stent in neck of aneurysm. B, CT scan
`with contrast shows normal flow through graft, and presence of thrombus between prosthetic
`material and aneurysm sac.
`
`lead to an underestimation of the length of graft
`required.
`Access to the aorta is a limiting factor to
`transluminal placement of grafts. The double-sheath
`system devised by ParodilO is the most hemostatic
`method and is least likely to result in the graft/stent
`device becoming dislodged from its correct position
`on the balloon. The double sheath, however, is not
`commercially available at present, and considerable
`blood can be lost in development and refinement of
`the sheath system and in learning its use. This has
`been well demonstrated in these three cases where the
`major loss was through the sheath. The double sheath
`system also has the limitation of requiring a 24F
`sheath to accommodate the preloaded 21F inner
`sheath. The external diameter of the outer sheath
`used in these cases was 10 mm in diameter. The
`preoperative aortogram in case 1 had demonstrated
`that the right external iliac artery was free from any
`
`focal stenoses and that its diameter was 6.5 mm. It
`was not surprising therefore that this artery could not
`accommodate the sheath without risk of injury. The
`technique of use of a temporary Dacron graft as a
`conduit for the sheath into the larger common iliac
`artery worked well and added only marginally to the
`magnitude of the procedure. It was not desirable to
`pass the sheath directly into the common iliac artery
`via the extraperitoneal approach in the right iliac fossa
`because of the angle between the sheath and the iliac
`artery. Although it would have been technically
`possible to pass the sheath through the femoral
`approach, deep to the inguinal ligament and directly
`through an arteriotomy in the common iliac artery
`this was not considered desirable. There can be
`moderate blood loss around the sheath at the
`arteriotomy, and there is an ever present risk of major
`blood loss should the sheath become dislodged.
`The choice of graft material was related to
`
`

`

`932 May et al.
`
`JOURNAL OF VASCULAR SURGERY
`May 1994
`
`Fig. 9. From case 3, duplex scan shows normal flow through graft and obliteration of
`aneurysm sac by thrombus.
`
`material thickness and availability. The grafts used
`were the thinnest available in their respective diam(cid:173)
`eters and lengths. The anastomosis between the two
`grafts was made in an oblique fashion to minimize the
`added bulk of the suture material. The diameter of the
`graft/stent device is so critical that a transverse (900 to
`long axis of graft) suture line can prevent it being
`loaded into the 21F sheath. Polytetrafluoroethylene
`Gore-tex suture was selected because of the fear that
`monofilament polypropylene might fracture in the
`loading process. One further technical consideration
`is the placement of the proximal aspect of the
`unexpanded stent over the renal artery. Once the
`stent is deployed, its overall length shortens, leaving
`the renal artery orifice clear.
`The hope that these endoluminal aneurysm re(cid:173)
`pairs can be performed rapidly with minimal blood
`loss and that the patient can be discharged a few days
`later has not been fulfilled in our experience to date.
`There is a definite learning curve in acquiring the
`technical skills required and the need to share
`radiologic equipment and personnel with other
`operating rooms add to the duration of the proce(cid:173)
`dure. The prolonged hospital stay after operation was
`for the most part related to medical comorbidities,
`which is to be expected if many of the patients are
`unfit for open AAA repair.
`With operating times and blood replacement
`volumes reported in these cases it may well be asked
`whether the patients would have been better served
`by having a standard open repair. Additional weight
`is given to this argument when one considers that
`
`two of the three patients would have been suitable for
`an open tube graft repair rather than a bifurcated
`graft. An important message emanating from this
`experience is that what may appear to be a simple
`endoluminal technique can become a complicated
`procedure during the learning process.
`These cases demonstrate the feasibility of treating
`a large AAA that does not have a distal neck by a
`transluminally placed aortofemoral graft. The reports
`also validate the techniques of access devised by
`ParodilO for narrow and tortuous iliac arteries and
`demonstrate some of the complexities involved in
`this emerging technology.
`
`REFERENCES
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`JOURNAL OF VASCULAR SURGERY
`Volume 19, Number 5
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`7. May J, White GH, Waugh R, Yu W, Harris JP. Transluminal
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`Submitted June 21, 1993; accepted Oct. 14, 1993.
`
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