Today, the proportion of emergent/acute symptomatic abdominal aortic aneurysm (AAA) patients being treated by endovascular means is steadily increasing, and ample evidence exists regarding the safety and efficacy of these procedures in academic tertiary medical centers as well as community hospitals.1-3 Most well-established centers performing emergent aortic procedures have developed strategies that facilitate a seamless transition of the patient from the emergency department to the operating room for endovascular aneurysm repair (EVAR). Although the standardization of any approach will vary from one institution to another, the fundamentals are simple in that success depends on the early diagnosis of emergent AAA, the ability to have an expeditious computed tomography scan to evaluate the aortoiliac morphology, and quick transition of the patient from the emergency department to the operating room, which is equipped to perform endovascular as well as open surgical repair under these emergent circumstances.4

Over the past decade, The Vascular Group in Albany, New York has treated nearly 400 cases of acute symptomatic abdominal and thoracic aortic aneurysms, approximately 50% of which underwent emergent EVAR. Through this evolution, in our experience, we have noticed an increasing percentage of patients with acute aortic emergencies being treated by endovascular means. Today, more than 75% of patients with acute symptomatic AAAs undergo EVAR, whereas in 2002, only 15% underwent EVAR.

In addition to the standardized triage approach that enables a seamless transition of patients from the emergency department to the operating room, we have also evolved to using a few of the standard tools (wires, catheters, snares, sheaths, occlusion balloons, stents, covered stents, and stent grafts). Frankly, there is no single kit for emergent AAA treatment that would necessarily be better than another. However, please see Table 1 for a list of tools that we routinely use, as we have found their simplicity to improve our ability to treat the vast majority of patients with emergent AAAs.

THE GORE® EXCLUDER® Device Featuring C3 DELIVERY SYSTEM

Currently available stent grafts with or without suprarenal fixation have their pros and cons for accommodating complex aortoiliac morphology, which is well beyond the scope of this discussion. In our experience of treating emergent AAAs, we have used all “off-theshelf” stent grafts approved by the US Food and Drug Administration and would recommend that surgeons/ interventionists have access to stent grafts with suprarenal as well as infrarenal fixation to have the greatest flexibility during these procedures. Particularly under emergent circumstances, the device with which the physician is most comfortable should be used. In our practice, we have most commonly used the GORE® EXCLUDER® Device featuring C3 Delivery System (Gore & Associates, Flagstaff, AZ). This system provides clinicians with the ability to deploy and then reposition the endoprosthesis prior to final release from the delivery catheter. There have not been any changes to the materials; the device is still constructed of an expanded polytetrafluoroethylene bifurcated graft with an outer self-expanding nitinol support structure. There have also been no changes to the profile of the device. The main difference between the GORE® C3 Delivery System and the original delivery system is that there are now three distinctive steps for deploying the trunkipsilateral endoprosthesis.

The deployment controls of the GORE® C3 Delivery System are housed in the device handle, which is ergonomically designed, is easy to maneuver, has great trackability similar to the original device, and allows for one-to-one rotation during device positioning.

The GORE® C3 Delivery System deployment of the main body up to the contralateral gate is similar to the original GORE® SIM-PULL Delivery System (Gore & Associates) and requires turning the outermost handle 90° counterclockwise and pulling a deployment cord. Once the first stage is deployed, the x-ray intensifier can be repositioned to adjust for parallax. The top of the stent graft main body can then be constrained by turning the gray knob on the back of the GORE® C3 Delivery System handle clockwise. This allows the proximal barbs to fully disengage from the aortic wall, enabling the stent graft to be advanced or pulled down as needed.

The constrained stent graft can also be rotated to align the contralateral gate with the catheter used for gate cannulation, easing the cannulation process. Subsequently, the constrained device can be advanced up to the lowermost renal artery. Once in position, the gray knob is turned counterclockwise to once again deploy the proximal end of the stent graft and engage the proximal barbs into the aortic neck for active fixation in a very controlled manner.

The second stage of the GORE® C3 Delivery System handle is then turned 90° counterclockwise and pulled to release the constraining mechanism. Finally, the third stage and innermost knob is turned 90° counterclockwise and pulled to release the constrained ipsilateral stent graft limb. The delivery catheter is then retracted over the wire.

RECENT Albany Vascular Group EXPERIENCE

At Albany Medical Center, during the past year, 14 patients underwent EVAR for emergent AAAs using the GORE® EXCLUDER® Device featuring C3 Delivery System, and we have found the additional distinctive features of the new system to be valuable in treating a wide range of complex, acute symptomatic AAAs.

The expected succession of new technology includes improvements in techniques that enable us to further explore new and often undiscovered boundaries. When it comes to managing patients with emergent AAA, subtle improvements in both techniques and technology can have a significantly favorable effect on patient's outcomes.

Manish Mehta, MD, MPH, is Associate Professor of Surgery with The Institute for Vascular Health and Disease, The Vascular Group, PLLC in Albany, New York. He has disclosed that he receives grant/research funding from Gore & Associates, ev3 Inc., Cordis Corporation, TriVascular, Inc., Abbott Vascular, Terumo Cardiovascular Systems Corporation, Lombard Medical Technologies, Inc., Bolton Medical, Inc., Medtronic, Inc., Aptus Endosystems, Inc., Maquet Cardiovascular, and Harvest Technologies Corporation. He is also a paid consultant to Gore & Associates, ev3 Inc., Cordis Corporation, and TriVascular, Inc. Dr. Mehta may be reached at (518) 262-5640; mehtam@albanyvascular.com.

  1. Mehta M. Endovascular repair of ruptured abdominal aortic aneurysms: The Albany Vascular Group Approach. J Vasc Surg. 2010;52:1706-1712.
  2. Dgorova N, Giacovelli J, Greco G, et al. National outcomes of treatment of ruptured AAA: comparison of open versus endovascular repair. J Vasc Surg. 2008;48:1092-1100.
  3. Starnes BW, Anderson CA, Ronsivalle JA, et al. Totally percutaneous aortic aneurysm repair: experience and prudence. J Vasc Surg. 2006;43:270-276.
  4. Mehta M, Taggert J, Darling RC III, et al. Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. J Vasc Surg. 2006;44:1-8.