US20070123972A1 - Modular stent graft assembly and use thereof - Google Patents

Abstract

A modular stent graft assembly (10) for repairing a ruptured abdominal aorta aneurysm (90) and having an aortic section tubular graft (12) and an iliac section tubular graft (14). The aortic section graft has a proximal attachment stent (32) thereon for suprarenal attachment of the assembly (10) to the aorta. A proximal end portion (50) of the iliac section graft (14) underlies the distal end portion (28) of the aortic graft (12) and presses outwardly thereagainst forming a friction fit, at a telescoping region (64). The assembly (10) can be selected from an inventory (300) containing a set of delivery systems (100) of four size aortic section grafts (12) and a set of delivery systems (200) of four size iliac section grafts (14), that together accommodate a large majority of aneurysm sizes, and delivery systems (250) containing four standard sizes of occluders (80).

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This is a continuation of application Ser. No. 10/104,672, filed Mar. 22, 2002, which claims priority of provisional application Ser. No. 60/279,329, filed Mar. 28, 2001, both of which are incorporated by reference.
TECHNICAL FIELD
• The present invention relates to medical devices and more particularly to modular endovascular stent grafts.
BACKGROUND OF THE INVENTION
• In recent years treatment of aneurysms has been performed prior to aneurysm rupture and has included the use of stent grafts that are implanted within the vascular system with minimally invasive surgical procedures and that include one or more stents affixed to graft material. The stent grafts are secured at a treatment site by endovascular insertion utilizing introducers and catheters, whereafter they are enlarged radially and remain in place by self-attachment to the vessel wall. In particular, stent grafts are known for use in treating descending thoracic and abdominal aortic aneurysms where the stent graft at one end defines a single lumen for placement within the aorta and at the other end is bifurcated to define two lumens, for extending into the branch arteries.
• One example of such a stent graft is disclosed in PCT Publication No. WO 98/53761 in which the stent graft includes a sleeve or tube of biocompatible graft material such as Dacron™ polyester fabric (trademark of E. I. DuPont de Nemours and Co.) or polytetrafluoroethylene defining a lumen, and further includes several stents secured therealong, with the stent graft spanning the aneurysm extending along the aorta proximally from the two iliac arteries; the reference also discloses the manner of deploying the stent graft in the patient utilizing an introducer assembly. The graft material-covered portion of the single-lumen proximal end of the stent graft bears against the wall of the aorta above the aneurysm to seal the aneurysm at a location that is spaced distally of the entrances to the renal arteries. Thin wire struts of a proximal stent extension traverse the renal artery entrances without occluding them, since no graft material is utilized along the proximal stent while securing the stent graft in position within the aorta when the stent self-expands. An extension is affixed to one of the legs of the stent graft to extend along a respective iliac artery and, optionally, extensions may be affixed to both legs. Another known stent graft is the Zenith AAA™ stent graft sold by William A. Cook Australia Pty. Ltd., Brisbane, Queensland, Australia.
• Because of life threatening time constraints, such conventional stent grafts are not practical to be utilized with ruptured aneurysms, which presently must be treated, if at all, by open surgery.
• Despite the multitude of advances in surgical management and intensive care, the devastating physiological effects of emergency aortic surgery for either ruptured abdominal aortic aneurysms (RAAA) or symptomatic abdominal aortic aneurysms (SAAA), carry an unacceptably high morbidity and mortality rate. Most patients who suffer from RAAA and SAAA are typically unaware of their aneurysmal disease prior to the development of symptoms of actual or impending rupture. The acuity of an RAAA precludes complex radiographic evaluation, does not allow for adequate preoperative planning, and is compounded by the relative unavailability of endovascular stent grafts. Additionally, because of the rapid blood loss from the patient, any substantial surgical delay cannot be tolerated. Another complication stems from the statistical fact that most patients who suffer RAAA or SAAA are elderly and have factors that preclude repair of the rupture by open surgery, with the result that patient mortality from RAAA is very high. Approximately 15,000 deaths per year occur in the United States from ruptured abdominal aortic aneurysms.
• Conventional surgical repair of ruptured and symptomatic aneurysms is itself associated with significant complications. Cardiopulmonary complications as a result of a prolonged abdominal operation, significant blood loss and aortic cross clamping, multiple blood transfusions, and hypothermia are most frequently encountered. Mortality of ruptured aneurysms is currently estimated to be between 50% and 75%.
• It is thus desired to provide medical devices enabling emergency endovascular treatment of RAAA and SAAA. It is further desired to provide such devices in a manner not requiring, on site at a surgical treatment center, a large inventory of different size devices while still enabling immediate treatment of a large range of aneurysm sizes, nor in a manner requiring preoperative study of the treatment site taking a substantial length of time in order to optimize the selection of an appropriate device. It is yet further desired to provide a medical device that is quickly deliverable and effectively deployable at the treatment site.
SUMMARY OF THE INVENTION
• The foregoing problems are solved and a technical advance is achieved in an illustrative modular stent graft assembly of the present invention. The stent graft assembly is to be a life-saving device first, and a permanent implant second. Each stent graft assembly comprises at least two components or sections, thus allowing for quick deployment; extensions can be added if necessary. The cranial or aortic section has a diameter corresponding to the normal or undiseased diameter of the aorta of the patient, and the caudal or iliac section has a diameter corresponding to the normal or undiseased diameter of the common iliac artery. The diameter of the aortic section of the assembly is sized to be at least 10 percent larger than the aortic artery for leakproof engagement therewith, while the diameter of the iliac section of the assembly is sized to be at least about 10 percent larger than the ipsilateral iliac artery, both thus assuring no deficiency in diameter that could otherwise result in leakage around the assembly or migration of the assembly following placement. Preferably, each section has an assembly interconnection portion with a constant diameter of, for example, 12 mm for at least a predetermined length of, for example about 56 mm to facilitate interconnection in a wide range of overall assembly lengths. The overall length of the implanted stent graft assembly is adjustable intraoperatively by varying the amount of overlap at the interconnection. An iliac occluder can also be utilized for occluding the contralateral iliac artery, with a conventional crossover connection to be made between the ipsilateral and contralateral iliac arteries, if possible.
• A preferred inventory of components or devices includes a set of aortic assembly sections of a common length (exclusive of the attachment stent length) with proximal end portions having one of a standard set (four) of proximal diameters (34, 30, 26 and 22 mm); and iliac sections of a common length with distal end portions having one of a standard set (four) of different distal diameters (24, 20, 16 and 12 mm). In addition, occluders having one of a standard set (four) of different diameters (24, 20, 16 and 14 mm) could be included in the inventory. Such inventory provides for the largest coverage of the different patient anatomy with the fewest number of components or devices; however, the lengths of the assembled devices can be varied to accommodate different patient anatomy.
• This invention is designed to perform a compromise operation which can be performed with a maximum of safety and yet produce a satisfactory and safe result. No time is spent on accurately measuring the dimensions of a patient's aorta, and no time is spent on manipulating a second graft down a second iliac artery and to thereby connect a second iliac leg thereto.
• The method of use includes inserting the aortic section of the assembly into the aortic artery and engaging the proximal end with portion thereof the aorta just below the renals with the distal end portion extending distally into the aorta. The iliac section is inserted into the ipsilateral artery with engagement thereagainst at the distal end portion thereof. The proximal end portion of the iliac section interconnects with the distal end portion of the aortic assembly section to provide an overlapping interconnection that can be adjusted to accommodate the patient's anatomy. An occluder is then implanted in the contralateral iliac to isolate the ruptured aneurysm.
• When an elderly patient is suffering from a rupture or dissection of an aortic aneurysm, all of the blood is immediately bypassed to one of the iliac arteries such as the ipsilateral iliac artery and the patient's life is saved. The provision of the contrailiac occluder and the bypass graft between the contrailiac artery and the ipsilateral iliac artery is a relatively unimportant detail and not too relevant to the life of the patient. Furthermore, the latter detail can be attended to after the ruptured vessel is isolated. The above operation may seem to be somewhat crude, but it is designed to protect the lives of elderly and very ill patients who would otherwise die. Each of the above steps has been performed separately for various reasons, but this is the first time that they have all been performed in sequence in a single permanent operation. One would not be expected to perform such an operation in a single procedure since it seems impractical and clumsy and yet it works and saves lives.
BRIEF DESCRIPTION OF THE DRAWING
• An embodiment of the present invention will now be described by way of example with reference to the accompanying drawings, in which:
• FIG. 1 diagrammatically illustrates the stent graft assembly of the present invention deployed within a ruptured aneurysm, and an occluder in a selected iliac artery;
• FIG. 2 is an exploded side view of the stent graft assembly of the present invention having an aortic section and an iliac section;
• FIG. 3 shows an occluder plug to be used with the present invention;
• FIG. 4 shows a first embodiment of a set of stent graft assembly components having an aortic section graft and two iliac section grafts;
• FIG. 5 illustrates a second embodiment of aortic section grafts;
• FIG. 6 shows a third embodiment of a set of graft assembly components having an aortic section style and three iliac graft styles;
• FIG. 7 is a Dimension Table containing dimension information on the stent graft sections of FIGS.4 to6;
• FIGS.8 to11 show the delivery systems for the three components, withFIG. 9 showing the trigger wire controls included in the aortic section system ofFIG. 8;
• FIGS. 12, 12A and12B show enlargements of the trigger wire containment arrangement for the attachment stent (proximal end) and for the distal end portion of the aortic graft;
• FIGS. 13 and 14 are enlargements of the proximal end of the aortic graft showing the trigger wire locking mechanism for the attachment stent; and
• FIG. 15 depicts a complete set of delivery systems having four standard size aortic section grafts, four standard size iliac section grafts, and four standard size occluders.
DETAILED DESCRIPTION
• The modular stent graft assembly of the present invention includes one or more devices and is intended for use in the abdominal aorta for symptomatic or ruptured aneurysm repair. Referring first to FIGS.1 to3, thestent graft assembly10 is modular and comprises anaortic section12, aniliac section14, and a contralateraliliac occluder80.
• Aortic section12 andiliac section14 are interconnected and overlap each other within theaneurysm90 upon deployment, whileoccluder80 is deployed separately within the contralateraliliac artery98.Aortic section12 is affixed at theaneurysm neck92 below therenal arteries94, withiliac section14 extending into ipsilateraliliac artery96. A conventional femoro-femoral bypass or cross-over procedure using a bypass graft (not shown) will reconnect the ipsilateral iliac artery to the contralateral iliac artery distal to theoccluder80, to convey blood from the side receiving the entire aortic blood flow through the stent graft assembly, to the other limb, in a manner disclosed in U.S. Pat. No. 5,693,084. The delivery systems (see FIGS.8 to11) for each component of the stent graft assembly are each comprised of a sheath into which the stent graft (or plug) is compressed, and a tapered tip for a smooth transition from wireguide-to-sheath diameters. The delivery system for the aortic section uses trigger wire release mechanisms to lock the endovascular graft onto the delivery system until the graft is precisely positioned axially and then released by the physician to be deployed at the deployment site. The delivery system is compatible with an 0.035 in (0.889 mm) wire guide.
• Theaortic section12 includes aproximal end portion26 and adistal end portion28, with a taperedtransition portion30 that interconnects the distal end portion having a constant diameter of 12 mm, and theproximal end portion26 having a selected larger diameter. Anattachment stent32 is secured to the proximal end portion, with the stent'sdistal end portion34 along the inside surface of thegraft material36, while the remainingattachment portion38 extending proximally from the graft material and havingbarbs40 for example for becoming affixed to the vessel walls.
• Aortic section12 also has severaladditional stents42,44,46 withstent42 adjacent to the attachment stent being disposed within the graft material, andstents44,46 being secured about the outer surface of thegraft material36 along the length thereof distally of theattachment stent32 andstent42.
• Theproximal end portion26 preferably is denoted by a plurality of radiopaque markers (not shown) such as gold marker members for facilitating fluoroscopic visualization of the proximal end of the graft material, for placement distally of the renal arteries.
• The contralateral iliac artery occluder inFIGS. 1 and 3, may be aconventional occluder80, such as the Zenith AAA™ Iliac Plug sold by William A. Cook Australia Pty. Ltd., Brisbane, Queensland, Australia, which comprises a tubular length ofgraft material82 of 20 mm with asingle stent84 sutured therewithin, having a diameter of between about 14 mm and 24 mm; oneend86 of the tubular structure traverses and closes the lumen therethrough withgraft material82 for sealing. A procedure for delivering such a contralateral iliac occluder and for performing a femoro-femoral bypass or cross-over procedure using a bypass graft is disclosed in U.S. Pat. No. 5,693,084.
• Preferably, the present invention includes a set of graft components limited in number but selected to accommodate most rupture sites, and includes fouraortic sections12 each differing in the size of their proximal diameters, and includes fouriliac section14 each differing in the size of their distal diameters, while the diameters of the distal ends of the fouraortic sections12 and the diameters of the proximal ends of the fouriliac sections14 is constant among the eight bodies. Preferably, the proximal diameter of theaortic section12 is standardized for each of four aortic sections to have one of four dimensions: 34 mm, 30 mm, 26 mm and 22 mm. Thedistal end portion52 of theiliac section14 is standardized for each of four iliac sections to have one of four standardized diameters: 24, 20, 16 and 12 mm.
• Several designs or embodiments of aortic sections are shown in FIGS.4 to6, and several designs or embodiments of iliac sections are also shown inFIGS. 4 and 6. Dimension information for the different standard sizes for the designs of the tubular grafts in FIGS.4 to6 is contained in the Dimension Table,FIG. 7, for easy reference, and includes proximal end and distal end diameters; proximal, distal and transition portion lengths; and interstent gap spacing for both the aortic and iliac tubular grafts. The lengths of the stents and their geometries and spacing can be varied to increase or decrease the flexibility of the system; also, two stents could optionally be utilized in the proximal end portion of the aortic section tubular graft.
• With respect toFIG. 4, one aorticsection tubular graft12 is shown, and two designs of iliac sectiontubular grafts14a,14bare shown. The diameter D_Pof the proximal end of aortictubular graft12 is one of four standardized diameters: 34 mm, 30 mm, 26 mm and 22 mm. The diameter D_Dof the distal end is 12 mm. The total length is preferably about 127 mm, with the proximal end portion length L_Pbeing 26 mm; the transition portion length L_Tbeing 33 mm; and with the distal end portion length L_Dbeing 68 mm.Transition portion30 is shown to include twotransition stents44,62 with substantial spacing therebetween. Regarding interstent gap spacings, G₁between the attachment stent and thefirst stent42 is 2 mm; G₂betweenfirst stent42 andfirst transition stent44 is 5 mm; G₃between the first andsecond transition stents44,62 is 5 mm; G₄betweensecond transition stent62 and the adjacentdistal stent46 is 3 mm; while gaps G₅between the severaldistal stents46 are 3 mm.
• The iliacsection tubular graft14ahas aproximal end portion50 with a diameter d_Pof 12 mm, and adistal end portion52 of a selected diameter d_Dof also 12 mm. Also, preferably, iliactubular graft14ahas a total length of 94 mm, with the proximal end portion length l_Pbeing about 73 mm in length, the distal end portion length l_Dbeing about 17 mm in length, and there is no tapered transition portion extending between the proximal and distal portions since the proximal and distal diameters are the same. As to iliacsection tubular graft14b, also having a total length of 94 mm, the diameter d_Pis 12 mm while the distal end portion has a selected diameter d_Dof 16, 20 or 24 mm. Proximal end portion length l_Pis 73 mm;transition portion54 has a length l_Tof 4 mm; and distal end portion length l_Tis 17 mm. The proximal and distal end portions may have respectively a proximal-most and adistal-most stent56,58 affixed internally of the graft material, and three axiallyshort stents60 therebetween affixed externally of thegraft material36. Gap g₁betweendistal stent58 and theadjacent stent60 is 4 mm, while gaps g₂between the remainingstents56,60 are 3 mm.
• Referring now toFIG. 5, theproximal end portion26 of the aorticsection tubular graft12 has a length L_Pof about 35 mm with onestent42 therewithin, thedistal end portion28 has a length L_Dof about 70 mm with four axiallyshort stents46 therearound, and the taperedtransition portion30 therebetween has a length L_Tof about 17 mm with onestent44 therearound.Transition portion44 is seen to have only onestent44 therearound and is shorter than thetransition portion44 of the embodiment ofFIG. 4. Regarding interstent gap spacings, G₁between the attachment stent and thefirst stent42 is 2 mm; G₂betweenfirst stent42 andtransition stent44 is 14 mm; G₄betweentransition stent44 and the adjacentdistal stent46 is 5 mm; while gaps G₅between the severaldistal stents46 are 3 mm. The iliac section tubular grafts for use therewith may be identical in design and dimension to those shown inFIG. 4.
• InFIG. 6 is shown one aorticsection tubular graft12, and three designs of iliac sectiontubular grafts14a,14b,14c. The total length of the aortictubular graft12 and each of the iliac tubular grafts is about equal. The diameter D_Pof the proximal end of aortictubular graft12 is, again, one of four standardized diameters: 34 mm, 30 mm, 26 mm and 22 mm. The diameter D_Dof the distal end is 12 mm. The total length is preferably about 108 mm, with the proximal end portion length L_Pbeing 28 mm; the transition portion length L_Tbeing 20 mm; and with the distal end portion length L_Dbeing 60 mm. Regarding interstent gap spacings, G₁between the attachment stent and thefirst stent42 is 2 mm; G₂betweenfirst stent42 andtransition stent44 is 3 mm; G₄betweentransition stent44 and the adjacentdistal stent46 is 3 mm; while gaps G₅between the severaldistal stents46 are 1 mm.
• As with the iliac section tubular grafts ofFIG. 4, the proximal and distal end portions of iliactubular grafts14a,14b,14cofFIG. 6 have respectively a proximal-most and adistal-most stent56,58 affixed internally of the graft material, and four axiallyshort stents60 therebetween affixed externally of thegraft material36. The iliactubular graft14ahas aproximal end portion50 with a diameter d_Pof 12 mm, and adistal end portion52 of a selected diameter d_Dof also 12 mm. Also, preferably, iliactubular graft14ahas a total length of 110 mm, and there is no tapered transition portion extending between the proximal and distal portions since the diameters are the same. As to iliactubular graft14b, also having a total length of 110 mm, the diameter d_Pis 12 mm while the distal end portion has a selected diameter d_Dof 16 or 20 mm.Proximal end portion50 length l_Pis 56 mm;transition portion54 has a length l_Tof 34 mm; anddistal end portion52 length l_Dis 20 mm. Gap g₁betweendistal stent58 and theadjacent stent60 is 3 mm, and gaps g₂between the remainingstents56,60 are also 3 mm. Iliacsection tubular graft14bdiffers fromgraft14cin thatgraft14chas a distal diameter of 24 mm. The transition portion need not be precisely symmetrically tapered, as can be seen.
• Regarding the differences between the embodiments ofFIGS. 4, 5 and6, the transition portion of theaortic section graft12 ofFIG. 4 is elongated with two stents therearound spaced substantially from each other, in comparison with the transition portions of the aortic grafts ofFIGS. 5 and 6. The greater spacing provides more flexibility while utilizing two stents minimizes any tendency of the graft to buckle and close slightly, when finally deployed in the aneurysm and also thereafter as the aneurysm shrinks over time, and minimizes the chance of endoleaks. The longer, more gradual taper of the transition portion ofFIG. 4 reduces somewhat forces from the blood flow through the deployed stent graft assembly tending to pull the stent graft assembly distally, and thus reduces any tendency of the graft assembly to migrate. Turbulent blood flow is also further reduced with the longer transition portion because of the longer transition portion length. Theaortic section graft12 ofFIG. 4 has a longer total length than the lengths ofaortic grafts12 ofFIGS. 5 and 6, while the iliac section grafts are correspondingly shorter with one less stent therealong, and with a shorter transition portion having no stent therearound.
• The graft to be selected is based on the findings from preoperative radiologic studies, including computerized tomography (CT), magnetic resonance imaging (MRI), or conventional angiography. The outside diameter of the graft is intended to be at least 10 percent larger than the proximal implantation site. The attachment site for distal implantation is also oversized at least about 10 percent. The assumption is being made that a small amount of graft redundancy or vessel stretching would be inconsequential, whereas a small deficiency in the diameter of the graft could result in either endoleakage or migration. Determination of the proximal diameter of the aortic graft depends primarily on a measurement of theaneurysm neck92 from preoperative or intraoperative imaging. If the neck of theaneurysm90 appears to have an elliptical section on trans-axial images, the true profile is assumed to be circular and the true diameter is the diameter of the narrowest part of the ellipse. If CT scanning is unavailable, intraoperative intravascular ultrasound (IVUS) may be used to determine the diameter. In determining the graft length, the intended implantation sites must first be identified. The proximal implantation site is generally just distal to the lowestrenal artery94 so that thegraft material36 does not cover therenal arteries94, with attachment made by the proximalbare stent portion38 extending over and past the renal arteries. The distal implantation site is in the ipsilateral iliac artery96 (typically proximal to the takeoff of the hypogastric artery). Both sections of the stent graft assembly have fixed lengths. The overall length of the assembly is adjusted intraoperatively by varying the amount of overlap at the interconnection of the two sections.
• Referring to FIGS.8 to11, the delivery systems for the aortic section, iliac section and contralateral iliac occluder will now be described. Thedelivery system100 foraortic sections12 is illustrated inFIGS. 8 and 9, having adelivery sheath102, atop cap104 and tapereddilator106 atproximal end108, and a fitting110 atdistal end112 of the delivery system.Top cap104 is affixed to the distal end ofdilator106, which is affixed at the proximal end of a small diameterinner cannula120 that extends completely through the delivery system to the distal end. Fitting110 is affixed tosheath102, and joined to the side of fitting110 isinjection system114, for
• saturating the stent graft with anticoagulant heparin prior to deployment, and optionally for the injection of contrast medium thereafter.
• At the distal end of fitting110 is a check-flow valve116 through which extendspusher118. Distally ofpusher118 is seenhandle122 ofcannula120, and triggerwire control systems124.
• Stylet126 extends throughcannula120, throughpusher118 andintroducer sheath102 andtop cap104 to aproximal tip128 that protrudes from the proximal end of the tapereddilator106;stylet126 is of protective value during shipping and handling but is removed prior to use in the medical procedure.Tabs130 are provided at the distal end ofshort sheath132, for peeling away the sheath prior to the medical procedure;sheath132 protects the patency of the introducer lumen at the check-flow valve during shipping and handling, and extends only intofitting110. For protection of the distal end components during handling, aprotective tube134 is secured therearound, and it also is removed prior to the procedure.
• Triggerwire control systems124 are shown in greater detail inFIG. 9.Control systems124 for the twotrigger wires136,138 of thedelivery system100 each include asafety lock140 that is removed laterally, and arelease ring142 that is moved distally (away from the patient) parallel to thecannula120 and pulls the respective trigger wire out of the assembly. Thetrigger wire136 for securing theattachment stent32 of theaortic graft12 against any axial movement until released, is first to be removed prior to being able to actuate the controls fortrigger wire138 that secures thedistal end portion28 of the aortic graft against any axial movement until released. Also, therelease ring142 for the distal end portion may be a different color than that for the attachment stent, to clearly indicate to the physician which trigger wire the particular control system actuates. The release rings142 haveaxial slots144 therealong to permit lateral removal from about theinner cannula120.Pin vise146 tightens upon and releasesinner cannula120 so thattop cap104 andtip106 can be advanced to deploy and be withdrawn for docking and system withdrawal.
• Delivery system200 forextension leg14 is shown inFIG. 10, and is similar tosystem100, including adelivery sheath202, tapereddilator204 atproximal end206, and a fitting208 atdistal end210 of the delivery system. Joined to the side of fitting208 is theheparin injection system212, andinner cannula214 withhandle216 therefor extends fromdistal end210.Tabs220 are provided at the distal end ofshort sheath222 that extends only into fitting208, for peeling away the sheath prior to use, andstylet224 is also removed prior to use. Also inFIG. 10 is seen check-flow valve226,pusher228, pusher fitting230 andpin vise232, with aprotective tube234 thereover similar toprotective tube134 ofFIG. 7.
• Delivery system250 for a conventional contralateraliliac occluder80 is shown inFIG. 11, and includes two assemblies.Introducer252 includes atapered dilator254 and adelivery sheath256 that is adapted for delivery over a guide wire along the contralateral iliac artery.Second assembly258 includes ashort sheath260 containingoccluder80, a fitting262 with aheparin injection system264 extending from the side thereof, a three-disk check-flow valve266, and apusher268 for pushing the contralateraliliac occluder80 from the distal end of thesheath260.
• Proximal end270 ofsheath260 is inserted into the proximal end272 ofintroducer252 once the introducer is positioned and the guide wire and dilator removed.Pusher268 then is utilized to move theoccluder80 into thedelivery sheath256 and therealong to the deployment site adjacent to the bifurcation with the aorta. Alternatively, an occluder may be utilized that is deliverable over a guide wire, and that transversely closes completely upon withdrawal of the guide wire after complete deployment of the occluder.
• In FIGS.12 to14, thetrigger wire136 is shown in detail in relationship toattachment stent32 ofaortic graft12.FIG. 13 illustratesattachment stent32 beforetop cap104 has been placed over the exposed struts148, during which a suture holds the strut ends48 gathered near theinner cannula120; the suture is removed once the top cap is in place.Trigger wire136 extends from itscontrol section124 alongsmall diameter cannula120 of thedelivery system100 withinpusher118, and includes alocking section150 that extends outwardly through an aperture ofproximal pusher body152 and forwardly throughaortic graft12 and then outwardly thereof nearproximal end26 thereof, then forwardly and into a small aperture of the top cap and through a loop at the joinedproximal ends48 of a pair ofstruts148 and then further into the dilator, held therein by friction fit by the inner cannula threaded into the dilator.Release portion150 holds the proximal ends48 of the exposed struts of the attachment stent within the top cap, fixed against axial movement with respect to the top cap and dilator.Top cap104 surrounds all the exposed struts148 ofattachment stent32 when theaortic section graft12 is delivered to the site of the ruptured aneurysm, until it is accurately positioned at the aneurysm neck.
• First sheath102 is then pulled distally with respect toaortic graft12 by manual movement of fitting110 while the struts of the attachment stent are held within and still restrained withintop cap104, as seen inFIGS. 12 and 14, after which triggerwire136 is pulled from the top cap and withdrawn completely from the catheter, thus releasing the loop of the attachment stent struts. With the aortic graft held against axial movement relative to pusher118 bytrigger wire138, the dilator/topcap/cannula assembly is pushed forwardly (proximally) by pushing forwardly on cannula handle122 to release theattachment stent32, whereupon the ends38 ofstruts148 self-expand radially outwardly to engage the vessel wall, as shown inFIG. 1, andbarbs40 seat into the vessel wall to thereafter secure theaortic graft12 in its desired position. Such a trigger wire system is disclosed in WO 98/53761. Optionally, a molding balloon may be used to inflate within self-expandedattachment stent32 to assuredly press the struts against the vessel wall and seat the barbs.
• Similarly, as shown inFIG. 12A, thesecond trigger wire138 secures thedistal end portion28 ofaortic graft12 against any axial movement as thetop cap104 is being urged forwardly fromattachment stent32 which would otherwise tend to pull the attachment stent and the aortic graft due to friction.Trigger wire138 includesrelease portion154 that first extends outwardly fromproximal pusher body152 and alonggroove156, then inwardly through the graft material of thedistal end portion28 and through astent end48 loop and into an opening in theproximal pusher body152, and then forwardly alonginner cannula120 where it is held in a force fit thereagainst by the proximal tip ofpusher118. Then, upon actuation of itscontrol system124,trigger wire138 is pulled from the delivery system which releases thedistal end portion28 of theaortic graft12 which then fully self-expands within the aneurysm toward the vessel wall.
• Proximal pusher body152 is then pushed proximally through now-deployedaortic graft12 to abut against the distal end of thetop cap104; the abutment portion ofproximal pusher body152 is selected to have an outer diameter the same as the distal end of the top cap. The configuration ofproximal pusher body152 is shown inFIG. 12. Upon pulling the dilator/topcap/cannula assembly distally, and in turn upon movingproximal pusher body152 distally, tapered surfaces of the distal end (not shown) of the proximal pusher body gently engage and deflect radially outwardly any portions of the stents of the aortic graft to prevent any stubbing or snagging that otherwise would occur by engagement of the top cap distal end were it to be exposed when pulled distally through the now-deployedaortic graft12.Proximal pusher body152 similarly has taperedsurfaces158 at itsproximal end160 that gently engage and deflect outwardly any stent portions when it is pushed proximally through the aortic graft to abuttop cap104.Delivery system100 is then removed from the patient.
• Then,delivery system200 is introduced into the patient throughsheath102 and ipsilateraliliac artery96 and intodistal end portion28 ofaortic section12 that is now deployed in the aneurysm, until theproximal end portion50 ofiliac section14 is withindistal end portion28.Proximal end portion50 ofiliac section14 is then released in a fashion similar to aortic section12 (although no trigger wires or top cap are involved), and self-expands to press against the inner surface ofdistal end portion28 intelescoping region64 and establish a friction fit therewithin, after whichdistal end52 ofiliac section14 is then released to self-expand against the vessel wall of ipsilateraliliac artery96, completing the assembly and deployment ofstent graft10 in the aorta of the patient, withproximal end portion26 of aortic section sealing against the vessel wall in theaneurysm neck92, and thedistal end portion52 ofiliac section14 sealing against the vessel wall of the ipsilateral iliac artery.
• Delivery system250 is then delivered through the contralateral iliac artery to deliver the contralateraliliac occluder80 to its proper location distally of the aortic/iliac bifurcation.Occluder80 is then pushed assheath256 is withdrawn, so thatoccluder80 emerges from the sheath proximal end and self-expands to press and seal against the vessel wall of the contralateral iliac artery, whereafter thedelivery system250 is fully withdrawn from the patient. The femoro-femoral bypass graft is then secured to connect the ipsilateral iliac artery to the contralateral iliac artery distally of the occluder.
• After deployment of thestent graft10 and theoccluder80 and securing of the bypass graft, blood will flow intoproximal end portion26 of aorticsection tubular graft12, and through the remainder ofstent graft assembly10 into the ipsilateral iliac artery, completely bypassing the ruptured aneurysm, and a portion of the blood flow will pass through the bypass graft to the contralateral iliac artery.
• The deployment systems are fabricated with a single lumen vinyl radiopaque tubing of 18 to 20 Fr (6.0 to 6.67 mm) aortic section or a 14 to 16 Fr (4.66 to 5.33 mm) iliac section, an 18 gauge cannula (stainless steel), 0.013 and 0.015 in (0.330 and 0.381 mm) trigger wires (stainless steel), nylon radiopaque top cap and radiopaque PTFE sheath material. The graft consists of uncrimped tubular fabric such as Twillweave™ Micrel™ polyester fabric (product of Vascutek) with stents such as of stainless steel strategically sewn into place with suture such as braided polyester and monofilament polypropylene suture. The stents are preferably well-known self-expanding Gianturco Z-stents, however, balloon expandable stents an also be used. The stent at the proximal end of the aortic section preferably contains barbs that are placed at a 3 mm stagger. A number of gold marker bands are preferably positioned around the top of the main graft body to facilitate fluoroscopic visualization.
• The stent graft aortic section and iliac section delivery system is designed to first be inserted into the femoral artery following surgical exposure of the artery. Prior to the insertion of the delivery system, the ruptured aneurysm is properly diagnosed and controlled if necessary with an occlusion balloon, and access to the artery is achieved with an arterial needle, “J” wire, and appropriate angiographic equipment. The “J” wire is exchanged for a stiff guide wire. The aortic section is then inserted and deployed as described in the instructions for use. Guide wire access is kept through the aortic section. The iliac section is then placed in a similar fashion to the aortic section and is positioned so that the distal portion will be deployed at the proper implantation site and there is at least one, preferably two, full stent overlap between the iliac section and the aortic section. Access is gained in a similar way to the contralateral femoral artery with a large sheath, and the occluder is then loaded and deployed through the large sheath. The attachment of the stent graft at the implantation site can be maximized by inflating a molding balloon at each site to fully expand the attachment stent to press against the arterial wall and seat the barbs of the stent into the wall.
• A complete inventory or set ofdelivery systems300 for treatment of a ruptured aneurysm is depicted inFIG. 15. Theset300 includesdelivery systems100A,100B,100C,100D each containing an aortic section graft having a different one of the standardized proximal diameters;delivery systems200A,200B,200C,200D each containing an iliac section graft having a different one of the standardized distal diameters; anddelivery systems250A,250B,250C,250D each containing an occluder having a different one of the standard diameters for the iliac vessel. The set thus allows the practitioner to quickly select an aortic section graft size and an iliac section graft size and to begin treatment immediately. Theset300 thus provides a minimized inventory of delivery systems capable of treating a great majority of ruptured aneurysms with only relatively rudimentary aneurysm size estimation procedures. Immediate replacement of the delivery systems actually used in a particular treatment, can then be made to complete the set for the next emergency ruptured aneurysm event.
• No particular departure is necessary from the usual perioperative management of patients undergoing aneurysm repair. The perioperative evaluation and intraoperative monitoring should be performed as though the patient was undergoing conventional surgical repair. Post-operative management should be dictated by clinical circumstances, and is likely to differ somewhat from the usual management of patients following aneurysm repair, because the patients should tend to experience fewer physiologic difficulties.

Claims (20)

1. A modular stent graft assembly comprising;

an aortic section including a first tubular graft having a proximal end portion and a distal end portion, said distal end portion having a first constant diameter for a first predetermined length, said proximal end portion having a second diameter greater than said first constant diameter and sized for engagement against an aortic artery, said aortic section also including a first plurality of stents attached along said first tubular graft, wherein said aortic section is selected from a set of aortic sections each having a proximal end portion with a second diameter different from the second diameter of any other proximal end portion of the aortic sections in the set and greater than said first constant diameter of the distal end portion of said aortic section; and

an iliac section including a second tubular graft including a distal end portion having a third diameter sized for engagement against an iliac artery, said second tubular graft also including a proximal end portion having a fourth constant diameter for a second predetermined length and approximating said first constant diameter of said distal end portion of said aortic section, said iliac section also including a second plurality of stents attached along said second tubular graft, wherein said iliac section is selected from a set of iliac sections each having a distal end portion with a third diameter different from the third diameter of any other distal end portion of the iliac sections in the set and at least equal to said fourth constant diameter of the proximal end portion of said iliac section, whereby when said aortic and iliac sections are positioned in an aortic artery and an iliac artery, respectively, said proximal end portion of said iliac section and said distal end portion of said aortic section overlap at least a minimum length and engage each other when positioned one within another for said at least minimum length;

wherein said first tubular graft has a tapered transition portion between said proximal end portion and said distal end portion and wherein said tapered transition portion has one or two stents from said first plurality of stents attached therealong.

2. The modular stent graft assembly ofclaim 1, wherein the second diameter of the proximal end portion of the first tubular graft is in a range of 22 to 34 mm.

3. The modular stent graft assembly ofclaim 2, wherein said first and said fourth constant diameter are approximately 12 mm.

4. The modular stent graft assembly ofclaim 1, wherein the third diameter of the distal end portion of the second tubular graft is in a range of 12 to 24 mm.

5. The modular stent graft assembly ofclaim 1, wherein said first predetermined length of said distal end portion of said first tubular graft is in a range of 60 to 70 mm.

6. The modular stent graft assembly ofclaim 1, wherein said first tubular graft has a total length in a range of 108 to 127 mm.

7. The modular stent graft assembly ofclaim 6, wherein said second tubular graft has a total length in a range of 94 to 110 mm.

8. The modular stent graft assembly ofclaim 1, wherein said second tubular graft has a tapered transition portion between said distal end portion and said proximal end portion and wherein said tapered transition portion has one or two stents from said second plurality of stents attached therealong.

9. The modular stent graft assembly ofclaim 8, wherein said second predetermined length is in a range of 56 to 73 mm.

10. The modular stent graft assembly ofclaim 1, wherein said assembly further comprises a bypass graft for interconnecting the contralateral and ipsilateral iliac arteries.

11. The modular stent graft assembly ofclaim 1, wherein said assembly further comprises an occluder.

12. The modular stent graft assembly ofclaim 11, said occluder including a tubular graft and said occluder including at least one stent, said graft having a constant diameter in a range of 14 to 24 mm.

13. The modular stent graft assembly ofclaim 8, wherein said assembly further comprises an occluder.

14. The modular stent graft assembly ofclaim 13, said occluder including a tubular graft and said occluder including at least one stent, said graft having a constant diameter in a range of 14 to 24 mm.

15. The modular stent graft assembly ofclaim 1, wherein said aortic section includes an attachment stent attached to a proximal end of said first tubular graft and extending proximally therefrom.

16. The modular stent graft assembly ofclaim 1, wherein said first and said second pluralities of stents are attached to said first and said second tubular grafts, respectively, with first and second sets of predetermined spacings or gaps longitudinally therebetween, respectively.

17. The modular stent graft assembly ofclaim 1, wherein said at least minimum length where said aortic and said iliac sections overlap includes at least two stents from each of said first and second pluralities of stents.

18. A modular stent graft assembly comprising;

an aortic section including a first tubular graft having a proximal end portion and a distal end portion, said distal end portion having a first constant diameter for a first predetermined length, said proximal end portion having a second diameter greater than said first constant diameter and sized for engagement against an aortic artery, said aortic section also including a first plurality of stents attached along said first tubular graft, wherein said aortic section is selected from a set of aortic sections each having a proximal end portion with a second diameter different from the second diameter of any other proximal end portion of the aortic sections in the set and greater than said first constant diameter of the distal end portion of said aortic section; and

an iliac section including a second tubular graft including a distal end portion having a third diameter sized for engagement against an iliac artery, said second tubular graft also including a proximal end portion having a fourth constant diameter for a second predetermined length and approximating said first constant diameter of said distal end portion of said aortic section, said iliac section also including a second plurality of stents attached along said second tubular graft, wherein said iliac section is selected from a set of iliac sections each having a distal end portion with a third diameter different from the third diameter of any other distal end portion of the iliac sections in the set and at least equal to said fourth constant diameter of the proximal end portion of said iliac section, whereby when said aortic and iliac sections are positioned in an aortic artery and an iliac artery, respectively, said proximal end portion of said iliac section and said distal end portion of said aortic section overlap at least a minimum length and engage each other when positioned one within another for said at least minimum length;

said modular stent graft assembly being assembled from a kit of parts comprising:

a set of aortic sections each having a proximal end portion with a second diameter different from the second diameter of any other proximal end portion of the aortic sections in the set and greater than a first constant diameter of a distal end portion, each aortic section including a first tubular graft having a proximal end portion and a distal end portion, said distal end portion having a first constant diameter for a first predetermined length, said proximal end portion having a second diameter greater than said first constant diameter and sized for engagement within an aortic artery, said aortic section also having a first plurality of stents attached along said first tubular graft; and

a set of iliac sections each having a distal end portion with a third diameter different from the third diameter of any other distal end portion of the iliac sections in the set and at least equal to a fourth constant diameter of a proximal end portion, each iliac section including a second tubular graft including a distal end portion having a third diameter sized for engagement against an iliac artery, said second tubular graft also including a proximal end portion having a fourth constant diameter for a second predetermined length and approximating said first constant diameter of said distal end portion of said aortic section, said iliac section also having a second plurality of stents attached along said second tubular graft, whereby when said aortic and iliac sections are selected and positioned in an aortic artery and iliac artery, respectively, said proximal end portion of said iliac section and said distal end portion of said aortic section overlap at least a minimum length and engage each other when positioned one within another for said at least minimum length.

19. A modular stent graft assembly according toclaim 18, wherein the kit of parts also comprises an occluder for the other iliac artery whereby the flow of blood to both iliac arteries can be maintained by a bypass graft between the two iliac arteries.

20. A kit of parts for a modular stent graft assembly for repairing a ruptured or symptomatic aneurysm in an aortic artery, said kit of parts comprising:

a set of aortic sections each having a proximal end portion with a second diameter different from the second diameter of any other proximal end portion of the aortic sections in the set and greater than a first constant diameter of a distal end portion, each aortic section including a first tubular graft having a proximal end portion and a distal end portion, said distal end portion having a first constant diameter for a first predetermined length, said proximal end portion having a second diameter greater than said first constant diameter and sized for engagement within an aortic artery, said aortic section also having a first plurality of stents attached along said first tubular graft; and

a set of iliac sections each having a distal end portion with a third diameter different from the third diameter of any other distal end portion of the iliac sections in the set and at least equal to a fourth constant diameter of a proximal end portion, each iliac section including a second tubular graft including a distal end portion having a third diameter sized for engagement against an iliac artery, said second tubular graft also including a proximal end portion having a fourth constant diameter for a second predetermined length and approximating said first constant diameter of said distal end portion of said aortic section, said iliac section also having a second plurality of stents attached along said second tubular graft, whereby when said aortic and iliac sections are selected and positioned in an aortic artery and iliac artery, respectively, said proximal end portion of said iliac section and said distal end portion of said aortic section overlap at least a minimum length and engage each other when positioned one within another for said at least minimum length.

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