Fig. 21.1
(a) Supraceliac balloon control via a large contralateral sheath. (b) Main body of endograft is deployed via ipsilateral access. Slight temporary deflation of the balloon may be required to allow for passage of the tip of the device. (c) After the endograft body and ipsilateral limb are deployed, a second balloon is placed via the ipsilateral groin and inflated within the main body of the graft, maintaining continuous aortic control. (d) The contralateral gate is cannulated and the contralateral limb is deployed while maintaining balloon control from the ipsilateral side. (e) To allow for extension of the ipsilateral limb without losing aortic control, a third balloon is placed through the contralateral groin, maintaining wire access on the ipsilateral side. (f) With the third balloon still inflated via the contralateral groin, the ipsilateral limb is extended to allow for a distal seal. The balloon is then deflated and angiography is performed (see text for details)
By injecting into the contralateral (side with first balloon) sheath, below the balloon, the renal arteries can be visualized and the most proximal covered portion of the endograft positioned precisely below their orifices. The ipsilateral sheath is retracted, deploying the covered portion of the main body of the endograft along with the remaining ipsilateral limb. Its delivery system is removed, leaving the wire and a large sheath in place on that (ipsilateral) side.
A second large, compliant balloon is passed over that (ipsilateral) wire into the main body of the endograft and infrarenal aneurysm neck and inflated under fluoroscopic control to occlude aortic flow. The first (supraceliac) balloon is fully deflated and removed through its large contralateral sheath (Fig. 21.1c), which had been fixed in place. At this point, the visceral and renal vessels are perfused.
The contralateral wire and sheath (which are outside the deployed endograft) are withdrawn into the aneurysm sac. The contralateral gate is cannulated, and the contralateral limb is placed as in a standard EVAR procedure for an unruptured AAA. The only difference is that the wire and tip of the deployment system for the contralateral limb must be carefully guided above the inflated second balloon in the body of the main graft using the precautions already described. Using similar techniques, any extensions needed to obtain a distal seal in the contralateral iliac system are placed (Fig. 21.1d).
If the ipsilateral iliac system has not been sealed, a third large compliant balloon must be placed in the body of the graft via the contralateral side and inflated within the graft as the second (ipsilateral) balloon is deflated and removed (Fig. 21.1e). With this third balloon maintaining aortic control, any extensions are placed on the ipsilateral side to obtain a distal seal, again taking care to pass the tip of any extension device carefully alongside the balloon without losing this control. Only when the aneurysm is fully excluded with appropriate proximal and distal seals should aortic balloon control be given up and all balloons removed (Fig. 21.1f).
Discussion
EVAR has been used increasingly to treat patients with RAAAs and offers many theoretical advantages over open repair. In addition to being less invasive, it eliminates the complications that can occur during laparotomy, minimizes hypothermia, and can be performed with the patient under local anesthesia [6, 8]. Because of these advantages, many investigators have deemed EVAR to be superior to open repair for the treatment of RAAAs [2]. Combined results from centers committed to EVAR treatment of RAAAs indicate that the 30-day mortality for EVAR is 19.7 % vs. 36.3 % for open repair [6]. With increasing enthusiasm and procedural experience, the more modern series in the literature attribute lower mortality to several key strategies, adjuncts, and technical factors [6]. These include a standardized approach, hypotensive hemostasis [6], local anesthesia [8], recognition and treatment of abdominal compartment syndrome [2], and supraceliac balloon control of the aorta [7–10]. Variations in these techniques may account for the variable results reported in the literature [6].
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