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394 Technical aspects of treating aortic aneurysms
hemostasis. A second ProGlide™ is advanced using
the same maneuver. Aer guidewire removal, the
ProGlide™ is advanced into place until back-
bleeding is achieved through the side port. e
ProGlide™ is angled 30° to the opposite side and
the sutures are placed. e catheter is removed and
the guidewire advanced again into the aorta. e
8-Fr sheath is replaced over the wire and the sheath
is ushed. e two sets of sutures are then covered
with towels for later usage to close the artery. e
process is repeated on the contralateral side.
CLOSURE OF LARGE BORE ACCESS
Aer endovascular aortic treatment or other pro-
cedure requiring large bore access is completed,
closure is performed (Figure 28.2). In the course of
closure the following steps are taken. e sutures
are monolament and will slide easily when wet.
If there is dried blood or tissue clinging to the
sutures, they may form a knot. ese must be thor-
oughly wetted with heparinized saline.
One of the two sutures is completely blue in
color and this is the one that should primarily be
retracted or pulled when bringing the knot down
to the surface of the artery. e other suture has
a long white segment at its tip and should only be
retracted to set the knot. Inadvertently pulling on
this suture will lock the knot and make that par-
ticular pre-close suture useless. A knot pusher
is placed on the blue suture. e blue suture is
retracted slightly to make sure it is free, to remove
any redundancy in the suture, and to begin to bring
the knot down to the surface of the artery. e
guidewire is le in place. An assistant holds exter-
nal pressure on the patient proximal and distal to
the access site to avoid bleeding when the sheath tip
comes out of the artery. A second assistant removes
the large bore sheath leavingthe guidewire in place.
As the sheath is removed, the assistant holding the
pressure typically senses that the tip of the sheath is
about to be removed from the artery and can gauge
external pressure accordingly. While retracting the
blue suture, the operator pushes the knot using the
knot pusher. To set the knot, the suture end with
the white tip must also be retracted. Typically, the
white-tipped suture is not retracted at this point
and the knot is not set until it is clear that the pre-
close sutures, as placed, will achieve hemostasis.
e assistant holding the pressure gently releases
the pressure to assess the degree of backbleeding.
Ifthe bleeding is nil or mild, the Bentson guidewire
is gently and slowly removed. A Bentson guide-
wire is used for this maneuver because the stier
exchange guidewire may cut or slice the artery wall
at the access site; the Bentson is soer and more pli-
able and less likely to cause this type of damage. e
assistant continues to hold external pressure. With
the wire out, attention is turned to the second set of
sutures. e sutures must be thoroughly wet prior
to setting them, since they are monolament. e
knot pusher is used to push the second knot down
on the blue suture while retracting the blue suture.
e second suture can then be set by putting trac-
tion on the white-tipped suture and the blue-tipped
suture simultaneously. Attention is then turned
back to the rst suture. e rst suture is set by put-
ting tension on both the suture with the white tip
and the suture with the blue tip while simultane-
ously pushing the knot.
If there is signicant bleeding when the assis-
tant releases the pressure, the Bentson guidewire
is maintained in place prior to pushing down the
second knot. Aer the second knot is pushed down,
if there is hemostasis, the wire is carefully removed.
If hemostasis is poor, the wire can be used to place
a third ProGlide™, if needed. Do not set any of
the sutures in place (i.e., do not retract the white-
tipped suture) until it is determined that a third
ProGlide™ is not required and the wire can be
removed. Very occasionally, a fourth ProGlide™ is
required. Aer all four knots are set and the suture
ends are trimmed, direct nger pressure is admin-
istered onto the artery. Protamine may be adminis-
tered if desired.
MANAGING BAD ILIAC ARTERIES
Iliac arteries serve as the access arteries for proce-
dures of the aortic arch, thoracic aorta, abdominal
aorta, and also for structural heart procedures.
e majority of patients considered for these pro-
cedures can be treated, but in certain categories of
patients, access will be challenging or impossible.
e larger the sheath, the greater the challenge.
Iliac arteries that are calcied, tortuous, small, or
diseased can also be challenging. A combination
of some of these factors is present in a minor-
ity of patients. Calcication is usually the most
signicant challenge faced in managing bad iliac
arteries (Figure 28.3). Arteries that have occlusive
disease can generally be repaired. Tortuosity can
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Managing bad iliac arteries 395
A
D
C
FE
B
Fig. 28.2 Closure after pre-close technique. (A) During the procedure, there are two sets of sutures
on each femoral artery. These are held securely using shodded clamps. At the conclusion of the pro-
cedure the stiff exchange wires are replaced with soft-tipped, atraumatic wires such as Bentson wires.
This is because withdrawal of a stiff exchange wire through the pre-close site may cause the hole to
enlarge or the artery to be cut longitudinally. (B) One of the two small groin incisions is shown here.
The wire extends from outside the patient into the aorta. The knot pusher is placed on the clear blue
colored suture. Pressure is applied proximal and distal to the incision by an assistant to prevent sig-
nificant backbleeding. This prevents major bleeding when the sheath is removed. (C) When the sheath
comes out, the knot pusher is used to rapidly push the knot down to the arterial surface while holding
tension on the clear blue suture and leaving the white-tipped suture without tension. Tension on the
suture with the white tip is avoided at this juncture. Tension on the white-tipped suture sets the knot.
This is not desirable if a third Perclose ProGlide™ closure device is required for hemostasis. (D)After
the first knot has slid down to the artery, the knot pusher is left on the blue suture. The shodded
clamp can be replaced and the sutures left at rest. The process is repeated with the other suture.
The knot pusher is placed on the clear blue suture and the knot is slid down to the artery surface. At
this point the assistant can gently and gradually release pressure enough so that bleeding through
the site can be assessed. If bleeding is not severe the wire is removed. If bleeding is severe, consider
placing another Perclose ProGlide™ closure device over the wire and deploying it. (E) After the wire is
removed, the knot pusher is placed back down to the surface of the artery to secure the knot in place,
and both sutures are then held under tension while keeping the knot pushed down. Tension on the
suture with the white tip sets the knot. Once the knot is set, no further tension or tightening should
be placed on it. (F) The same process is completed with the initial set of sutures. The knot pusher is
again used to place the knot down to the artery surface with tension on the blue-tipped suture. At
this time, tension is also placed on the white-tipped suture to set the knot.
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396 Technical aspects of treating aortic aneurysms
be manipulated. Small arteries can be stretched to
their limit and, if not adequate in caliber, an alter-
native must be sought.
Calcified arteries
Manipulation of calcied arteries is challenging
and tolerance is poor. ese arteries may suddenly
break, rather than bend. When tortuous arteries
are calcied, they generally cannot be manipu-
lated. Calcication, even in straight arteries, may
prevent the passage of a larger sheath and may
prevent the endogra from opening in an accept-
able manner. ese arteries must be dilated to
permit passage of a larger sheath. A common nd-
ing is that a calcic segment of the iliac arteries
may prevent passage of the sheath at specic catch
points, even if they do not appear to be severely
narrowed and sometimes if they have already been
treated with balloon angioplasty. A preoperative
CT angiogram will show whether calcication is
continuous. If there are segments that are soer
and less calcied, this can be used to the opera-
tor’s advantage. Aer guidewires are placed, the
operator has the choice of using long progressively
sized angioplasty balloons or using graduated
arterial dilators. Either way, gradually stretch-
ing the arteries and identifying points of resis-
tance is extremely helpful. One option is to use
angioplasty balloons that are 8 or 10 cm in length
and gradually dilate from the smallest required,
sometimes as small as 4 mm, up to 6 or 8 mm.
Even then, sometimes a calcium ledge will resist
sheath placement. Occasionally, the operator has
to switch plans and go from the contralateral side
and change the operative plan accordingly.
Artery size
When the artery diameter is 1 mm or more larger
than the outside diameter of the sheath, the like-
lihood is high that passage of the sheath will be
straightforward. If calcication or occlusive dis-
ease is present, or some combination of these, and
A B C
Fig. 28.3 Managing bad iliac arteries: calcified, small, or diseased arteries. (A) Bilateral iliac wires are
placed. These are exchanged for stiff exchange guidewires. These will mark the path of the delivery
sheath for the endovascular device. When the iliac access vessels are small, diseased, or calcified, the
arteries must be dilated in preparation for use as access vessels. (B) A series of smooth, over-the-wire,
graduated dilators are used with progressively enlarging diameters in order to dilate the arteries
slowly and assess the locations where the sheath is likely to hit obstacles. (C) Progressive enlarge-
ment of the artery can also be performed with long angioplasty balloons of progressive sizes. It is
usually best to start with a small diameter (4–6 mm) balloon and use a long balloon that covers most
of the area or all of the area in question. The balloon can be slowly inflated and left inflated for several
minutes.
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Managing bad iliac arteries 397
the sheath is nearly as large as the artery in caliber,
this disease must be managed with gradual, step-
wise dilation. When the artery diameter is equal
to the outer diameter of the sheath, there will be at
least some resistance to sheath placement. Passage
is likely only if the artery is otherwise healthy. If
the artery has stenosis, calcication, or tortuosity,
a plan to manage these should be considered prior
to the procedure. is might include progressive
balloon angioplasty or progressive placement of
rigid, over-the-wire arterial dilators. In the situ-
ation in which the artery luminal diameter is the
same size as the outer diameter of the sheath, the
sheath may not pass through the femoral access,
even with preparation of the access artery. If the
artery diameter is smaller than the outer diameter
of the sheath, the operator must decide if a con-
duit is a better choice or whether the sheath can
be placed through the femoral artery aer prep-
aration of the pathway artery. e operator may
decide to switch access to the contralateral side,
even if gra placement, once introduced inside
the patient, may be more challenging based on
the sidedness of the access. Lastly, if the access
iliac artery luminal diameter is smaller than the
sheath diameter and the access artery has calci-
cation, occlusive disease, or tortuosity, a conduit
should be performed. A plan for managing these
characteristics must be put into place prior to
the procedure, with contingencies and some idea
about bailout points. Conduits may be external or
internal and are discussed in a later section. e
correct answer is not always apparent and these
are general rules. e presence of small iliac access
arteries may also inuence the operator’s choice of
which device to use for treating the patient. ere
is signicant variation in sheath size for dierent
devices. For example, infrarenal abdominal aor-
tic aneurysms may be treated with endovascular
gras with access ranging from 14-Fr to 20-Fr.
Diseased arteries
Occlusive disease involving the common and
external iliac arteries occurs with some regularity.
is can usually be treated with dilation at the
time of the aortic procedure. e balloons or dila-
tors are sized to the artery in the same manner that
routine iliac occlusive disease is treated. When a
stent is required, it is usually best to perform bal-
loon angioplasty of the artery to prepare it for the
sheath access, and then to stent the artery aer
the endovascular procedure as the sheath is being
removed (Figure 28.4). e benet of this “plasty
on the way in, stent on the way out” approach is
that the stent cannot be damaged during sheath
insertion. Occasionally, even a very well-placed
stent may present an obstacle to the approaching
sheath. is is more likely to occur if the stent is
in a curved segment or if there is a rm, calci-
ed segment next to the stent that inhibits vessel
pliability.
Tortuosity
Iliac artery tortuosity is quite common and must
be managed for successful delivery of a large bore
sheath (Figure 28.5). Arterial injury occurs when
the vessels are pushed beyond their tolerance.
Noncalcied but tortuous arteries generally have
good tolerance to manipulation and can change
conguration signicantly during access for an
aortic procedure. Tortuosity does not resolve with
stenting; tortuosity typically is transferred to
another segment of the vessel. If a substantial por-
tion of the arterial length is to be stented, tortuosity
along other segments proximally or distally may
appear to worsen as the curvature is transferred to
those sections. Tortuosity can usually be managed
in a stepwise fashion. e artery may not accept
the stiest device at rst, but a process of progres-
sively and gradually stiening the artery can be
performed. Initially, a so guidewire followed by a
catheter, followed by placement of a slightly stier
wire is useful. At this point, the tactile feedback to
the operator will tell how resistant the artery will
be to straightening. Next steps might include a low-
prole sheath, followed by an exchange guidewire,
such as an Amplatz Super Sti
®
or Lunderquist
®
.
Next, graduated arterial dilators can be used over
the exchange guidewire to prepare the tract. In a
worst-case scenario, a through-and-through wire
can be placed and externalized to create a rail with
the ability to put traction on both ends. When tor-
tuosity is associated with occlusive disease, it can
usually be managed, but care must be taken to
avoid stenting of any segments that do not require
it. As much tortuous vessel as possible should be
le without coverage so that vessel curvature can
be permitted in these segments. Tortuosity com-
bined with calcication is usually the most chal-
lenging situation. Tortuous arteries that are also
https://t.me/med1917
398 Technical aspects of treating aortic aneurysms
calcied will not ex anywhere near the extent
that noncalcied arteries will ex to allow sheath
placement.
If there is substantial tortuosity in the bilateral
iliac arteries, sometimes it makes sense to place
an exchange wire just on one side and use that for
the largest sheath placement; leave a so wire on
the contralateral side while doing this so that all
of the tension favors straightening of the side with
the larger sheath. is avoids the need to have both
iliac arteries perfectly straight at the same time. In
terms of dilation or preparing the arteries, if there
is calcication or signicant disease, the author
recommends using dilators that extend to the size
of the sheath or just less than that. When using bal-
loon angioplasty, it makes sense to go larger than
the size of the sheath, knowing that there will be
some recoil and some relative areas where dilation
will not be as eective on the calcied or diseased
arteries.
CONDUITS
A conduit may be used to create access to the vas-
cular system that is not otherwise possible given the
restrictions of the available anatomy. Most conduits
are “external”, meaning that there is a hand sewn
anastomosis between a major access artery and a
A
B
C
D
Fig. 28.4 Balloon on the way in, stent on the way out. (A) A patient presents for aneurysm treat-
ment with severe bilateral iliac artery occlusive disease that will likely require stenting. (B) Bilateral
wires and sheaths are placed. Balloon angioplasty is performed in preparation for stent–graft access
through the iliac arteries. Iliac artery bare metal stenting of occlusive disease at this point can result
in a potential obstacle through which the sheath must pass, and is therefore best avoided at this
juncture. (C) After endovascular graft placement the access iliac arteries are reassessed. (D) In this
example, the stent–graft extends to the iliac artery bifurcation. Occlusive disease in the external iliac
artery is treated with a standard nitinol stent.
https://t.me/med1917
Conduits 399
prosthetic gra and the prosthetic gra is tempo-
rarily “externalized” to permit the introduction of
devices. e inclusion of this maneuver means that
a component of the procedure is open and this is
akin to a hybrid operation; less in magnitude than
if the entire procedure were performed as an open
operation, but greater in magnitude than a com-
pletely endovascular solution. ere is another
category of conduit, an “internal” conduit, where
theiliac artery is relined with covered stents, such
as Viabahn™, and the artery is stretched beyond its
acceptable diameter to the point of rupture or near
rupture. Placing an internal conduit is less common
than placing an external conduit. Internal conduits
are limited to the iliac arteries, and access is not
guaranteed. e advantage of an internal conduit is
that it can be used as a backup plan when a conduit
is needed but has not been prepared for in advance,
A B C
D E
Fig. 28.5 Managing bad iliac arteries: tortuous arteries. (A) There is significant bilateral tortuosity
of the iliac arteries. (B) A femoral access sheath is placed and a Glidewire
®
advanced. With severely
tortuous arteries, the simple placement of a femoral access sheath may cause some of the tortuosity
to become more severe. In general, it is best to gradually straighten the artery with a progressively
stiffened or telescoping system. The guidewire and catheter are advanced as far as possible, through
the sheath. Tortuous arteries also tend to cause the femoral sheath to back up as the sheath is pushed
backward. (C) After guidewire and catheter advancement the sheath can also usually be advanced,
typically beyond the first severe curve. This may permit the wire and catheter to be advanced further.
Some or all the components in the system might require being manually stabilized since the prevail-
ing forces generally will be aimed toward backing these devices out of the artery. (D) In this case the
catheter and guide are advanced further. After the catheter has extended fully through the tortuous
segment and is secure in the thoracic aorta, a stiff exchange wire can be placed. (E) A stiff exchange
wire is advanced through the catheter. As the severely tortuous iliac artery is straightened, a cor-
rugated or beaded appearance may result. The integrity of the artery cannot be judged when it has
assumed this configuration.
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400 Technical aspects of treating aortic aneurysms
or when the patient is not able to have an external
conduit due to comorbid issues.
Conduits are used to allow entry of a sheath that
is too large for the native artery. is may be due to
basic arterial size or it may be due to severe disease,
calcication, or tortuosity. Conduits may be placed
for proximal access, usually at the axillary artery, or
may be placed for distal access, usually at the iliac
artery. A distal conduit at the common or external
iliac artery permits the operator to avoid passing a
delivery sheath through a small or diseased com-
mon femoral and distal iliac system. ese large
conduits are typically for the delivery of endogras
or structural heart devices. Conduits associated
with the upper extremity arteries are usually placed
for delivery of branch gras, which are performed
in concert with endovascular aneurysm repair.
ere may be several smaller sheaths requiring
access through the same conduit. Structural heart
devices may also be placed through an axillary
artery conduit. is permits the operator to avoid
passage through the brachial artery and distal por-
tion of the axillary artery.
Iliac artery conduits require open exposure,
usually through a ank incision and usually on the
patient’s le-hand side (Figure 28.6). Anastomosis
is required so a proximal and distal clamp zone
is needed. Axillary artery conduits are placed
through a transverse infraclavicular incision in
order to expose the axillary artery (Figure 28.7).
Proximal and distal clamping is required. A 10 mm
or 12 mm prosthetic gra is sewn into place and
the required sheaths are passed into the conduit.
Aer a conduit has been placed, it is usually best
to clamp its end. If smaller caliber sheaths are to be
placed, from 5- to 12-Fr, it is usually best to punc-
ture the conduit and insert the sheath through
the side of the conduit gra. is way numerous
sheaths may be included without any additional
access. To avoid bleeding, a dacron tape is looped
around the conduit and cinched up with a Ramel
tourniquet. Several dacron loops may be placed, if
needed. If a larger sheath is required, larger than
10–12-Fr, consider placing it into the end of the
conduit, looping it with a dacron tape, and cinch-
ing it with a Ramel tourniquet.
e sheaths may be manipulated in this man-
ner in the same way they would be if percutane-
ous access had been achieved. Take care not to put
excess traction on the artery-to-gra anastomosis.
A
B
C
Fig. 28.6 Conduit for aortic access. (A) A left flank incision is performed. The dissection is carried into
the extraperitoneal space. A roll may be placed under the patient’s left lumbar area during position-
ing to bring the flank in an anterior direction. (B) The left iliac artery is exposed and the left iliac vein
is often visible in the field. (C) The iliac artery is dissected out and clamps are placed proximally and
distally along the artery. A longitudinal incision is performed on the anterior surface of the artery.
A10 or 12 mm diameter prosthetic graft (either dacron or PTFE) is sewn to the side of the artery.
Thesheath may be advanced through the end of the graft. A dacron tape and Ramel tourniquet are
used to secure the conduit around the graft and prevent further bleeding.
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Endograft placement 401
With the conduit in this position, ow through the
iliac artery or axillary artery is maintained. When
the procedure is completed, the conduit gra
is le on the artery and ligated just distal to the
anastomosis.
Internal conduits are created by lining the
iliac artery with covered stents, such as 10 mm
Viabahn™ stent–gras, and intentionally over-
dilating the artery. is could be performed in a
planned way, in which the preoperative case plan
includes this maneuver. However, more oen, this
is a bailout maneuver that is performed because
the important working sheath for device insertion
cannot be advanced, and this is a viable option.
ere is some uncertainty in this procedure, which
oen requires coverage of the internal iliac artery.
e artery is enlarged using the equivalent of a
controlled rupture, but it is usually hemostatic. If
the artery ruptures through the adventitial level,
the procedure may not be hemostatic. e weak
points are at the ends of the endogra and also at
the origin of the internal iliac artery, where bleed-
ing may occur.
ENDOGRAFT PLACEMENT
ere are numerous device-specic issues with
regard to thoracic or abdominal gra placement
that will not be covered here. One issue that is
common to all devices is the need to obtain a rea-
sonable landing zone. In order to do this, the best
angulation must be obtained to show the origin
of the pertinent branch artery (Figure 28.8). In
the case of thoracic stent–gras, there is usually
one arch branch that makes the proximal limit of
the landing zone. In the case of infrarenal gras,
the lowest renal artery is usually the target. It is
worth spending a few moments to achieve this.
In addition, the relationships may change slightly
aer the sti exchange guidewire and sheath are
inserted and these relationships may need to be
rechecked prior to gra deployment. It is also com-
mon to advance the tip of the sheath and the gra
to a location beyond the landing zone and then
to pull the sheath and then the gra back. Gra
deployment is usually started at a level that is more
proximal than its intended placement site. For all
of the devices, the natural tendency is for the gra
to move distally during the placement process. e
most challenging situations in this area have to
do with tortuosity near the landing zone, such as
A
B
C
Fig. 28.7 Conduit for upper extremity access.
(A) An infraclavicular incision is performed and
the axillary artery is exposed. The axillary artery
is clamped proximally and distally and a longi-
tudinal incision is performed. A 10 or 12 mm
diameter graft is sewn to the side of the axillary
artery. The end of the graft is cross clamped to
prevent bleeding. (B) The conduit is punctured
and the wire and then the sheath are inserted
and advanced through the anastomosis across
the axillary and subclavian arteries and into the
aorta. The end of the graft is cross clamped.
Any additional sheath access can be per-
formed through the side of the prosthetic graft.
(C)Bleeding can be controlled with dacron tapes
encircling the graft and the sheaths and one or
more Ramel tourniquets to secure the sheath
within the conduit.
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402 Technical aspects of treating aortic aneurysms
arch curvature or a tortuous infrarenal aortic neck
(Figure 28.9). is circumstance provides a situa-
tion in which small movements of the device may
suddenly result in a large change in device posi-
tion, usually falling distal to the intended landing
zone. Straightening of the arch or neck as much as
possible is helpful. A through-and-through wire
may also be helpful (Figure 28.10). With endogra
placement, blood pressure manipulation for inter-
mittent hypotension or bradycardia is usually not
required, but in the case of a tortuous landing zone,
this may be of value. When landing the end of gra
in a tortuous aortic neck, it also makes sense to use
the sheath as a support and to only retract it as nec-
essary. If the sheath is retracted too much, the gra
may fall into the aneurysm.
A
B
C
Fig. 28.8 Angulation of the image intensifier for graft placement. (A) In this example, the growth of the
aneurysm has caused anterior displacement of the aorta. In order to see the neck in its true dimension
and identify the location of the origin of the renal artery, a craniocaudal angulation of the image
intensifier must be performed. This is a very common configuration. Since the aorta is a left-sided
structure, the aorta also rotates as it migrates anteriorly. Because of this, the renal arteries are usu-
ally best visualized in a slight left anterior oblique projection. (B) The iliac artery bifurcation is typically
visualized with severe caudocranial angulation and sometimes with significant obliquity, depending on
the rotation of the iliac arteries as the system elongates. The internal iliac artery has a posterior trajec-
tory and typically anchors the iliac bifurcation. Tortuosity along the common and external iliac arteries
can cause a variety of configurations. (C) The celiac and superior mesenteric arteries originate from
the anterior surface of the aorta. When the graft is being placed close to the origins of these vessels, a
lateral view or substantially oblique view is required to identify the origins of these arteries.
https://t.me/med1917
Cannulation of the contralateral gate 403
CANNULATION OF THE
CONTRALATERAL GATE
In most situations, cannulation of the contralat-
eral gate can be performed by withdrawing the
angiographic catheter from the contralateral side,
which is used to guide aortic gra placement, and
withdrawing that catheter into the aneurysm sac
(Figure 28.11). e Glidewire
®
is advanced. A sim-
ple angled catheter is passed over the Glidewire
®
and this is used to cannulate the contralateral gate.
Oblique views are helpful to demonstrate the dif-
ference in depth between the contralateral gate and
the guidewire. Usually, the guidewire and cath-
eter are posterior within the aneurysm, but this
depends on the trajectory determined by the angle
of entry from the iliac artery. e contralateral
gate is oen pointed anteriorly. Care is taken to
position the endogra during placement so that
the location of the contralateral gate is reachable.
Sometimes, a more acutely angled catheter is use-
ful. A Glidecath
®
catheter or an MPB catheter is
a good choice for a start. An MPB catheter has a
longer reach at its tip but the angulation is about
the same as a Glidecath
®
catheter. Sometimes,
a double angulation is required: one trajectory
comes out of the iliac artery and another trajec-
tory is required to get into the contralateral gate.
is type of platform can be produced by advanc-
ing a 6-Fr sheath with an angled tip into the aneu-
rysm and combining that with an angled catheter
so that two curves are created. e Glidewire
®
is
used to touch and encounter the contralateral gate
and eventually to enter it. Advance the Glidewire
®
A
C
D
B
E
Fig. 28.9 Managing the angulated aortic neck. (A) A severely angulated
aortic neck is prepared for treatment. (B) Bilateral femoral sheaths are placed.
Very stiff Lunderquist
®
wires are placed on both sides in an effort to help
straighten the neck of the aorta. (C) During endograft placement, the sheath
is advanced through the tortuous segment and all the way into the suprare-
nal aorta. (D) The stent–graft is advanced over the stiff wire and through the
sheath. The stent–graft tip is visible extending beyond the tip of the sheath.
The stent–graft is exposed at a level more proximal to its landing zone than
usual. This exposure of the graft and the need to withdraw it helps to remove
angulation from the graft. (E) The sheath is withdrawn very slowly and only to
a level needed to support the graft. Full removal of sheath support in a tortu-
ous neck permits the partially deployed endograft to become unstable.
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