Ann Vasc Surg 2012; 26: 141-148-Selected technique- Funnel Technique for EVAR: ‘‘A Way Out’’ for Abdominal Aortic Aneurisms With Ectatic Proximal Necks (Chirurgia Vascolare-ULSS 15 Alta Padovana) (Vascular Surgery -ULSS 15 Alta Padovana)

1. Selected Technique
Funnel Technique for EVAR: ‘‘A Way Out’’
for Abdominal Aortic Aneurisms With Ectatic
Proximal Necks
Salvatore Ronsivalle,1
Francesca Faresin,1
Francesca Franz,1
Carlo Rettore,2
Mario Zanchetta,3
and Loretta Zonta,2
Cittadella, Padua, Italy
Background: To describe an endovascular technique for proximal stent-graft fixation in
patients with an abdominal aortic aneurysm and an ectatic aortic neck.
Methods: We describe a method in which using currently available devices in a hybrid
assembly offers another option for circumventing the limitations of problematic proximal fixation.
Conclusions: Through four examples, we illustrate the feasibility of placing a straight endograft
as proximal extension of a bifurcated or aorto-uni-iliac graft in patients with a dilated proximal
aortic neck. It appears secure and effective, with no type I endoleak or migration over a midterm
follow-up.
INTRODUCTION
Endovascular aneurysm repair (EVAR) is used
increasingly to treat abdominal aortic aneurysm
(AAA) in patients with suitable anatomy.1,2
However, as many as 20-50% of AAA patients
have anatomy that is not suitable for endovascular
repair.3-5
Therefore, the adverse features of an
individual’s vascular anatomy, such as the mor-
phologic characteristics of the proximal and distal
fixation sites, must be studied carefully to make
decisions regarding the suitability and feasibility
of endografting.
Moreover, secure fixation and adequate sealing
at the proximal and distal AAA necks are the most
important factors in predicting a successful outcome
of EVAR.
Whereas the management of ectatic common
iliac arteries by using iliac flared extension (bell-
bottom)6
has become an option used worldwide, it
is not so easy to use when treating ectatic proximal
aortic necks.
In fact, there are no devices currently available
for this purpose.
Patients with ectatic necks often require complex
surgical open repair, which is associated with high
perioperative mortality and morbidity. In most
patients, given the high anesthetic risk (ASA 3-
ASA 4) due to comorbidity conditions, modifying
the technique of EVAR may be required to success-
fully exclude aneurysm.5
One such modification is the ‘‘funnel technique.’’
As reported in an our previous case report,7
we
describe a method for stent-graft fixation in ectatic
aortic necks in patients with AAA, in which using
currently available devices in a hybrid assembly
offers another option for circumventing the limita-
tions of problematic proximal fixation (Fig. 1A).
We use four clinical cases to illustrate the feasibility
of placing a straight thoracic endograft as a proximal
extension of a bifurcated aortic or aorto-uni-iliac
endograft in patients with an abdominal aortic aneu-
rysm and a dilated proximal aortic neck.
1
Department of Cardiovascular Disease, Vascular and Endovascular
Surgery and Angiology, Cittadella Hospital, Cittadella, Padua, Italy.
2
Department of Radiology, Cittadella Hospital, Cittadella, Padua,
Italy.
3
Division of Cardiology, Cittadella Hospital, Cittadella, Padua, Italy.
Correspondence to: Salvatore Ronsivalle, MD, Department of Cardio-
vascular Disease, Vascular and Endovascular Surgery, Via Riva
dell’Ospedale, 35013 Cittadella, Padua, Italy, E-mail: vascolare_cit@
ulss15.pd.it
Ann Vasc Surg 2012; 26: 141-148
DOI: 10.1016/j.avsg.2011.03.019
Ó Annals of Vascular Surgery Inc.
Published online: November 2, 2011
141

2. To guarantee a correct choice and positioning of the
endograft it is mandatory to measure the ectatic neck
diameter and length, the AAA length and the distance
between the lower renal artery and aortic carrefour.
Currently, aortic straight thoracic standard en-
dografts (100 mm), straight thoracic custom-made
endografts, and both abdominal aortic bifurcated
and aorto-uni-iliac endografts are all available.
After careful examination of all the measure-
ments, it is possible to plan the hybrid assembly to
guarantee a correct proximal and distal sealing and
an adequate component overlap.
TECHNIQUE, MATERIAL AND
METHODS, AND RESULTS
Preoperative assessment included standard contrast
arteriography with a marker catheter and computed
tomography (CT) with intravenous contrast and
imaging acquisition at 0.6-mm intervals.
Given the high anesthetic risk (ASA 3-ASA 4) due
to patients’ comorbidity conditions (chronic obstruc-
tive pulmonary disease, hypertension, peripheral
and carotid arterial disease, coronary artery disease
with severely impaired left ventricular function), we
believed they could be candidates for EVAR.
The endovascular procedures were carried out in
an operating room under fluoroscopic and angio-
graphic guidance by a team of vascular surgeons
and interventional cardiologists.
A portable C-arm fluoroscopy device (ZIEHM
IMAGING-Vision RFD mobile C-arm; ZIEHM
IMAGING GmbH, Nuremberg, Germany) and
a radiolucent operating table (MAQUET 115016B0
Rastatt, Germany) were used.
Surgery was performed under general anesthesia
orregional anesthesia and local anesthesiainthe arm.
Through an oblique incision of 3-4 cm below the
inguinal ligament, the common femoral artery was
isolated in the groin bilaterally, and the devices
were introduced over a stiff guidewire in a brachial
artery femoral loop.
For endoleak prevention, all patients underwent
EVAR with sac thrombization and stabilization
through intrasac biomaterial insertion.8
During follow-up, all patients underwent a color
duplex ultrasonography (CDU) at discharge, at 3, 6,
and 12 months, and once every 6 months thereafter.
For each patient, two abdominal radiographs were
taken, the first at discharge and the second a year
later, and a spiral CT scan at 6 months.
First case: R.O., an 84-year-old man diagnosed
with a 70-mm asymptomatic infrarenal AAA and
Fig. 1. (A) Currently available grafts; (B) Currently available grafts in a hybrid assembly.
142 Ronsivalle et al. Annals of Vascular Surgery

3. having an ectatic neck with a diameter of 38 mm
and length of 32 mm.
A 34 Â 16 Â 170-mm Talent bifurcated stent-graft
was placed in the lower part of the aneurysm after
examining the measurements and characteristics
of aneurysm and neck.
A 44-mm-diameter, 90-mm-long thoracic tube
endograft (Talent) with a 16-mm free-flow proximal
stent was selected on the basis of the adventitia-to-
adventitia CT measurement of the aortic neck diam-
eter, allowing 6 mm of oversizing (Fig. 2A). The tube
graft was delivered to the proximal neck through the
bifurcated device via the ipsilateral femoral access; it
was deployed with at least 30 mm of overlap, leaving
more than 40 mmextending beyond the main body of
the bifurcated device to ensure expansion to its
Fig. 2. (A) First case’s graft in a hybrid assembly (thoracic graft 44-44-90 and aorto-bifurcated graft 34-16-170). (B) a:
abdominal X-rays follow-up; b, c: postsurgery angio-CT scan follow-up.
Vol. 26, No. 1, January 2012 Funnel technique for EVAR 143

4. nominal diameter as well as an adequate seal. An iliac
extension was deployed into the left external iliac
artery to obtain adequate distal vessel wall apposition
and hemostatic seal. Finally, the sac was excluded by
insertingtwosequentialiliacextensionsfromtheinte-
gral limb of the bifurcated stent-graft to the right CIA
in a bell-bottom configuration.
The resultant ‘‘funnel configuration’’ at the
infrarenal aortic neck is evident on the control CT
scan, which shows the intact structure of the
composite three-component stent-graft, with no
endoleak or migration (Fig. 2B).
The patient was regularly followed up; he died
4 years later of prostatic cancer.
Fig. 3. (A) Second case’s graft in a hybrid assembly (thoracic graft 44-44-80 and aorto-bisiliac graft 34-18-170). (B)
Presurgery (a) and postsurgery (b) angio-CT scan follow-up.
144 Ronsivalle et al. Annals of Vascular Surgery

5. During the follow-up, the aneurysmatic sac
diameter remained stable (69 mm at 3 months,
68.6 mm at 6 months, 68.2 mm at 1 year, 68 mm
at 2 years, 68 mm at 3 years).
Second case: T.A., a 77-year-old man hospitalized
with a 74.7-mm asymptomatic infrarenal AAA, with
a 35.3-mm-wide and 49.2-mm-long ectatic neck.
Given the measurements and characteristics of
aneurysm and neck, a bifurcated stent-graft (E-
Vita 34 Â 18 Â 170 mm) and its contralateral right
leg 16 Â 18 Â 90 mm were chosen and placed in
the lower part of the aneurysm.
Thereafter, a thoracic stent-graft (E-Vita, custom-
made 70SO4440508-00) was delivered to the prox-
imal neck through the bifurcated device via the right
femoral access (Fig. 3A).
It was deployed with at least 45 mm of overlap,
leaving more than 35 mm extending beyond the
main body of the bifurcated device to ensure expans-
ion to its nominal diameter as well as an adequate seal.
The postoperative CT scan demonstrates the fun-
nel configuration at the infrarenal aortic neck and
evidence of the intact structure of component
stent-graft, with no endoleak or migration (Fig. 3B).
The patient is stable after 2 years of follow-up.
During the follow-up the aneurysmatic sac
diameter remained stable (74 mm at 3 months,
73.8 mm at 6 months, 73.7 mm at 1 year. 73 mm
after 2 years).
Third case: R.M.A., a 74-year-old man was diag-
nosed with a 60-mm asymptomatic infrarenal
AAA, with a 36-mm-wide and 38.6-mm long ectatic
neck (Fig. 4A).
We discovered that opening the contralateral
gate limb to deliver a bifurcated stent-graft was not
possible due to the length and diameter of the ectatic
neck, the length of AAA, and the distance between
the lower renal artery and aortic carrefour.
Therefore, an aorto-uni-iliac stent-graft (Talent
36 Â 16 Â 124 mm) was placed in the lower part
of the aneurysm.
Then, a thoracic extension (Valiant 40 Â 40 Â
100 mm) was delivered to the proximal neck
through the device via the right femoral access.
Finally, an occluder (OCL22, Medtronic Cardio-
Vascular, Santa Rosa, CA) was inserted in left
common iliac artery, and a righteleft femoro-
femoral crossover bypass was sewn (Fig. 4B).
Fig. 4. (A) Presurgery angio-CT scan (a), diameter of the
aneurysm neck (b), and diameter of the aneurysm (c).
(B) Third case’s graft in a hybrid assembly (thoracic graft
40-40-100, aorto-uni-iliac graft 36-16-124, and occluder
OCL22). (C) Postsurgery angio-CT scan follow-up.
Vol. 26, No. 1, January 2012 Funnel technique for EVAR 145

6. The resultant funnel configuration at the infrare-
nal aortic neck is evident on the control CT scan,
which shows the intact structure of component
stent-graft, with no endoleak or migration (Fig. 4C).
The patient is stable after 1 year of follow-up.
During the follow-up, the aneurysmatic sac
diameter remained stable (59 mm at 3 months,
58.8 mm at 6 months, 58.4 mm at 1 year).
Fourth case: L.A., a 66-year-old man diagnosed
with a 69-mm asymptomatic abdominal aneurysm
with an ectatic neck with a diameter of 43 mm
and a length of 43.3 mm; he had also an aneurysm
of the thoracic aorta.
Given the particular characteristics of the aneu-
rysm and neck, a bifurcated stent-graft (Talent
LY3216C155) using the bilateral bell-bottom
Fig. 5. (A) Fourth case’s graft in a hybrid assembly (thoracic graft 44-44-80, aorto-bisiliac graft 32-15-155). (B) Post-
surgery angio-CT scan follow-up.
146 Ronsivalle et al. Annals of Vascular Surgery

7. technique (Talent IXW, Q8 16x 22x 80 mm) was
placed in the lower part of the aneurysm, and
a custom made thoracic stentgraft E-Vita
70SO4440508-00 was accessed via ipsilateral femoral
artery through the bifurcated device into the prox-
imal neck (Fig. 5A).
It was deployed with at least 40 mm of overlap,
leaving more than 40 mm extending beyond the
main body of the bifurcated device to ensure expan-
sion to its nominal diameter as well as an adequate
seal.
In the same procedure, three thoracic stent-grafts,
namely, E-vita 70SO4440S17-00, 70SO4444S17-00,
and 70ST4040F15-00 were placed from the aortic
isthmus under the left subclavian artery up to 1 cm
from the celiac trunk in order to correct the thoracic
aneurysm.
Again, the resulting funnel configuration at the
infrarenal aortic neck is evident on the control
CT scan showing the intact structure of component
stent-graft, with no endoleak or migration
(Fig. 5B).
The patient is stable after 2 years of follow-up.
During the follow-up, the aneurysmatic sac diam-
eter remained stable (68 mm at 3 months, 67.7 mm
at 6 months, 67.6 mm at 1 year, 67 at 2 years).
DISCUSSION
Large or wide infrarenal necks in patients with AAA
remain a challenge for endovascular interventionists.
Hybrid assembly with latest-generation devices
offers another option for circumventing the limita-
tions of problematic proximal fixation.
The funnel technique in which a straight thoracic
stent-graft is placed through the main body of
a bifurcated or aorto-uni-iliac endograft may repre-
sent an appealing alternative.
In all cases, the thoracic tube endograft was
deployed with at least 30-40 mm of overlap to
ensure expansion to its nominal diameter as well
as an adequate seal.
A greater oversizing of 10% and central posi-
tioning of the thoracic graft so that one-half of
its length extends into the native infrarenal aorta
and the other into the bifurcated aortic or aorto-
uni-iliac endograft are mandatory to ensure
expansion of the straight thoracic graft to its
nominal diameter to guarantee a correct proximal
fixation and prevent type I endoleak or migration
due to the loss of device fixation over a midterm
follow-up.
All the procedures were performed with Med-
tronic or Jotec devices because these are the
ones that we are most familiar with and that
have shown to be best suitable to the characteris-
tics of the grafts.
It is also possible to use other brands as long
as they fit the patient’s anatomic measures and
characteristics.
In all cases, the aneurysmatic sac diameter
remained stable during the follow-up, but the obser-
vational time was short.
The first patient died 4 years later of prostatic
cancer, whereas the other patients are still being
regularly followed.
To prevent endoleaks, all patients undergo EVAR
with sac thrombization and stabilization through
intrasac biomaterials insertion in our hospital.8
Our experience indicates a lower risk of type II
endoleak in patients who were treated with intrasac
‘‘thrombization’’ during EVAR using biomaterials
compared to patients having undergone standard
EVAR alone.8
They form a structure that accelerates
and consolidates the clot formation process forming
a ‘‘concrete’’ compound, resulting in manifesting
a durable, long-lasting, sturdy stabilization of the
whole complex fixed en bloc.8
Patients are also treated with brachial artery
femoral loop. This technique allows for the device
to advance more easily, overcoming kinking or
stenosis, and therefore consenting to a more precise
releasing of the endograft in the presence of angled,
flared, or short necks. This, in turn, enables the
device to reach the iliac axis with less difficulty for
the positioning of the prosthetic contralateral leg.
CONCLUSIONS
These four cases illustrate the feasibility of placing
a straight endograft as proximal extension of a bifur-
cated or aorto-uni-iliac graft in patients with
abdominal aortic aneurysm and a dilated proximal
aortic neck.
These endograft configurations are found to be
secure and effective, with no type I endoleak or
migration over a midterm follow-up.
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