Recovery of EndoAnchors Using a Four Loop Vascular Retriever Snare: Adaptive Solutions for Adverse Events Related to Endovascular Material

Abstract

Introduction

EndoAnchors are adjuncts used for the prevention and treatment of type I endoleak and graft migration in thoracic or abdominal endovascular aortic aneurysm repair in patients with a challenging aortic neck. They secure the stent graft mechanically to the aortic wall by means of metallic screws. Adverse events are infrequent; however, the most common ones are fracture and or dislodgment (0.3–0.9%) and applicator malfunction (0.3%), as observed in this case.

Case

A 77 year old woman showed symptoms of increasing interscapular chest pain for three months. A computed tomography angiography scan revealed a large and symptomatic ascending thoracic aortic aneurysm with extension to the arch and descending thoracic aorta. The patient was operated on urgently using a frozen elephant trunk technique, with pain cessation. The residual thoracic aneurysm was repaired six months later with two overlapped thoracic endografts placed 15 mm above the celiac trunk and distal EndoAnchors, an off label use, due to a severely angulated distal landing zone. During the seventh and last EndoAnchor deployment on an angulated surface, a malfunction of its applicator was detected, which caused EndoAnchor detachment and migration, flying into the aorta's lumen and landing close to the aortic wall below the graft. It was then trapped with a CloverSnare four loop vascular retriever (CookMedical, Bloomington, IL, USA), supported by an 8.5 F TourGuide steerable sheath. During extraction, it fractured into two pieces at the common iliac artery. The previous manoeuvre was repeated at this level, recovering the fractured piece. Final completion angiography showed a good result without endoleak. The immediate post-operative and follow up scans were uneventful.

Conclusion

EndoAnchor detachment is uncommon but when it does occur, it is a solvable issue and can be retrieved using a snare and extracted with the proper endovascular tools and expertise.