FUNNEL TECHNIQUE: A WAY OUT IN ABDOMINAL AORTIC ANEURYSM WITH ECTATIC PROXIMAL NECK. TECNICA FUNNEL: UNA SOLUZIONE ALTERNATIVA IN ANEURISMA DELL'AORTA ABDOMINALE CON COLLETTO PROSSIMALE ECTASICO. (Chirurgia Vascolare-ULSS 15 Alta Padovana) (Vascular Surgery -ULSS 15 Alta Padovana)

1. J ENDOVASC THER
2006;13:775–778
775
ᮊ 2006 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at www.jevt.org
ࡗCASE REPORT ࡗ
Funnel Technique for First-Line Endovascular
Treatment of an Abdominal Aortic Aneurysm With an
Ectatic Proximal Neck
Mario Zanchetta, MD; Francesca Faresin, MD; Luigi Pedon, MD; Melania Riggi, MD;
Stefania Colonna, MD; Rosario Lipari, MD; Francesco Pettenuzzo, MD; and
Salvatore Ronsivalle, MD
Department of Cardiovascular Disease, Ospedale Civile, Cittadella, Padua, Italy.
ࡗ ࡗ
Purpose: To describe a novel endovascular technique for proximal stent-graft fixation in
an abdominal aortic aneurysm (AAA) with an ectatic aortic neck.
Case Report: An 84-year-old man with multiple comorbidities and an asymptomatic 7-cm
infrarenal AAA with a 38-mm aortic neck diameter was treated with a 3-component Talent-
LPS stent-graft system. After the left internal iliac artery was embolized with coils, a
34ϫ16ϫ170-mm Talent bifurcated stent-graft was placed in the lower part of the AAA. A
44-mm-diameter, 90-mm-long free-flow thoracic tube endograft (6-mm oversizing) was de-
livered to the proximal neck through the bifurcated device and deployed with at least 30
mm of overlap, leaving more than 40 mm extending into the infrarenal aorta to ensure
expansion to its nominal diameter as well as an adequate seal. An iliac extension was
deployed into the left external iliac artery, and 2 sequential iliac extensions were inserted
from the bifurcated stent-graft limb to the right common iliac artery in a bell-bottom con-
figuration. Serial computed tomographic angiograms at up to 18 months have documented
the intact 3-component stent-graft, with no endoleak or migration and no increase in an-
eurysm sac diameter.
Conclusion: This case illustrates the feasibility of placing a straight thoracic endograft as
a proximal extension of a bifurcated aortic endograft into a dilated proximal aortic neck.
This endograft configuration appears secure and effective, with no type I endoleak or mi-
gration over a midterm follow-up.
J Endovasc Ther 2006;13:775–778
Key words: abdominal aortic aneurysm, endovascular repair, stent-graft
ࡗ ࡗ
The authors have no commercial, proprietary, or financial interest in any products or companies described in this article.
Address for correspondence and reprints: Mario Zanchetta, MD, FACA, FSCAI, FESC, Dipartimento di Malattie Cardio-
vascolari, Ospedale Civile, Via Riva Ospedale, 35013, Cittadella, Padua, Italy. Fax: 39-049-942-4531; E-mail: emodinacit@
ulss15.pd.it
Endovascular aneurysm repair (EVAR) is a vi-
able alternative to an open surgical procedure
for treatment of abdominal aortic aneurysm
(AAA). However, adverse features of an indi-
vidual’s vascular anatomy, such as the mor-
phological characteristics of the proximal and
distal fixation sites, require thoughtful consid-
eration about suitability for and feasibility of
endografting. In fact, secure fixation and ad-
equate sealing at the proximal and distal AAA
necks are probably the most important factors
in predicting a successful outcome of EVAR.
To accomplish these goals, precise sizing and
accurate deployment of all aortic endovascu-
lar grafts are of paramount importance, so de-
vices must be ϳ10% to 20% larger in diameter
than the inner proximal neck diameter.
Whereas the management of ectatic (i.e.,

2. 776 FUNNEL TECHNIQUE FOR WIDE NECKED AAA
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J ENDOVASC THER
2006;13:775–778
Figure 1ࡗ(A) Sagittal 3-dimensional contrast-enhanced CT reconstruction shows the neck
and the aneurysm sac as 2 distinct components: in fact, the proximal neck is defined more
by the rate of change of aortic diameter than by its absolute diameter. (B) Graphic image of
preoperative AAA diameter and length measurements. (C) Diagram of the 3-component com-
posite Talent-LPS stent-graft used in the funnel technique.
Ͼ14 mm in diameter) common iliac arteries
(CIA) using aortic cuffs or custom-made flared
extensions has become a option worldwide,1,2
many EVAR candidates are still appropriately
rejected due to a dilated proximal aortic neck.
Actually, if the aortic neck diameter between
the renal arteries and the aneurysm is too
wide (i.e., Ͼ25 mm), it may be difficult to find
a commercially available endovascular device
big enough to accommodate the neck with
appropriate oversizing. In such cases, the
possibilities for providing successful stent-
graft fixation may be accomplished by lapa-
roscopic proximal aortic ‘‘primary banding’’3
or fenestrated endograft implantation.4,5
We describe a new method for stent-graft
fixation in ectatic nonaneurysmal aortic
necks, in which using currently available de-
vices in a hybrid assembly offers another op-
tion for circumventing the limitations of prob-
lematic proximal fixation.
CASE REPORT
An 84-year-old man presented with a 7-cm
asymptomatic infrarenal AAA. His medical
history was notable for chronic obstructive
pulmonary disease, hypertension, extensive
arteriopathy (peripheral and carotid arterial
disease), and 3-vessel coronary artery disease
with severely impaired left ventricular func-
tion.
Preoperative assessment included standard
contrast arteriography with a marker catheter
and computed tomography (CT) with intra-
venous contrast and imaging acquisition at 3-
mm intervals (Fig. 1A). Preoperative AAA
measurements (Fig. 1B) were a 38-mm aortic
diameter at the lowest renal artery; 69-mm
maximal aneurysm diameter; 20- and 29-mm-
diameter iliac landing zones on the right and
left, respectively; 32-mm-long aortic neck be-
low the renal artery; 112 mm of aorta from the
beginning of the aneurysm to the bifurcation;
and 52- and 54-mm-long CIAs on the right
and left, respectively. Given the patient’s co-
morbid conditions, we believed he was a can-
didate for EVAR. We elected to use a 3-com-
ponent Talent-LPS stent-graft (Medtronic
Vascular, Santa Rosa, CA, USA), consisting of
a straight thoracic stent-graft, a bifurcated
aortic stent-graft, and 3 iliac extensions (Fig.
1C).
The endovascular procedure was carried
out in an operating room under fluoroscopic
and angiographic guidance by a team of vas-
cular surgeons and interventional cardiolo-
gists. A portable C-arm fluoroscopy device
(OEC 9800 Plus, GE Medical Systems, Salt
Lake City, UT, USA) and a radiolucent table
were used. After administration of general an-
esthesia, the common femoral arteries were
surgically exposed, and the devices were in-

3. J ENDOVASC THER
2006;13:775–778
FUNNEL TECHNIQUE FOR WIDE NECKED AAA
Zanchetta et al.
777
Figure 2ࡗA step-by-step diagram of the funnel technique for assembling a 3-component
Talent-LPS stent-graft. (A) Step 1: after coil embolization of the left internal iliac artery, the
main body of the bifurcated aortic stent-graft with its integral limb is deployed into the an-
eurysm sac. (B) Step 2: the straight thoracic endograft is inserted as an extension of the main
body of the bifurcated aortic endograft through the ipsilateral femoral access. (C) Step 3: the
left iliac limb extension is deployed into the left external iliac artery. (D) Step 4: aneurysm
sac exclusion is obtained by placing 2 sequential iliac extensions from the integral limb of
the bifurcated aortic stent-graft to the right common iliac artery in a bell-bottom configuration.
troduced over a stiff guidewire in a brachial-
femoral arterial loop. Initially, the left internal
iliac artery was embolized with coils, then a
43ϫ16ϫ170-mm Talent bifurcated stent-graft
was placed in the lower part of the aneurysm
(Fig. 2A). A 44-mm-diameter, 90-mm-long tho-
racic tube endograft with a 16-mm free flow
proximal stent was selected on the basis of
the adventitia-to-adventitia CT measurement
of the aortic neck diameter, allowing 6 mm of
oversizing. The tube graft was delivered to
the proximal neck through the bifurcated de-
vice via the ipsilateral femoral access (Fig.
2B); it was deployed with at least 30 mm of
overlap, leaving more than 40 mm extending
beyond the main body of the bifurcated de-
vice to ensure expansion to its nominal di-
ameter as well as an adequate seal. An iliac
extension was deployed into the left external
iliac artery to obtain adequate distal graft–
vessel wall apposition and a hemostatic seal
(Fig. 2C). Finally, the sac was excluded by in-
serting 2 sequential iliac extensions from the
integral limb of the bifurcated stent-graft to
the right CIA in a bell-bottom configuration
(Fig. 2D). The resultant funnel configuration at
the infrarenal aortic neck was evident on the
postprocedural radiogram (Fig. 3A). CT angio-
grams obtained at 3, 6, and 18 months (Fig.
3B) after the procedure showed the intact
structure of the composite 3-component
stent-graft, with no endoleak or migration and
no increase in aneurysm sac diameter.
DISCUSSION
Progress in endovascular therapy has left few
areas in need of major improvement, but
large infrarenal necks remain a challenge for
endovascular interventionists. Until recently,
EVAR was limited by the 28-mm proximal
neck diameter of custom-made aortic stent-
graft systems, so 25 mm was the largest prox-
imal aortic neck suitable for endovascular
procedures. However, the latest-generation
devices have surmounted these traditional
limitations, and patients with aortic neck di-
ameters up to 34 mm have been enrolled in

4. 778 FUNNEL TECHNIQUE FOR WIDE NECKED AAA
Zanchetta et al.
J ENDOVASC THER
2006;13:775–778
Figure 3ࡗ(A) The postprocedural abdominal ra-
diogram shows the intact composite stent-graft
and its funnel configuration. (B) Coronal 3-dimen-
sional contrast-enhanced CT reconstruction 18
months later shows the intact 3 stent-graft com-
ponents, with no endoleak or migration and no in-
crease in either neck or sac diameters. The over-
lapping between the bifurcated aortic and thoracic
stent-grafts can be discerned by the double-strut
configuration.
Talent trials. Early success in AAA exclusion
has been achieved,6,7 but not all cardiovas-
cular surgeons have agreed with this liberal-
ization of the selection criteria.
To meet the challenges imposed by our pa-
tient’s vascular anatomy, we used a compos-
ite 3-component stent-graft to satisfy the min-
imal 4-mm tolerance between the endograft
and aortic neck diameters to optimize graft
fixation as well as to ensure adequate sealing.
Primary laparoscopic proximal aortic band-
ing3 or a fenestrated endograft4,5 might also
be performed to treat patients with a similar
anatomy, but these procedures are, respec-
tively, more invasive and time consuming.
In this setting, the funnel technique, in
which a straight thoracic stent-graft is placed
through the main body of a bifurcated endo-
graft, may represent an appealing alternative
because this concept is similar to surgical
placement of a tube graft at open AAA repair.
Furthermore, this stent-graft assembly in the
funnel configuration is a simplified approach
to the lesion and optimizes hemodynamic
performance from the aorta to the main body
of the bifurcated endograft. A greater oversiz-
ing of 10% and central positioning of the tho-
racic graft so that one half of its length ex-
tends into the native infrarenal aorta and the
other into the bifurcated aortic endograft are
mandatory to ensure expansion of the
straight thoracic graft to its nominal diameter
and to prevent type I endoleak or migration
due to the loss of device fixation.
Conclusion
This case illustrates the feasibility of placing
a straight thoracic endograft as a proximal ex-
tension of a bifurcated aortic endograft in a
patient with a dilated proximal aortic neck.
This endograft configuration appears secure
and effective, with no type I endoleak or mi-
gration over a midterm follow-up.
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