Cardiovascular Journal of Africa: Vol 25 No 5 (September/October 2014)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 5, September/October 2014

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AFRICA

more distal longitudinal flexibility and are designed to prevent

kinking and provide refined adaptation to tortuous iliac arteries.

Finally, the graft delivery system is reduced by approximately

3 French (Fr) sizes from the smallest prior endograft delivery

system. It is available in outer diameters from 18- to 20-Fr for the

main body and from 14- to 16-Fr for the extensions. Bifurcated

main body proximal diameters include sizes of 23, 25, 28, 32

and 36 mm; limb diameters include sizes of 10, 13, 16, 20, 24

and 28 mm. The diameter of the stent-graft is oversized by

approximately 20% in relation to the outer aortic diameter at the

proximal fixation zone and about 10% in the distal landing zones

(usually the common iliac arteries).

Recently, renovation of the Endurant™ system has resulted

in an improved version. Endurant

II provides three additional

advanced design features: (1) a 35% extended hydrophilic coating

allows the 28-mm-diameter bifurcated component to fit inside an

18-Fr outer diameter catheter (initially 20-Fr with the original

Endurant); (2) availability of two new contralateral limb lengths

(156 and 199 mm) enables more configuration options and

requires fewer total components; and (3) improved radiopacity

of the distal end of the bifurcated component’s contralateral

gate increases visibility. The Endurant

II device received FDA

approval in June 2012.

The following technical scenarios are

also applicable to Endurant

II.

Technical notes

Scenario 1: Capture of the tip sleeve within the

suprarenal bare-stent anchoring pins

This scenario assumes that the main body of the bifurcated

component of the Endurant

stent-graft is deployed and the

delivery system advanced proximally as far as 3 cm apart from

the suprarenal stent [see manufacture instructions for use (IFU)

for system details]. The next step is very crucial and failure to

withdraw the delivery system until the spindle is retracted into

the fabric portion of the stent-graft results in trapping of a

suprarenal crown within the tapered tip sleeve.

Even though the steps described in the IFU for the Endurant

stent-graft system may be followed accurtely, in some cases,

especially severe angulated necks (

≥

60°), the markedly flexible

delivery system will follow the aortic configuration and stack

within the hooks of the suprarenal stent. To avoid the need for

open conversion, three simple techniques to successfully remove

the delivery system of this endograft are described:

•

The first action is to completely remove the stiff or super-

stiff guide wire (usually Amplatz™, Ontract, Archer™ or

Lunderquist) inside the delivery system, and then rotationally

withdraw the delivery system. Removing the wire allows the

graft to follow the natural aortic anatomy. Under straightfor-

ward circumstances, the device may bend along the body–ipsi-

lateral endograft, possibly avoiding stacking at the level of the

anchoring pins.

•

The above manoeuvre might be performed more safely if

catheterisation of the docking limb and insertion and deploy-

ment of the contralateral limb precedes delivery system with-

drawal. Otherwise its removal may be facilitated by keeping

the contralateral limb in place while moderately inflating (less

than the suprarenal aortic diameter) the molding balloon (e.g.

Reliant

, Equalizer or Coda) at the pins’ level prior to down-

ward removal of the delivery system (Fig. 1A, 1B).

•

When compelling anatomical conditions exist, another option

is to place a large introducer sheath (e.g. Cook 16- or 24-Fr),

through the already catheterised docking limb, advancing

above the suprarenal stent before delivery system withdrawal.

This manoeuvre leads to aorto-iliac axis ‘technical remodel-

ling’ with further proximal neck straightening, a condition

Fig. 1. (A) Inflation of the moulding balloon at the level of the pins prior to downward removal of the delivery system. (B) Angiogram

showing the above manoeuvre. Note the balloon that pushes the delivery system in the opposite direction. (C) Use of a snare

device to capture the spindle, while simultaneously retracting the delivery system with slow rotational movements.