3.2 Endografts for Aortic Aneurysm: How do they ADVANCE? Stay in Bounds or Pay the Price? Suprarenal vs. Infrarenal Grafts? Or is Stabilization Therapy (EAST) the Answer?

These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.

Faculty Disclosures     Vendor Acknowledgments

2024 IAGS Summary Document

Statement of the problem or issue

Nikolai Volodos implanted the very first stent graft in a stenotic iliac artery in 1985. Then, in 1987 he placed another stent graft into a traumatic aneurysm of the descending aorta. Independently from Volodos, Juan Parodi first implanted a stent graft of his own design into an aorta in 1990 in Argentina, and then again two years later in 1992 in the US. The first self-expanding stent grafts were implanted in 1993 by Michael Lawrence-Brown and David Hartley in Perth, Australia, and Krassi Ivancev in Malmo, Sweden. The first bifurcated stent graft was implanted the same year, 1993, by Tim Chuter in Aachen, Germany. The first fenestrated stent graft was implanted 1997, again by the Australians Lawrence-Brown and Hartley. The key points of stent graft development are summarized in Table 1.

Table 1. Key developments in aortic endografts.

The problem we realize now is we have a highly progressive underlying disease, which not only causes circumferential enlargement of the aorta, but also elongates or propagates up and down the aorta over time; in other words, we have disease progression.

Gaps in current knowledge

The basic problem is sealing. There must be a sufficient landing zone for an endograft, particularly for the proximal end, and there must be tight sealing here. The difficulties are: (1) angulated necks; (2) irregular necks which are calcified and thrombotic; (3) short necks. The patient may come back after 2 to 3 years with a Type 1 endo-leak because the landing zone may not have been adequate enough to achieve long-term sealing, and the patient may have had disease progression leading to further enlargement.

In addition to identifying appropriate landing zones, there is the problem of visceral branches. Manufacturers have developed fenestrated protheses as well as branched prostheses to deal with these. There is more experience with fenestrated prostheses than with the branched variety. However, the branched protheses are more forgiving if the pre-procedure measurements were slightly off, or if there is a twist during placement: it is possible to correct much better than with a fenestrated prosthesis. There are also prostheses containing both, that is, fenestrations in the upper section and branches in the lower section.

Possible solutions and future directions

Custom made prostheses rather than off-the-shelf designs are possible, but the prices are very high. Physician modified endografts are available, but these require meticulous planning, extensive experience, and highly technical training.