Endovascular Aneurysm Sealing for Abdominal Aortic Aneurysm Repair: Evolution or Revolution?

Abstract

When Juan Parodi, an Argentinian vascular surgeon, performed the first endovascular aneurysm repair (EVAR) in 1989 [1], the interventional world expected that a revolution in aneurysm repair would quickly follow. The idea of a percutaneously delivered endograft was predicted in 1969 by Charles Dotter and first reported in 1986 at the Radiological Society of North America by another American radiologist, Cesar Gianturco [2]. He used endografts in the tracheobronchial tree amongst other locations [3]. Parodi initially treated type A aneurysms with a surgical tube graft fixed only with a proximal stent. However, he quickly developed a technique to treat aneurysms extending to the aortic bifurcation, and even involving the iliac arteries, using an aorto-uni-iliac endograft with femoral–femoral cross-over (Fig. 1) [4]. During the next few years, pioneers around the world advanced the technologies and techniques, and early commercial endografts became available with most being fully supported by self-expanding stents. By 1993, methods to reconstruct the aorta with a bifurcated endograft were being developed: The most effective involved a graft body with a short and a long limb with the short limb being cannulated and extended from the contralateral femoral artery. At this time, in Perth, Western Australia (the most remote city in the world), a project commenced at Royal Perth Hospital (RPH) to develop an endograft and EVAR programme. This was truly a collaborative project between vascular surgery and interventional radiology lead by two talented and influential pioneers: vascular surgeon Michael Lawrence-Brown and charge medical radiation technologist David Hartley. Patients were first treated in 1993 with a tube graft system, but in June 1994—the exact week I arrived at RPH as interventional radiology fellow [5]—the first bifurcated endograft was deployed (Fig. 2). During the following years, the team made some influential improvements to the procedure and device—including the use of a bifurcated flow model, fixation hooks on a suprarenal stent, delivery nose cone, and integrated safety wire—that would affect EVAR worldwide. A close relationship developed between RPH and Cook Medical (Bloomington, IN) resulting in the development of sheaths and haemostatic valves. Eventually, Cook Medical acquired the technology, and it became the highly successful Cook TriFlex EVAR system.