Feature | March 19, 2009| Dave Fornell

New Technologies Are Pushing the Envelope for Endovascular Repair of Aortic Aneurysms

Michel Makaroun, M.D., professor and chief of the division of vascular surgery, University of Pittsburgh Medical Center.

Endovascular repair for aortic aneurysms has gained popularity in the past five to six years as physicians has learned how to use and became more comfortable with the new generations of stent graft technology. “The number of endovascular repairs is going up,” said Michel Makaroun, M.D., professor and chief of the division of vascular surgery, University of Pittsburgh Medical Center, and president of the Association of Chairs in Vascular Surgery, a section of the Society for Vascular Surgery. Today he says between 50-60 of aortic aneurysm repairs are done endovascularly. The first generation of aortic endo repair devices in the mid-1990s had issues with endoleaks, fixation, manufacturing, and in materials used, he explained. Some devices had poor fixation, causing late migration. Some fabrics leaked, stent polishing techniques contributed to fatigue strut failure, and there were questions about how much devices should be overlapped. However, today Mr. Makaroun said aortic endo repair devices have achieved a level of reliability on par with surgical repair. “There have been a lot of advancements over the past 10 years,” Dr. Makaroun said. “The results are getting better and better.” He said in the late 1990s endovascular aortic repairs were usually only stable for about two or three years, but today’s devices offer stability of at least eight or nine years. Better fixation systems have also made migration mostly a thing of the past, Dr. Makaroun said. That is not to say today’s devices are not devoid of problems. He said vessel tortuosity and repairs around side branch vessels still cause issues with the devices, making a proper seal to isolate the aneurysm difficult, or it can risk occluding the collateral vessels. But, he said the next generation of devices hold promise to overcome these issues. “Technologies are now coming out to address areas where we would not have even attempted endovascular repairs a few years ago,” Dr. Makaroun said. “There is practically no region of the aorta that we will not be able to repair endovascularly... In the next few years the envelope of the technology will be pushed with the availability of these new devices.” New devices currently available in Europe, and in some cases working their way through FDA approval in the U.S., will allow repairs near or on top of side branches. This will allow better, long-term device fixation in the more stable area around the renals, Dr. Makaroun said. He said the region of the aorta below the renals tends to be unstable, resulting in aneurysms. Even if stent grafts are placed on a stable area of the aorta below the renals, the vessel can continue to deteriorate and cause leaks or migration. If stents can be fixed around the renals he said the repairs will have a much better longer-term prognosis. The sizes of the devices used for endovascular repair of the aorta have become smaller over the last 15 years, making them more attractive to some interventional cardiologists and making the devices easier to implant without surgical assistance. Dr. Makaroun said the devices in the mid-1990s were 25-26 Fr., today devices are around 18-22 Fr. and new generations of devices are being developed with sizes as small as 14-16 Fr. However, size alone will not determine if more cath labs or interventionalists take on aortic repairs. He said surgeons are still the best qualified because they offer more options to patients and can switch to surgical techniques in case of complications during a procedure if more extensive follow-up repairs are needed. While deployment of stent grafts can be done using a mobile C-arm in an OR for repairs of straightforward anatomy, more detailed procedures or for deployments around collateral vessels and tortuous anatomy require the high quality imaging of a fixed fluoroscopy system. However, since most cath labs do not offer a sterile environment, many hospitals have created hybrid ORs with fixed imaging systems. At the University of Pittsburgh Medical Center Dr. Makaroun said all endovascular aortic repairs are done in a hybrid OR in case surgical interventions are required. He said hybrids are becoming the standard of care in most institutions that have a large number of these repairs.

Related Content

Pie Medical Imaging, Frost & Sullivan, technology leadership, CAAS, cardiovascular diagnostics

CAAS MRV is part of Pie Medical Imaging's suite of imaging solutions for quantitative cardiovascular diagnosis and treatment planning. - See more at: http://www.itnonline.com/content/pie-medical-imaging-recognized-innovati...

News | Cardiac Imaging| September 01, 2015
Based on its recent analysis of the cardiovascular image management market, Frost & Sullivan recognizes Pie Medical...
Absorb, BVS, bioresorbable stent
News | Stents Bioresorbable| September 01, 2015
September 1, 2015 — A bioresorbable drug-eluting coronary stent showed similar efficacy and safety results compared t
bivalirudin,angiomax
Feature | Antiplatelet and Anticoagulation Therapies| September 01, 2015
September 1, 2015 — Extending treatment with the anticoagulant bivalirudin for at least four hours after completion o
Mitralign, Percutaneous Tricuspid Valve Annuloplasty System

Mitralign's Percutaneous Tricuspid Valve Annuloplasty System uses catheter delivered pledgeted sutures that can be cinched together to change the valve annulus geometry to help eliminate valvular regurgitation. 

News | Heart Valve Repair| August 31, 2015
August 31, 2015 — Mitralign Inc. said the U.S.
biomimics, 3D stent
News | Peripheral Arterial Disease (PAD)| August 28, 2015
August 28, 2015 — PinnacleHealth CardioVascular Institute enrolled the first patient in Pennsylvania and second in th
iFR, FFR, Philips, Volcano
News | Cath Lab| August 28, 2015
August 28, 2015 — Philips Healthcare is showcasing its latest cardiology solutions at the European Society of Cardiol
News | Heart Failure| August 28, 2015
August 28, 2015 — BioControl Medical said it has completed enrollment in its INOVATE-HF (INcrease Of VAgal TonE in He
Stent graft, computational fluid dynamics, CFD, stent engineering

In this vector velocity model, brighter colors indicate blood flow acceleration as it passes through a bifurcation. Computation fluid dynamic modeling provides insight on blood flow through and near the walls of the stent graft. Image courtesy of Sanford Health

News | Cath Lab| August 27, 2015
August 27, 2015 — The use of computational fluid dynamics (CFD) modeling has been used for years to better engineer l
News | Cath Lab| August 26, 2015
August 26, 2014 — The Cardiovascular Research Foundation (CRF) announced the late-breaking trials and first report in

Mitral regurgitation viewed under color Doppler. Image courtesy of Toshiba.

Feature | Heart Valve Repair| August 26, 2015
August 25, 2015 — Medtronic announced it entered a definitive agreement to acquire Twelve Inc., a start–up medical de
Overlay Init