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Endovascular devices for abdominal aortic repair

Rabih A Chaer, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Endovascular aortic repair requires that specific anatomic criteria are fulfilled, and, for those with appropriate anatomy, this technique has become a preferred approach and allows the treatment of patients who might not otherwise be candidates for surgical aortic repair due to medical comorbidities.

Endovascular repair with abdominal stent-graft devices is primarily used to treat infrarenal abdominal aortic aneurysm with or without associated iliac artery aneurysm. Although not yet approved for clinical use in the United States, branched and fenestrated endovascular aortic devices have been developed to allow perfusion into specific aortic branches depending upon the level of repair (eg, renal artery, internal iliac artery). These advanced devices allow endovascular management of juxtarenal and potentially suprarenal aneurysms, and preservation of hypogastric flow when an adequate landing zone in the common iliac artery is not present.

The placement of aortic endovascular grafts is associated with device-related complications, which can include component disconnection, stent-graft buckling and migration over time. Secondary intervention is frequently needed [1-3]. As such, these devices require lifelong surveillance; the long-term outcomes for these devices continue to be studied.

The specific devices available for endovascular repair of the abdominal aorta will be reviewed here. The indications for, placement of, and complications of these devices are discussed elsewhere. (See "Endovascular repair of abdominal aortic aneurysm" and "Complications of endovascular abdominal aortic repair".)


The aorta is the major arterial conduit conveying blood from the heart to the systemic circulation. It originates immediately beyond the aortic valve ascending initially, then curving to form the aortic arch, and finally descending caudally adjacent the spine. The descending thoracic aorta continues through the hiatus of the diaphragm to become the abdominal aorta which extends into the retroperitoneum to its bifurcation into the common iliac arteries at the level of the fourth lumbar vertebra. The abdominal aorta lies slightly left of the midline to accommodate the inferior vena cava which is in close apposition. The branches of the abdominal aorta (superior to inferior) (figure 1) include the left and right inferior phrenic arteries, left and right middle suprarenal arteries, the celiac axis, superior mesenteric artery, left and right renal arteries in addition to occasional accessory renal arteries, left and right gonadal arteries, inferior mesenteric artery, the paired lumbar arteries (L1-L4) and middle sacral artery. The abdominal aorta bifurcates into the left and right common iliac arteries, which most often arise at the level of the 4th lumbar vertebra. The common iliac artery bifurcates into the external iliac and internal iliac arteries at the pelvic inlet. The internal iliac artery has superior and inferior divisions that supply the pelvic viscera and muscles. The external iliac artery passes beneath the inguinal ligament to become the common femoral artery [4].

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Literature review current through: Nov 2017. | This topic last updated: Aug 24, 2016.
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  1. Ohrlander T, Dencker M, Acosta S. Morphological state as a predictor for reintervention and mortality after EVAR for AAA. Cardiovasc Intervent Radiol 2012; 35:1009.
  2. Brown LC, Greenhalgh RM, Powell JT, et al. Use of baseline factors to predict complications and reinterventions after endovascular repair of abdominal aortic aneurysm. Br J Surg 2010; 97:1207.
  3. Karthikesalingam A, Holt PJ, Hinchliffe RJ, et al. Risk of reintervention after endovascular aortic aneurysm repair. Br J Surg 2010; 97:657.
  4. Sandhu RS, Pipinos II. Isolated iliac artery aneurysms. Semin Vasc Surg 2005; 18:209.
  5. Caronno R, Piffaretti G, Tozzi M, et al. Stent-graft treatment for isolated infrarenal aortic dissecting aneurysms. World J Surg 2006; 30:1360.
  6. Halkos ME, Nicholas J, Kong LS, et al. Endovascular management of blunt abdominal aortic injury. Vascular 2006; 14:223.
  7. http://www.cookmedical.com/ai/familyListingAction.do?family=AAA (Accessed on August 24, 2016).
  8. Greenberg RK, Chuter TA, Sternbergh WC 3rd, et al. Zenith AAA endovascular graft: intermediate-term results of the US multicenter trial. J Vasc Surg 2004; 39:1209.
  9. Väärämäki S, Suominen V, Pimenoff G, et al. Long-term experience of endovascular aneurysm repair with Zenith prosthesis: diminishing graft-related complications over time. Ann Vasc Surg 2012; 26:845.
  10. http://www.goremedical.com/excluder/configurations/ (Accessed on August 24, 2016).
  11. Matsumura JS, Brewster DC, Makaroun MS, Naftel DC. A multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 2003; 37:262.
  12. Melissano G, Bertoglio L, Esposito G, et al. Midterm clinical success and behavior of the aneurysm sac after endovascular AAA repair with the Excluder graft. J Vasc Surg 2005; 42:1052.
  13. Peterson BG, Matsumura JS, Brewster DC, et al. Five-year report of a multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysms. J Vasc Surg 2007; 45:885.
  14. Haider SE, Najjar SF, Cho JS, et al. Sac behavior after aneurysm treatment with the Gore Excluder low-permeability aortic endoprosthesis: 12-month comparison to the original Excluder device. J Vasc Surg 2006; 44:694.
  15. Hogg ME, Morasch MD, Park T, et al. Long-term sac behavior after endovascular abdominal aortic aneurysm repair with the Excluder low-permeability endoprosthesis. J Vasc Surg 2011; 53:1178.
  16. Bastos Gonçalves F, Jairam A, Voûte MT, et al. Clinical outcome and morphologic analysis after endovascular aneurysm repair using the Excluder endograft. J Vasc Surg 2012; 56:920.
  17. http://www.endologix.com/fls/IntuiTrak_Product_Specifications_MM0157_Rev_05_usa.pdf (Accessed on August 24, 2016).
  18. Carpenter JP, Endologix Investigators. Midterm results of the multicenter trial of the powerlink bifurcated system for endovascular aortic aneurysm repair. J Vasc Surg 2004; 40:849.
  19. Wang GJ, Carpenter JP, Endologix Investigators. The Powerlink system for endovascular abdominal aortic aneurysm repair: six-year results. J Vasc Surg 2008; 48:535.
  20. http://www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/wcm_prod067491.pdf (Accessed on February 24, 2012).
  21. Makaroun MS, Tuchek M, Massop D, et al. One year outcomes of the United States regulatory trial of the Endurant Stent Graft System. J Vasc Surg 2011; 54:601.
  22. Rutherford RB. Open versus endovascular stent graft repair for abdominal aortic aneurysms: an historical view. Semin Vasc Surg 2012; 25:39.
  23. Rouwet EV, Torsello G, de Vries JP, et al. Final results of the prospective European trial of the Endurant stent graft for endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2011; 42:489.
  24. Singh MJ, Fairman R, Anain P, et al. Final results of the Endurant Stent Graft System in the United States regulatory trial. J Vasc Surg 2016; 64:55.
  25. Perdikides T, Georgiadis GS, Avgerinos ED, et al. The Aorfix stent-graft to treat infrarenal abdominal aortic aneurysms with angulated necks and/or tortuous iliac arteries: midterm results. J Endovasc Ther 2009; 16:567.
  26. Prospective Aneurysm Trial: High angle Aorfix bifurcated stent graft (PYTHAGORAS). http://clinicaltrials.gov/ct2/show/NCT00522535 (Accessed on February 24, 2012).
  27. http://www.trivascular.com/clinical-outcomes (Accessed on June 28, 2016).
  28. Mehta M, Valdés FE, Nolte T, et al. One-year outcomes from an international study of the Ovation Abdominal Stent Graft System for endovascular aneurysm repair. J Vasc Surg 2014; 59:65.
  29. Georgakarakos E, Ioannou CV, Georgiadis GS, et al. The ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives. Expert Rev Med Devices 2016; 13:253.
  30. Irace L, Venosi S, Gattuso R, et al. Initial single-site experience with the Ovation abdominal stent-graft system in patients with challenging aortoiliac anatomy. J Cardiovasc Surg (Torino) 2016; 57:846.
  31. Ierardi AM, Tsetis D, Ioannou C, et al. Ultra-low profile polymer-filled stent graft for abdominal aortic aneurysm treatment: a two-year follow-up. Radiol Med 2015; 120:542.
  32. Ioannou CV, Kontopodis N, Kehagias E, et al. Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia. Br J Radiol 2015; 88:20140735.
  33. Sfyroeras GS, Moulakakis KG, Antonopoulos CN, et al. Anaphylactic Reaction During Implantation of the Ovation Stent-Graft System in a Patient With Abdominal Aortic Aneurysm. J Endovasc Ther 2015; 22:620.
  34. de Donato G, Setacci F, Sirignano P, et al. Ultra-low profile Ovation device: is it the definitive solution for EVAR? J Cardiovasc Surg (Torino) 2014; 55:33.
  35. Torsello G, Scheinert D, Brunkwall JS, et al. Safety and effectiveness of the INCRAFT AAA Stent Graft for endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2015; 61:1.
  36. Bertoglio L, Logaldo D, Marone EM, et al. Technical features of the INCRAFT™ AAA Stent Graft System. J Cardiovasc Surg (Torino) 2014; 55:705.
  37. Coppi G, Njila M, Coppi G, et al. INCRAFT® Stent-Graft System: one-year outcome of the INNOVATION Trial. J Cardiovasc Surg (Torino) 2014; 55:51.
  38. Torsello G, Brunkwall J, Scheinert D. Cordis INCRAFT™ ultra-low profile AAA stent-graft system. J Cardiovasc Surg (Torino) 2011; 52:661.
  39. Mazzaccaro D, Occhiuto MT, Stegher S, et al. Tips About the Cordis INCRAFT Endograft. Ann Vasc Surg 2016; 30:205.
  40. Scheinert D, Pratesi C, Chiesa R, et al. First-in-human study of the INCRAFT endograft in patients with infrarenal abdominal aortic aneurysms in the INNOVATION trial. J Vasc Surg 2013; 57:906.
  41. http://www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@endov/documents/documents/aaa_brochure.pdf (Accessed on February 24, 2012).
  42. http://www.medtronicendo.com/us/product/abdominal/talent-aaa?quicktabs_8=3#quicktabs-8 (Accessed on August 24, 2016).
  43. Chiesa R, Riambau V, Coppi G, et al. The Bolton Treovance abdominal stent-graft: European clinical trial design. J Cardiovasc Surg (Torino) 2012; 53:595.
  44. Freyrie A, Gargiulo M, Fargion A, et al. AnacondaTM: the Italian Registry. Study protocol and preliminary perioperative results. J Cardiovasc Surg (Torino) 2011; 52:629.
  45. Böckler D, Holden A, Thompson M, et al. Multicenter Nellix EndoVascular Aneurysm Sealing system experience in aneurysm sac sealing. J Vasc Surg 2015; 62:290.
  46. Carpenter JP, Cuff R, Buckley C, et al. Results of the Nellix system investigational device exemption pivotal trial for endovascular aneurysm sealing. J Vasc Surg 2016; 63:23.
  47. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
  48. Blankensteijn JD, de Jong SE, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005; 352:2398.
  49. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:1881.
  50. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365:2179.
  51. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:1863.
  52. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med 2010; 362:1872.
  53. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302:1535.
  54. Veith FJ, Lachat M, Mayer D, et al. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009; 250:818.
  55. Tambyraja AL, Fishwick NG, Bown MJ, et al. Fenestrated aortic endografts for juxtarenal aortic aneurysm: medium term outcomes. Eur J Vasc Endovasc Surg 2011; 42:54.
  56. Greenberg RK, Sternbergh WC 3rd, Makaroun M, et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2009; 50:730.
  57. Amiot S, Haulon S, Becquemin JP, et al. Fenestrated endovascular grafting: the French multicentre experience. Eur J Vasc Endovasc Surg 2010; 39:537.
  58. Greenberg RK, Haulon S, O'Neill S, et al. Primary endovascular repair of juxtarenal aneurysms with fenestrated endovascular grafting. Eur J Vasc Endovasc Surg 2004; 27:484.
  59. O'Neill S, Greenberg RK, Haddad F, et al. A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc Surg 2006; 32:115.
  60. Verhoeven EL, Vourliotakis G, Bos WT, et al. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg 2010; 39:529.
  61. Semmens JB, Lawrence-Brown MM, Hartley DE, et al. Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997-2004). J Endovasc Ther 2006; 13:320.
  62. Anderson JL, Berce M, Hartley DE. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001; 8:3.
  63. Kristmundsson T, Sonesson B, Malina M, et al. Fenestrated endovascular repair for juxtarenal aortic pathology. J Vasc Surg 2009; 49:568.
  64. Ziegler P, Avgerinos ED, Umscheid T, et al. Fenestrated endografting for aortic aneurysm repair: a 7-year experience. J Endovasc Ther 2007; 14:609.
  65. Scurr JR, Brennan JA, Gilling-Smith GL, et al. Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg 2008; 95:326.
  66. Bicknell CD, Cheshire NJ, Riga CV, et al. Treatment of complex aneurysmal disease with fenestrated and branched stent grafts. Eur J Vasc Endovasc Surg 2009; 37:175.
  67. Cross J, Gurusamy K, Gadhvi V, et al. Fenestrated endovascular aneurysm repair. Br J Surg 2012; 99:152.
  68. Cross J, Raine R, Harris P, et al. Indications for fenestrated endovascular aneurysm repair. Br J Surg 2012; 99:217.
  69. Greenberg RK, Qureshi M. Fenestrated and branched devices in the pipeline. J Vasc Surg 2010; 52:15S.
  70. Brown LC, Greenhalgh RM, Kwong GP, et al. Secondary interventions and mortality following endovascular aortic aneurysm repair: device-specific results from the UK EVAR trials. Eur J Vasc Endovasc Surg 2007; 34:281.
  71. Ouriel K, Clair DG, Greenberg RK, et al. Endovascular repair of abdominal aortic aneurysms: device-specific outcome. J Vasc Surg 2003; 37:991.