The Upside-Down Gore Excluder Limb and Double-Barrel Sandwich Technique for Penetrating Aortic Ulcer and Iliac Aneurysm Exclusion

Abstract

Endovascular aneurysm repair has become the first-line treatment for abdominal aortic aneurysms and iliac artery aneurysms in recent years. However, the diameter of the infrarenal aorta is larger than that of the aortic bifurcation, especially with small aortic diameters, for which a reversed tapered device is necessary. We describe the off-label use of the upside-down Gore Excluder limb and double-barrel sandwich technique for the treatment of a penetrating abdominal aortic ulcer with a large common iliac artery aneurysm. These techniques offer an easy endovascular approach for excluding an aneurysm in selected patients. However, this technique is outside the standard instructions for use, therefore careful planning and long-term follow-up are mandatory.

Stent graft for a longstanding femoral artery pseudoaneurysm with arteriovenous fistula– A case report of the first infra-inguinal application of the upside-down gore excluder limb technique

“…[5][6][7][8] Upside down technique for Cook Zenith and Medtronic Endurant stent-grafts would need deployment of the stent-graft outside the body and re-sheathing the stent-graft into the deployment system which is cumbersome, increases operating time significantly, and could cause graft damage or stent fracture in the long term. [5,6] Gore Excluder stent-graft is constrained by a suture and is deployed by pulling on the suture line instead of unsheathing as in other grafts. So, the Gore Excluder iliac leg can be turned upside down without extracorporeal deployment making the procedure easy and less time-consuming.…”

“…Upside down deployment is outside the standard instructions for use but is a good clinical skill to acquire and is documented to be very helpful in treating various aortic and iliac aneurysms where commercially available devices are inappropriate in either size or length. [5,6] The only disadvantage is the necessity of large vascular sheaths above 12 F size which require either a surgical cut down for access or vessel preparation with percutaneously placed suture based devices, compared to smaller sheaths lesser than 8F size suitable for most of the other covered stents available for peripheral arteries; however, these stents are not suitable for this patient due to aforementioned reasons. distal to the fistula, which may cause ischemic symptoms like claudication as in the case described.…”

“…So, the Gore Excluder iliac leg can be turned upside down without extracorporeal deployment making the procedure easy and less time-consuming. [ 5 , 6 ] With Gore Excluder stent-grafts, advancing end diameters from 10 to 23 mm can be achieved with a fixed end diameter of 16 mm. Upside down deployment is outside the standard instructions for use but is a good clinical skill to acquire and is documented to be very helpful in treating various aortic and iliac aneurysms where commercially available devices are inappropriate in either size or length.…”

“…The technique of inverting the stent-graft was the same as described previously in the literature. [ 5 , 6 ] The olive tip at the end of the stent-graft deployment system was detached by bending and breaking; the deployment line was cut close to the deployment knob after unscrewing the knob, and the stent-graft was slid off the delivery system. The stent-graft was inverted in such a way that the tapered tip was the advancing end, and inserted into the 16F sheath over a stiff guidewire.…”

Total Endovascular Repair by Sandwich Technique Thoracoabdominal Aortic Dissecting Aneurysm with Aneurysm Related Disseminated Intravascular Coagulation (DIC)

“…Considering the tortuosity, calcification of the aorta, the multiple lesions and the complexity of the EVAR in this patient, we decided to adopt sandwich technique to reconstruct the visceral arteries. This technique is outside the standard instructions for use, therefore careful planning and long-term follow-up are mandatory [10]. In this case, we made a deliberate plan and a long-term follow-up.…”