The GORE® C3 Delivery System (Gore & Associates, Flagstaff, AZ) further strengthens the GORE® EXCLUDER® Device (Gore & Associates), an aortic stent graft that has long been an exceptionally reliable device. Using this delivery system, the user has the option to partially deploy (specifically bringing the device to full diameter from the top to the contralateral gate), constrain, and reposition the device, which is a clear advantage if the device has been positioned inappropriately relative to either the landing zone or gate position. This capability has the potential to prevent renal ischemia due to coverage of the renal arteries, to reduce the need to use cuffs for low deployment, and to reduce prolonged irradiation and operative times due to difficult gate cannulation. Although renal artery coverage is not common and is usually discovered immediately intraprocedurally, Gabrielli and colleagues1 reported an incidence of 0.9%. Rates may be higher, as this is generally poorly documented in the literature.

Verhoeven et al2 found that they used the repositionable ability of the GORE® EXCLUDER® Device featuring C3 Delivery System in 72% of their cases to achieve better positioning or facilitate cannulation. Additionally, they did not use any proximal cuffs.

The ability to reposition would ideally suit challenging abdominal aortic aneurysm (AAA) cases because it allows for cannulation and ideal positioning to rapidly exclude the aneurysm.

CASE REPORT

A 64-year-old man presented to the emergency department with a symptomatic AAA. His medical history included hypertension, chronic obstructive pulmonary disease, three previous myocardial infarctions, and prostate cancer. On computed tomography, he was found to have a nonruptured AAA measuring 5.6 cm. The patient was evaluated by cross-sectional imaging, which identified a nonruptured AAA and adequate access vessels, but a significantly angulated neck. We believed that the angulated neck could render appropriate device placement challenging and, therefore, would benefit from the unique repositionable feature of the GORE® EXCLUDER® Device featuring C3 Delivery System.

Bilateral groin cutdowns were performed, and wire access was obtained. Initial angiography (Figure 1) identified the angulated neck as well as better positioning by crossing the limbs of the device. We delivered the main body via the right femoral artery as we believed that this would likely allow for better positioning with the angulated neck. Initial device positioning was poor (Figure 2A) despite having placed the device at the level of the lowest renal artery (Figure 2B). This poor device position, if unchanged, would likely lead to a significant type I endoleak with need for additional cuffs. We constrained the graft (Figure 3A) and moved the device proximally into a better position (Figure 3B). After we deployed the limbs and ballooned the device, completion aortography showed adequate positioning of the graft with exclusion of the aneurysm and no appreciable endoleaks (Figure 4).

After the procedure, the patient's abdominal pain was completely relieved, and he was discharged after 2 days without any further issues. On 6-month follow-up, the patient had no complications, and the stent graft remained in a good position without endoleaks.

CONCLUSION

This case illustrates the ability to reposition the GORE® EXCLUDER® Device and achieve a more effective exclusion of the AAA without the need to place additional aortic cuffs. This fundamentally changes the way we think about performing endovascular aneurysm repair, as we cannot always predict how a graft will behave in challenging anatomy. Having the opportunity to modify positioning can both be less costly (as in this case, by avoiding the need for additional devices) and also accelerate cases, thereby avoiding prolonged operative times and reducing radiation and contrast usage.

Jean Bismuth, MD, is with Cardiovascular Associates, DeBakey Heart & Vascular Center, The Methodist Hospital in Houston, Texas. He has disclosed that he is a paid consultant to Gore & Associates and Hansen Medical. Dr. Bismuth may be reached at jbismuth@tmhs.org.

  1. Gabrielli L, Baudo A, Molinari A, Domanin M. Early complications in endovascular treatment of abdominal aortic aneurysm. Acta Chir Belg. 2004;104:519-526.
  2. Verhoeven EL, Oikonomou K, Möhner B, et al; European C3 Global Registry Participants. First experience with the new repositionable C3 Excluder stent graft. J Cardiovasc Surg (Torino). 2011;52:637-642.