Table of Contents  
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 80-83

Endovascular Aortic Aneurysm Repair for Type - III Abdominal Aortic Aneurysm Following Aortic Neck Reconstruction with an External Cuff - Making the Unsuitable Neck Anatomy Suitable!

1 Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka, India
2 Division of Peripheral Vascular and Endovascular Surgery, Medanta -The Medicity, Gurgaon, Haryana, India
3 Sri Jaideva Institute of Cardiovascular Sciences, Bengaluru, Karnataka, India

Date of Web Publication31-Jul-2015

Correspondence Address:
Ramesh K Tripathi
Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0820.161949

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We report a case of infra-renal aortic aneurysm which was not suitable for standard endovascular aneurysm repair. Unsuitable neck was reconstructed by dacron graft cuff around the neck with fixing sutures. Following this, standard EVAR was performed.

Keywords: Dacron cuff, juxtra-renal aneurysm, short neck abdominal aortic aneurysm

How to cite this article:
Tripathi RK, Verma H, Hiremath N. Endovascular Aortic Aneurysm Repair for Type - III Abdominal Aortic Aneurysm Following Aortic Neck Reconstruction with an External Cuff - Making the Unsuitable Neck Anatomy Suitable!. Indian J Vasc Endovasc Surg 2015;2:80-3

How to cite this URL:
Tripathi RK, Verma H, Hiremath N. Endovascular Aortic Aneurysm Repair for Type - III Abdominal Aortic Aneurysm Following Aortic Neck Reconstruction with an External Cuff - Making the Unsuitable Neck Anatomy Suitable!. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2022 Sep 28];2:80-3. Available from:

  Introduction Top

Endovascular aortic aneurysm repair (EVAR) is an emerging modality of treatment for aneurysms, which has revolutionized the management of aortic aneurysms. It incorporates the concept of "excluding" the aneurysm from the blood flow in the aorta by placing a stent graft within the lumen of the aneurysm. Endovascular exclusion of abdominal aortic aneurysms (AAAs) is an alternative treatment to open surgical repair in patients who have other co-morbidities such as ischemic heart disease, decreased pulmonary functions, borderline respiratory function tests which might cause severe and sometimes fatal outcomes of an open aneurysm surgery. EVAR also decreases the duration of hospital stay by faster recovery and lesser postoperative complications. The goal of endovascular treatment of AAA is to provide a durable repair maintaining prograde flow in the graft while excluding flow within the aneurysm. [1]

In cases where anatomically and morphologically the aneurysm is not suitable for EVAR, open repair is opted. In a rare scenario we present one such case where the unsuitable infra-renal aneurysm neck was reconstructed by suturing a Dacron graft around the neck with fixing sutures to the aneurysm, thus providing an adequate landing zone for the endovascular stent grafting.

  Case Report Top

A 65-year-old male patient presented with pulsatile abdominal mass and diffuse low-grade pain since 6 months. He had a 90 pack year smoking history. Co-morbidities included chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and schizophrenia. Clinical examination revealed a nontender, diffuse mid abdominal pulsatile mass with bilateral palpable femoral and pedal pulses. All other clinical parameters were normal.

The preoperative evaluation consisted of a computed tomography (CT) angiogram of the aorta. The angiogram revealed a 7.5 cm juxtra-renal AAA extending up to the bifurcation of the common iliac arteries. The angiogram also showed dual renal arteries bilaterally, and the right inferior branch was situated at a lower level than the left renal artery [Figure 2].
Figure 1: Morphological types of infra-renal aortic aneurysm

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Figure 2: Type-III abdominal aortic aneurysm - preoperative computed tomography aortogram

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There was no significant thrombus or angulation of the neck. Based on these findings and taking into account the age and co-morbidities of the patient a unique surgery was planned to create an artificial neck externally and infrarenally around the neck of the aneurysm using a piece of Dacron graft, thus avoiding an open surgery and supra renal clamping which might have caused peri- and post-operative complications and morbidities.

  Technique Top

The surgery was planned in two stages. The patient was adjudged to be a high-risk candidate for general anesthesia.

Stage - I

Under high epidural and spinal anesthesia, a mini-laparotomy was performed. Retroperitoneum was opened, and aneurysm dissected superiorly up to the level of the left renal vein and renal arteries. Bilateral renal arteries were looped. The aneurysm neck was carefully dissected all around and looped. A 3 cm length of a 40 mm Dacron tube graft was wrapped around the neck of the aneurysm. The edges of the cuff were approximated compressing the neck and were sutured in a "double-breasting" fashion with anchoring sutures through the thick adventitia of the aneurysm wall with 3-0 prolene, to prevent migration of the cuff [Figure 3] and [Figure 4]. After complete hemostasis was achieved, abdomen was closed in layers.
Figure 3: Cuff fixed with "double-breasting" technique

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Figure 4: Intra operative picture of Dacron cuff around the aortic neck

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Stage - II

Bilateral groins were exposed, and 18F sheath introduced into the right common femoral artery. Gore Excluder 31 mm Χ 14 mm stent graft was aligned infrarenally and deployed upto the right external iliac artery. Contralateral limb was canulated deployed within the cuff of the left limb up to left common iliac artery. Distally the iliac limbs of the stent graft were deployed up to the common iliac confluences bilaterally. Proximal and distal endoseal was procured with a Gore trilobed ballon. Check angiogram showed no endoleaks and complete exclusion of the aneurysm [Figure 5].
Figure 5: Digital subtraction angiography showing (a) aortic neck (b) anchoring of the stent graft at the neck (c) complete proximal and distal endoseal of the stent

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On the postoperative period, he developed to paralytic ileus which was managed conservatively. He recovered well and was discharged on the 10 th postoperative day. A check CT angiogram of the abdominal aorta showed no endoleaks and complete exclusion of the aneurysm.

  Discussion Top

Aortic fixation of the stent graft may be infrarenal, relying on radial expansile force with or without hooks or barbs attached to the proximal covered stent, or suprarenal with uncovered metal stent struts that maintain perfusion of the renal arteries, while the infrarenal covered component provides the seal.

The suitability of a patient with an infrarenal AAA for endovascular therapy is determined by the morphology of the aneurysm [Figure 1]. [2],[3] A few of the critical anatomic determinations which must be made in planning an endovascular aortic graft implantation are:

  • Diameter and length of the infrarenal aorta and neck of the aorta;
  • Diameter and length of the iliac attachments (landing zones);
  • Tortuosity and size of the access vessels and critical accessory vessel anatomy.

This case report describes how an infrarenal AAA which was unsuitable for an EVAR was converted into a suitable case by altering the morphology of the aneurysm.

Endovascular aortic aneurysm repair of thoracic and AAAs has evolved over the past few years which has not only made the procedure simpler to execute but also significantly reduced the perioperative morbidity, mortality, and late aneurysm-related deaths of patients that was seen in these cases earlier. This difference in outcome has resulted in EVAR replacing open repair as the procedure of choice for most patients with infrarenal AAAs with suitable anatomy.

An artificial aortic neck reconstruction for an EVAR procedure has been reported earlier which was done to treat a type-I endoleak. According to the case report, a type-I endoleak was detected after 30 days of endoluminal aortic stent grafting and nonregression of the size of the aneurysm in a follow-up CT. This was approached in one of two ways: Complete endograft preservation with external wrap of the aortic neck to secure a proximal seal and eliminate type-I endoleak, or partial endograft removal with interposition of a surgical prosthetic graft from the infrarenal aortic neck to the remaining endograft or iliac limbs.

In our case owing to the patients' active smoking, COPD and other comorbidities this unique procedure was planned. [4],[5],[6],[7],[8],[9]

Anatomic requirements for an aortic stent graft procedure

  • Infrarenal aortic neck length ≥20 mm (for infrarenal fixation) or 10-15 mm (for suprarenal fixation)
  • Infrarenal aortic neck diameter ≤28 mm, with no more than 1-2 mm thrombus lining and <3 mm diameter discrepancy at any point in the neck
  • Aortic neck angulation (junction between the aortic neck and the aneurysm) <60° (ideally <40°)
  • External iliac diameter ≥7 mm (with extensively calcified vessels) or ≥6 mm (with noncalcified vessels)
  • Iliac vessels without severe tortuosity, significant aneurysmal or occlusive disease.

In our case, the patient's infrarenal aortic neck was <1 cm with very minimal mural thrombus and dual renal arteries bilaterally. An aortic neck Dacron cuff proved to be an ideal solution to get a comfortable landing zone of 4 cm for the stent graft and providing good endoseal proximally and distally.

  Conclusion Top

Endovascular treatment of aortic pathologies has obvious appeal: Avoiding large surgical incisions, reduced blood loss, reduced Intensive Care Unit stay, less perioperative morbidity, earlier ambulation and shorter hospital stay. This case report depicts that modifying one of these criteria to convert an unsuitable case into a suitable one is feasible and can significantly boost the number of cases treated with EVAR. The Dacron cuff proved to be an ideal plan to convert a type-E infrarenal AAA to a type-B, thus avoiding the complications and morbidity of open repair, nevertheless careful selection of an "ideal" case cannot be emphasized more.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nabi D, Murphy EH, Pak J, Zarins CK. Open surgical repair after failed endovascular aneurysm repair: Is endograft removal necessary? J Vasc Surg 2009;50:714-21.  Back to cited text no. 1
Allenberg JR, Schumacher H, Eckstein HH, Kallinowski F. [Infrarenal abdominal aortic aneurysm: morphological classification as decision aid for therapeutic procedures]. Zentralbl Chir. 1996;121:721-6. German. PubMed PMID: 9012230.  Back to cited text no. 2
Pacanowski JP Jr, Dieter RS, Stevens SL, Freeman MB, Goldman MH. Endoleak: The achilles heel of endovascular abdominal aortic aneurysm exclusion - A case report. WMJ 2002;101:57-8, 63.  Back to cited text no. 3
Rose DF, Davidson IR, Hinchliffe RJ, Whitaker SC, Gregson RH, MacSweeney ST, et al. Anatomical suitability of ruptured abdominal aortic aneurysms for endovascular repair. J Endovasc Ther 2003;10:453-7.  Back to cited text no. 4
Gabrielli L, Baudo A, Molinari A, Domanin M. Early complications in endovascular treatment of abdominal aortic aneurysm. Acta Chir Belg 2004;104:519-26.  Back to cited text no. 5
Paravastu SC, Jayarajasingam R, Cottam R, Palfreyman SJ, Michaels JA, Thomas SM. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014 Jan 23;1:CD004178..  Back to cited text no. 6
Faries PL, Cadot H, Agarwal G, Kent KC, Hollier LH, Marin ML. Management of endoleak after endovascular aneurysm repair: Cuffs, coils, and conversion. J Vasc Surg 2003;37:1155-61.  Back to cited text no. 7
Sze DY, van den Bosch MA, Dake MD, Miller DC, Hofmann LV, Varghese R, et al. Factors portending endoleak formation after thoracic aortic stent-graft repair of complicated aortic dissection. Circ Cardiovasc Interv 2009;2:105-12.  Back to cited text no. 8
Veith FJ, Abbott WM, Yao JS, Goldstone J, White RA, Abel D, et al. Guidelines for development and use of transluminally placed endovascular prosthetic grafts in the arterial system. Endovascular Graft Committee. J Vasc Surg 1995;21:670-85.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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