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M. Drakopoulou et al.
When performing the procedure with ICE for imaging, two
vascular accesses are needed, while if TEE is used, a single
venous access is adequate. Access for the ICE catheter
requires an 8–10 French sheath placement and preferably a
length of 25–35cm sheaths are used as this gives stability to
the ICE catheter and helps avoid the tortuosity of the femoral
veins. The second access, depending on the operator preference, can start with a 6 French and can be upgraded to the
appropriate sheath size in the range of 6–12 French depending on the size of the closure device being used. Additional
arterial access may be obtained for pressure monitoring,
depending on the operator. Once both accesses are obtained,
the patient is anticoagulated, preferably with unfractionated
heparin. An activated clotting time (ACT) of >250s is maintained for the duration of the procedure. Thereafter the defect
is crossed with the J-tip guidewire from the right atrium into
the left atrium under uoroscopic and ICE guidance. Then
the J-tip guidewire is advanced into the left superior pulmonary vein, and a multipurpose catheter is advanced into the
left superior pulmonary vein. The J-tip guidewire is then
exchanged for a super stiff guidewire, and the multipurpose
catheter is removed. After this, the venous sheath in the femoral vein is removed, and an ASD sizing balloon is advanced
over the wire into the ASD.Under uoroscopic guidance, the
sizing balloon is slowly inated with contrast until the ow
across the ASD stops as visualized by the TOE.At this stage,
care should be taken to avoid overination of the balloon as
this will overestimate the size of the defect. The preferable
approach is to deate the balloon until the ow across the
ASD resumes and thereafter inate the balloon until the ow
across the ASD ceases again (“stop-ow” technique). Next,
the size of the defect will be measured on both uoroscopy
and the TOE using the “waist” on the ASD sizing balloon.
After this, the balloon is deated and removed over the wire
with care taken to prevent the wire from prolapsing out from
the pulmonary vein. Following this, the appropriately sized
sheath that can deliver the ASD device is advanced over the
wire into the left atrium, and the sheath dilator and the wire
are removed. Next, the appropriately sized ASD device is
prepared. The device is rst checked for integrity, and then is
immersed in a saline tub. After this, the device is attached to
the delivery cable, and is slowly pulled back into the loader
sheath while the side ush of the loader sheath is constantly
ushed to prevent any air from being trapped in the device or
the loader sheath. Next, the loader is attached to the delivery
sheath carefully without the introduction of air. The delivery
cable is advanced into the sheath, thereby advancing the
device into the delivery sheath. Thereafter, the device is
slowly advanced toward the tip of the sheath under uoroscopic guidance. Once the device reaches the tip of the
sheath, the sheath is withdrawn over the delivery cable to
unsheathe the left atrial disc. This can be visualized on both
TOE and uoroscopy. Once the left atrial disc is fully formed,
both the delivery sheath and the delivery cable are withdrawn
until the left atrial disc is well opposed to the interatrial septum on the left atrial side. A little tension should be maintained to cause tenting of the interatrial septum. Once the left
atrial disc anchors well on the left side of the septum and
there is sufcient tension on the interatrial septum by the left
atrial disc, the next step would be to unsheathe the right atrial
disc carefully. After this, the sheath is slightly withdrawn
away from the right atrial disc to decrease tension on the
device. Imaging is then used to examine the stability of the
device, and Color Doppler imaging is performed to verify
that the ASD is well sealed. Color ow may be noted across
the waist and the center of the device, but color ow at the
edges of the discs or away from the disc suggests that the
device may be smaller in size, or there may be additional
ASDs away from the current ASD location. In either case,
the device should be captured back into the sheath, and the
septum examined again for the presence of other ASDs in
proximity. In this situation, the device can be upgraded to a
larger ASD device or cribriform occluder if the other ASDs
are close to the primary ASD.If the other ASDs are >7mm
from the primary ASD, the other defects need to be closed
using additional ASD occluders. If there is no color ow
across the device, the delivery cable is wiggled with a strong
push and pull (Minnesota Wiggle) to examine the stability of
the device by both uoroscopy and imaging. If the device
looks stable and there is no ow across the device, the device
is released. Once the device is released, the stability and
color ow are again checked, and if they are satisfactory, the
sheath is withdrawn into the inferior vena cava [17].
Following this, imaging is performed to visualize the device
and look for pericardial effusion. Next, venous sheaths are
withdrawn from the body, and either a gure of eight stitch is
placed or manual pressure is held to achieve hemostasis.
Perioperative Care and Surveillance. The patient is given
clopidogrel 300–600mg orally in addition to aspirin, and dual
antiplatelet therapy is continued for 3months after the procedure. After the procedure, the patient is monitored overnight.
A follow-up echocardiogram is performed the following day
to verify the stability of the device and rule out any erosion
from the device and rule out any pericardial effusion. Then,
the patient is discharged and is followed up after 6months
with a repeat echocardiogram. Infective endocarditis prophylaxis is recommended after 6months for dental procedures.
Case Presentation
Continued from page 463
The Heart Team decided to proceed to transcatheter ASD
closure. As there were no signs of PAH, we did not proceed
to right heart catheterization. The procedure was performed
under general anesthesia and TOE guidance via right femoral approach. During the procedure the ACT was maintained
at >250s. A 6 French sheath was placed at the right femoral
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abc
461
Fig. 42.3 (a–c) Transoeosphageal (TOE) and corresponding uoros-
copy imaging in transcatheter ASD closure procedure. (a) Multipurpose
catheter crossing the ASD to the left upper pulmonary vein. (b) “Stop-
vein and the defect was crossed with the J-tip guidewire that
was advanced in the left upper superior pulmonary vein. A
multipurpose catheter was placed over the guidewire
(Fig.42.3a) that was exchanged with a super stiff guidewire.
After removal of the multipurpose catheter and of the venous
sheath, an ASD sizing balloon was advanced over the wire
into the ASD for sizing of the defect. By performing the
“stop-ow” technique, the size of the defect was measured
at 18mm on both uoroscopy and TOE using the “waist” on
the ASD sizing balloon (Fig. 42.3b). It was decided to
implant a 22mm Amplatzer occluder device. The delivery
sheath (9 French) was advanced in the left atrium; the sheath
dilator and wire were removed. After preparation of the
device, it was slowly advanced toward the tip of the delivery
sheath under uoroscopic and TOE guidance. Once the
device reached the tip of the sheath, the sheath was withdrawn over the delivery cable to unsheathe the left atrial
disc. After gently withdrawing the left atrial disc toward the
left side of the interatrial septum, the right atrial disc was
released on the RA side. Proper alignment of the device
with captured rims and no residual ow was conrmed on
TOE before releasing the device (Fig.42.3c). The patient
was discharged the following day on dual antiplatelet therapy for 3 months and aspirin for another 3 months. At
3-month follow-up, the patient remained asymptomatic, in
sinus rhythm, and the device is in situ and well seated with
no residual shunt or valvular regurgitation on follow-up
ow” technique for assessing ASD sizing and devise selection. (c) Final
device deposition
echocardiography. The patient is on dual antiplatelet therapy for 6months.
Left Atrial Appendage Closure
Case Presentation
A 79-year-old male patient with persistent non-valvular atrial
brillation, hypertension, and diabetes mellitus was deemed a
poor candidate for anticoagulation due to recurrent gastrointestinal bleeding while being treated with oral anticoagulants.
A TOE study assessed the feasibility of left atrial appendage
(LAA) procedure, documented a ‘chicken wing’ LAA morphology, and excluded any luminal thrombosis. The Heart
Team decided to proceed to transcatheter LAA closure.
Continued at page 471
Background. Atrial brillation (AF) is the most common
arrhythmia, affecting 1–2% of the global population. Its incidence in the general population is 0.05% cases per year and
it is expected to more than double by 2050in Western countries. The presence of AF increases the risk of embolic stroke
by four- to vefold and results in stroke incidence of 2–5%
per year in untreated patients. Such a disabling complication
is mainly related to thrombus formation within the LAA.
Indeed, the LAA, due to its trabeculae and blood stasis, is the
most common site of thrombus generation in patients with
AF [18].
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Oral anticoagulant drugs (OAC) are an effective treatment
to prevent embolic events in patients with AF; however, several drawbacks such as patient’s compliance and bleeding
risk limit their applicability [19]. In daily clinical practice,
the decision for OAC coverage in patients with AF is challenging and based on balancing patient thromboembolic and
bleeding risks. For this purpose, several risk score calculators have been developed, such as the CHA2DS2-VASc
score for the risk of stroke (≥1 additive score in men and
≥2 in women indicates risk of thromboembolism) and the
HAS-BLED score for the bleeding risk (≥3 additive score
indicates risk of bleeding) [20]. Due to the overlapping of
bleeding and thrombotic risk factors often observed in complex patients, the choice of the most appropriate therapy is
tricky.
Percutaneous LAA closure has been developed as a less
invasive procedure to prevent stroke in patients with AF who
cannot tolerate oral anticoagulation. This catheter-based technique provides an atrial endoluminal mechanical orice
obstruction [21]. There are currently two commercially available devices for the LAA: Amplatzer Amulet LAA occluder
(St. Jude Medical Inc., MN, USA) and WATCHMAN™ LAA
closure device (Boston Scientic Natick, MA, USA) [22, 23].
Indications for LAA Closure. Based on European
Society of Cardiology guidelines, LAA occlusion is recommended (Class IIb) for stroke prevention in patients with AF
and contraindications for long-term anticoagulant treatment
(e.g., intracranial bleeding without a reversible cause) [24].
Closure Devices. WATCHMAN™ LAA Closure
Device. The occluder device consists of a nitinol frame
structure with ten xation anchors along its waist. When
fully deployed, the nitinol frame has a parachute-like conguration. The proximal part of the system, which faces the
left atrium after implantation, is covered with a thin polyethylene terephthalate membrane which is designed to reduce
post-implant thrombus formation on the occluder, thus
allowing faster endothelialization. The device sizes range
from 21 to 31mm. The device is implanted through the femoral vein via the trans-septal technique and is fully retrievable and repositionable [25].
The Amplatzer™ Amulet™ LAA Occluder. The
occluder is a second-generation self-expanding device made
of nitinol that has a distal lobe and a proximal disc, connected by an articulated waist. The main lobe of the device is
meant to be implanted in the proximal 10–15 mm of the
LAA, and the disc covers the LAA orice. The lobe sizes
range from 16 to 34mm. As for the WATCHMAN™ LAA
Closure Device, this device is implanted through the femoral
vein via the trans-septal technique and is fully retrievable
and repositionable.
Preprocedural Screening and TOE Imaging Protocol.
Prior to the implantation of an LAA occlusion device, all
patients must undergo preprocedural imaging to explore the
anatomy of the LAA and exclude the presence of thrombus.
Preprocedural multimodality imaging with TOE or multidetector computed tomography (MDCT) with contrast injection
(as an alternative to TOE) enables measurement of the LAA
ostium, the landing zone of the elected occlusion device, and
the length of the LAA body, and it allows for characterization
of the shape of the LAA, especially when there are multiple
lobes (number, shape, and localization) [26].
During TOE imaging, LAA is imaged at the mid- to upper
esophageal view from 0° through 180° (at 0°, 45–60°, 90°,
and 120–135°) to dene the maximum LAA width and maximum depth of the dominant lobe (Fig. 42.4). A complete
180° scan is needed due to the highly variable anatomy of the
LAA. Most importantly, in some cases, LAA closure may
not be feasible owing to large ostia, presence of early lobe, or
early and severe main lobe bending. The two commercially
available devices need the following pre-specied
1. The Amplatzer™ Amulet™ LAA closure device:
Measurement will be taken at the orice of the LAA, with
a second measurement for the landing zone of the stabilizer disc (lobe), which is located 15mm from the orice
into the left appendage. Device size is selected based on
the maximal landing zone diameter by upsizing. The
company recommends 3–5 mm for 16–22 mm devices
and 3–6mm for 25–34mm devices. Care must be given
to the measurement of the orice of the LAA, to be sure
that the disc diameter exceeds the diameter of the orice
and completely covers it [27].
2. WATCHMAN™ LAA closure device: Measurement
will be taken in at least four views (0°, 45°, 90°, and
135°) with the ostium of the left circumex artery as the
essential landmark. Measurement should be done from
the edge of the LCX to the opposite wall of the LAA,
perpendicular to the axis of the LAA to a point around
1–2 cm below the ridge of the pulmonary vein.
Measurement of LAA length must be obtained from
every view, to ensure that the dimensions are within the
available device range. Care must be given as the depth of
the appendage should be greater than the ostium diameter
to accommodate the device. The company recommends
an occluder size about 20% larger than the largest diameter measured to achieve the compression rate needed to
engage the xation barbs of the WATCHMAN™ device
into the wall of the LAA.
Procedure. The procedure is performed under moderate
sedation or general anesthesia based on the echocardiographic procedural guidance (ICE or TOE). Antibiotic prophylaxis should be administered before the procedure.
During the procedure an ACT >250seconds should be maintained. The rst step of the procedure is the trans-septal
42 Atrial Septal Defect: Left Atrial Appendage
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a
b
463
c
d
e
Fig. 42.4 Transoeosphageal (TOE) imaging for left atrial appendage (LAA) closure. (a) 0° with the corresponding measurements, (b) 45° with
the corresponding measurements, (c) 90° with the corresponding measurements, (d) 135° with the corresponding measurements, (e) 3D image
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M. Drakopoulou et al.
puncture that should be performed in the posterior and inferior segment of the fossa ovalis to facilitate an anterior superior trajectory that optimizes the device. In cases where the
orientation of the LAA is cranial, the puncture site should be
lower, whereas in cases with a caudal orientation, the puncture site should be higher. However, independently of the
LAA orientation, all trans-septal punctures should be carried
out as far posterior. After trans-septal puncture, the transseptal sheath is advanced though the puncture into the left
atrium, and the needle is pulled back into the sheath. A stiff
a
wire is placed in the left upper pulmonary vein and the transseptal sheath is exchanged over the wire for the occludespecic delivery sheath. Depending on the LAA occlusion
device chosen, thereafter different steps should be followed.
For the WATCHMAN™ LAA Closure Device, after the
access sheath is introduced to the left side of the heart and
the dilator is removed, a pigtail catheter (5 Fr or 6 Fr) is
introduced through the access sheath and advanced into the
LAA to perform an angiography and make the necessary
measurements (Fig.42.5). Knowledge of the specic mark-
b
c
Fig. 42.5 Transoeosphageal (TOE) and corresponding uoroscopy
imaging in transcatheter LAA closure procedure. (a) Trans-septal puncture at the inferior-posterior part of the atrial septum. Short axis view
and bicaval view showing tenting of the atrial septum. (b) Pigtail cath-
eter is introduced through the access sheath and advanced into the LAA
to perform an angiography and make the necessary measurements. (c)
Final device deposition
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ers on the access sheath is mandatory for correct device
placement. Thereafter, the delivery catheter is advanced into
the access sheath under uoroscopic guidance and continuous ushing with heparinized saline until its distal marker
almost aligns with the distal marker of the access sheath. The
access sheath must then be pulled back gently until the operator feels a click. This interlocks the access sheath with the
delivery catheter. After checking the position of the delivery
system uoroscopically, the occluder can be deployed. The
interlocked access and delivery sheath are pulled back while
holding the delivery cable of the device in a stable position.
This allows the device to deploy while still being xed to the
delivery system. The combined delivery system allows complete retrieval of a deployed occluder in case of insufcient
placement.
The Amplatzer™ Amulet™ LAA occluder device comes
preloaded in the delivery sheath. Pulling back the delivery
sheath while holding the device within the neck of LAA
deploys the distal lobe of the occluder. After satisfactory
positioning of the lobe, the proximal disc is deployed by further pulling back of the retrieval sheath. Successful implantation is dened by proper compression of the lobe, separation
of the lobe and the disc on angiography, concave shape of the
disc, and correct angulation of the lobe and disc in relation to
the plane of the LAA ostium. In case of unsatisfactory positioning, the device can be recaptured.
For both occluder devices, when optimal device position,
sizing, and device seal are ensured in angiography and in
TOE, a last test of stability, a tug test, should be performed
before releasing the occluder. For this purpose, the delivery
core wire is gently pulled under simultaneous injection of
contrast medium to see the movement of the LAA together
with the occluder. After successfully passing this test, the
device is released from the delivery system by turning the
core wire counterclockwise ve times. Final contrast injections as well as a nal control with TEE in all four views (0°,
45°, 90°, and 135°) to check for residual leaks are
recommended.
Perioperative Care and Surveillance. Dual antiplatelet
therapy with 100mg of aspirin and 75mg of clopidogrel for
6months is recommended after the implantation. In case of
successful occlusion of the LAA and missing evidence of
thrombus formation on the occluder, thereafter we stop clopidogrel and aspirin.
Case Presentation
Continued from page 467
The procedure was performed under general anesthesia
and TOE guidance through the right femoral access. The
Amplatzer™ Amulet™ LAA Occluder (28mm) was successfully implanted. The early echocardiographic control did
not report any device-related abnormality or any residual
leak. The hospital course was uneventful and the patient
received a dual antiplatelet therapy (clopidogrel 75mg o.d.
and aspirin 100mg o.d.) after discharge.
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Part VIII
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Aortic Aneurysm Disease
Endovascular Repair ofAbdominal
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Aortic Aneurysms (EVAR): Studies
onLong-term Results
ChristosD.Liapis
43
Case Presentation
A 72-year-old patient with a 7,2 ruptured infrarenal aortic
aneurysm was managed with endovascular aneurysm repair
using a Zenith Endograft (Cook Medical). The patient was
followed up yearly with a duplex ultrasound and a CT scan
due to the presence of a type II endoleak. While initially
stable, 4 years later the aneurysm sac started to grow. At
8-year follow-up the aneurysm sac was approximately 8cm
and a type Ia along with a type II endoleak were clearly visible. The right iliac limb was also pulled back at the orice of
the right common iliac artery (Fig.43.1).
An 80-year-old patient with a negative stress echocardio-
gram was scheduled to undergo hybrid aneurysm repair.
Continued at page 476
The mortality rate due to ruptured aortic aneurysms has
shown a remarkable decline over the last 20years [1]. This
is attributed to markedly reduced prevalence of the disease,
the initiation of population screening for aneurysms in many
countries, and probably the introduction of endovascular
aortic repair. Multiple publications indicate that the comparison of aneurysm-related deaths between the UK and
USA is in favor of the USA policy of adopting EVAR as rst
choice treatment, while in the UK they register more
aneurysm- related deaths than operations for non-ruptured
aneurysms, seven times higher than in the USA [2]. Another
reason for this difference is the real-world threshold for
repairing an abdominal aortic aneurysm (AAA), which is
over 55mm for both men and women in the UK and over
50mm in the USA [3].
The comparison of 30-day all-cause mortality between
open repair and EVAR in the three randomized trials
(DREAM, EVAR-1, OVER) showed a remarkable difference
in favor of EVAR (4.6% vs 1.2%, 4.7% vs 1.7%, 3.0% vs
0.5% respectively). This difference disappears in the 8-year
follow-up EVAR-1 trial. The increased late mortality is
C. D. Liapis (*)
Vascular and Endovascular Surgery Clinic, Athens Medical Center,
Athens, Greece
e-mail: liapis@med.uoa.gr
attributed to a higher number of complications and reoperations in the EVAR arm of the study [4], especially in the
period 6 months to 4 years when the reoperations were 6
times higher for the EVAR group. In the follow-up period
after 8 years, the EVAR group showed increased total
(p = 0.49, HR: 1.25) and aneurysm-related mortality
(p=0.0064, HR: 5.82) [5]. Of interest is the increased rate of
malignancies, especially gastrointestinal, in the EVAR group
after 8-year follow-up (adjusted HR 1.87, p=0.007) [6].
In the DREAM trial, 6years post randomization, the survival rates were similar between the two groups, while the
rate of secondary procedures was higher for the EVAR group
after the fourth year [7]. The secondary procedures were
almost entirely endovascular. The 12-year survival showed
no statistically signicant difference in total (42.2% OR,
38.5% EVAR p = 0.48) aneurysm-related (7.7% OR, 3.1%
EVAR p=0.33) or malignancy-related [8] mortality.
In the OVER trial, after 11years’ follow-up, an increased
number of secondary procedures was noted in the EVAR
group (193in 117 patients vs 116in 85, p=0.04), while the
long-term overall survival did not show any statistical difference between the groups (302/444 (68%) pts. EVAR,
306/437 (70%) OR P=0.61) [9].
In the EVAR-2 trial, comparing EVAR to no repair in
patients with considerable comorbidities, the 12-year results
showed similar overall survival but signicant aneurysmrelated survival in favor of the EVAR group [10].
For the treatment of ruptured aneurysms, the most comprehensive trial comparing open repair to endovascular strategy is the IMPROVE trial [11]. The 30-day death rates did
not show any statistically signicant difference. However,
the cumulative incidence of being discharged directly home
by randomized group showed 17 mean days of discharge for
the endovascular group and 26 for the open repair group, and
this difference was statistically signicant (p<0.001). The
1-year survival was similar for both groups with 4.5% difference in favor of EVAR (p=0.325). Further analysis of the
1-year survival showed that the endovascular strategy yields
better results for women and patients with multiple comor-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_43
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C. D. Liapis
ab
Fig. 43.1 Preoperative CT angiogram; (a, b) Type Ia and II endoleaks, (c) notice the right iliac limb retracted, (d) intraoperative angiogram con-
rming the long distance of the right iliac limb from the iliac bifurcation posing a risk for future type Ib endoleak
bidities. In the quality-of-life aspect, using the EQ-5D score
and up to 36months, the results were considerably better for
the endovascular strategy group up to 12months, but this difference was diminished until the end of the study period.
Reviewing the randomized trial EVAR vs open repair
and specically looking at the rate of myocardial infarctions
in the short and long term following the initial procedure, it
was noted that although in the short term there were fewer
MIs in the EVAR group, this trend was reversed in the long
term [12].
One of the reasons for this besides the increased number
of secondary procedures is the increased arterial stiffness
caused by the insertion of the stiff endovascular graft. This
has been shown by multiple studies examining the effects on
left ventricular function following EVAR [13].
There are multiple tests besides the cardiac ultrasound
that can evaluate arterial stiffness, the most popular being the
measurement of pulse wave velocity (PWV), which is an
independent predictor of cardiovascular morbidity and mortality [14–16]. We have previously shown that PWV is
upregulated in patients with AAA vs those without [17].
Furthermore, comparing patients with AAA open repair and
EVAR, we have found that open repair caused moderate
increase in PWV, while EVAR was associated with signicant (p<0.001) increase in PWV up to 6months following
the initial procedure [18]. In looking at differential effects of
stent-graft fabrics on arterial stiffness, it was noted that PWV
was more pronounced in the Polyester Woven group compared to the PTFE group [19].
Looking at the cardiac effects of aortic endografts by
measuring PWV and NT-proBNP changes in patients following TEVAR, we have also noted a statistically signicant
increase in both NT-proBNP and PWV 48h after the operation and up to 6months post operation [20].
Based on the above-mentioned studies, the International
Societies have published recommendations for the treatment
of patients with AAA.Comparing these recommendations,
we see that for the intact AAAs the NICE recommends open
repair unless contraindicated, while the ESVS feels that
EVAR should be considered in patients with reasonable life
expectancy (most patients). For ruptured aneurysms, NICE
suggests considering EVAR or open repair with the caveat
that open is better for men aged <71years, while ESVS recommends EVAR as a rst option [21].
The SVS Guidelines suggest assessment of operative risk
and life expectancy for intact AAA, as well as informing
patients about the perioperative mortality risk score, while
for ruptured AAA, EVAR is recommended over open repair
with a (strong) 1 level of recommendation, although with
(low) C quality of evidence [22].
Overall, the EVAR strategy initially has superior results
compared with open repair; however, the long-term results
have failed to show a clear advantage. We need careful and
individualized patient selection as well as improvement in
the design and quality of the endografts. This combined with
well-designed screening programs and improved training of
the vascular surgeons will guarantee further improvement in
the prevention and treatment of AAAs.
Case Presentation
Continued from page 475
Under general anesthesia, the patient underwent left axillary artery dissection and subsequently midline laparotomy.
The suprarenal aorta was dissected and prepped for possible
clamping.
A compliant balloon (Reliant, Medtronic) was advanced
over a wire and through a 12Fr sheath into the aorta at the
supraceliac level. After heparinization and balloon ination
for proximal control the aortic sac was opened. Lumbar
arteries and the inferior mesenteric artery were backbleeding and suture ligated. Temporary balloon deation conrmed a type Ia endoleak. Using pledgets and 3–0 prolene
the proximal endograft was hand sutured circumferentially
at the aortic neck (Fig. 43.2). Appropriate inow sealing
was conrmed. A 14mm iliac limb (Gore Excluder) was
then introduced through right femoral cutdown. Final angiogram and follow-up CT angiogram were unremarkable
(Fig.43.3).
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