Abdominal aortic endografting:

The treatment goals for elective endovascular and open surgical repair of abdominal aortic aneurysms are identical. Anyone attempting to remedy this condition desires longterm freedom from aneurysm rupture in association with minimal morbidity and mortality for the intervention required. The methods by which these objectives are achieved differ significantly between open and endovascular procedures. This article will address the means by which endografts achieve proximal fixation and sealing, two concepts that are paramount in durable endovascular aneurysm repair. The surgical anastomosis, when properly constructed, is the most secure way to fixate graft material to a section of normal arterial wall. This serves to prevent flow outside of the designated conduit and to secure the graft material in place. Although this is conceptually straightforward, individuals who treat this condition maintain a healthy respect for the potentially complex anatomy of the proximal neck. The ability to make adjustments while sewing the proximal anastomosis is extremely advantageous. Similar situations can be encountered during endovascular aortic repairs, but we are frequently unable to modify the device or technique once the procedure has been initiated. Consequently, the preoperative imaging and planning is critical to successful endovascular grafting. Appropriate patient selection, the conceptual design of an endovascular graft, and detailed planning of the operation must be completed before arrival in the operating room. Most assessments of acute technical and clinical success of endovascular grafting have been quite favorable, but complex analyses of longterm durability raise concerns that dwarf the early favorable results. The inevitable deterioration of the arterial system associated with age and accelerated by aneurysmal disease, in conjunction with morphologic changes associated with sac shrinkage, requires endovascular prostheses to adapt to altering anatomy. Endograft design must be tailored to specific anatomic factors that must be determined preoperatively, and acute success, with respect to proximal fixation and sealing methods, must be coupled with materials that will accommodate anatomic changes.