Aortic aneurysms are frequently associated with severe elongations and angulations. In these cases the endovas-cular devices are not easy to push upwards and to handle during the deployment. Intra- and post-procedural problems are not rare. The curved delivery system is under tension and graft deployment may be problematic [11, 39, 40]. This usually arises in aortic arch or descending aortic aneurysms that have c- or s-shaped elongations (Fig. 5.4.4). This occurrence is further worsened if the stent graft is deployed by the pull-back technique such as in Medtronic Talent®, Endomed Endofit® and Cook TX1/ TX2® stent graft systems. The use of flexible and kink-resistant devices with a long profile tip is essential. Some authors recommend heating the stiff dilatators (Endofit® stent graft system) in boiling water in order to make them more soft and flexible . For the implantation of TAG/ Excluder® devices, there is no need to pass a sheath for descending aorta and aortic arch aneurysms (Fig. 5.4.4). Pre-curved devices are developed in order to make deployment of the graft easier in the aortic arch. The decrease of systemic blood pressure minimizes further the risk of intra-procedural dislocation [24, 25]. The use of stiff guidewires in various modifications is necessary and helps to neutralize some angulations or elongations, but increases the risk of distal embolization. Systemic hepa-rinization and the careful use of catheter and guidewires are therefore very important for minimizing such risk . If two stent grafts or more are necessary to cover preop 3-D
m postop anqio postop stent
Fig. 5.4.4 This case demonstrates double descending aortic aneurysms (3D reconstruction) with s-shaped elongation. Only very flexible devices are able to treat such cases. An Excluder™ stent graft device was used and adequate exclusion of aneurysms was achieved the aneurysmal area, disconnection of the graft during the follow-up can occur. Long overlap between the grafts placed using the trombone technique is recommended. A graft-to-graft overlapping zone of more 50 mm is the current recommendation [19, 35, 39].
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