Technical challenges during emergent endovascular aneurysm repair with the ALTO system

ABSTRACT

Introduction

Ruptured abdominal aortic aneurysms (AAAs) pose an immediate threat for patient’s life and endovascular repair (EVAR) is currently the preferred treatment modality in the presence of suitable anatomy. This is determined based on the requirements of each endograft as described in the instructions for use (IFU). The new ALTO system (Endologix, Irvin, CA, U.S.A.), can accommodate a great range of anatomies such as short necks and/or narrow access, but its unique design requires specific technical modifications during treatment of ruptured AAAs.

Areas covered

The standard double balloon technique has long been described and it is used to provide circulatory support during EVAR for ruptured AAA. While this technique is straightforward with the use of endografts with a traditional design, this would not be the case if one uses the ALTO system. In that case specific maneuvers would be required to treat AAA patients in an acute setting.

Expert Opinion

The ALTO system although being able to treat AAAs with adverse anatomy, it may not be appropriate during treatment of ruptured AAA patients with profound hemodynamic instability. A careful evaluation of the individual’s patient anatomy and hemodynamic condition is mandatory in order to decide the best endograft for each case.

KEYWORDS:

• Rupture
• abdominal aortic aneurysm
• endovascular
• aortic balloon
• hemodynamic shock

Article highlights

• Endovascular aneurysm repair (EVAR) is the preferred treatment modality for the repair of ruptured abdominal aortic aneurysms (AAAs)

• A suitable anatomy is important to achieve optimal outcomes and this is based on the technical specifications of each endograft

• The ALTO system has been previously shown to be able to treat the widest range of aorto-iliac anatomies inside the instructions for use (IFU), compared to the rest of available systems

• Due to its distinct features, the ALTO system needs specific modifications of the technique of implantation compared to the standard technique used during ruptured AAA treatment.

• A careful patient selection based on their anatomy and hemodynamic stability is necessary in order for the treating physician to determine if the ALTO or an alternative traditional stent-graft should be selected for an individual patient.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewers disclosure

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.