Endovascular devices for abdominal aortic repair
- Rabih A Chaer, MD
Rabih A Chaer, MD
- Professor of Surgery
- The University of Pittsburgh School of Medicine
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
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 .
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- AORTIC ANATOMY
- BASIC PRINCIPLES
- Delivery system
- Main device
- ABDOMINAL DEVICES
- AFX and Powerlink
- WITHDRAWN/INVESTIGATIONAL DEVICES
- Withdrawn devices
- Investigational devices
- EVAR RANDOMIZED TRIALS
- ADVANCED DEVICES
- Fenestrated grafts
- Branched grafts
- CHOICE OF DEVICE
- SUMMARY AND RECOMMENDATIONS