May 7, 2007

No Fix for Stent-grafts

Are stents and stent-grafts at an evolutionary dead-end? Do extended

suprarenal stents with more flexibility lead to more acute fixation? Will a
shorter sealing zone, a shorter stent length, and electropolished stents
fulfill the need of a durable and permanent abdominal aortic aneurysm (AAA)
repair?

In the past, the favorable morbidity and mortality outcomes of stent-graft

procedures have led to increasing demand from both the public and medical
profession. The good news: it has been suggested that an endoluminal repair
results in less postoperative pain and gastrointestinal dysfunction. The
bad news: with the available stent-graft procedure (EVAR), reintervention
is required in a substantial number of patients. The most common reasons
for secondary intervention have been aneurysm rupture, lack of seal and
enlargement with or without endoleaks, graft limb occlusion, and/or stent-
graft migration. The potential mechanisms for the migration of stent-grafts
include poor proximal graft fixation and infrarenal aortic neck dilatation.

Many stent-graft marketers and design engineers attempt to reduce the

longitudinal columnar strength of the stent-graft in order to allow for
more resistance to the migration of the graft. The sales and marketing
representatives try to convince the physician community to use more modular
components for stenting the iliac limbs all the way to the hypogastric
bifurcation. According to the stent-graft companies and their physician
consultants, this may offer longer fixation zones with larger and longer
stented iliac limbs. Other designs come with a proximal uncovered stent,
which is deployed so as to cover one or both renal artery orifices.

Nevertheless, the forces acting within the pressurized aorta and upon a
stent-graft overcome the limited fixation of radial attachment. The
curvature of the graft limbs creates an additional sideways force that
works to displace the distal limbs of the stent-graft from the iliac
arteries.

The many questions about device design, fixation, durability, and

deployment methods are cause to search for new techniques. Patients are
assuming an increasingly dominant role in decisions about their care and
many are less than thrilled about the bad news for stents. The need for
less-invasive procedures is the driving force for new designs of
endoluminal grafts with methods for secure and permanent fixation.

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