title: Graft inflow stenosis induced by the inflatable ring fixation mechanism of the Ovation stent-graft system: hemodynamic and clinical implications.
abstract: OBJECTIVE
  To investigate the observed inflow stenosis at the O-rings of the Ovation stent-graft and evaluate its hemodynamic and clinical impact.
  
  
  METHODS
  The study involved 49 consecutive patients (48 men; mean age 71.2 ± 7.7 years) treated successfully with the Ovation abdominal aortic stent-graft between June 2011 and January 2014 at a single center. Cross-sectional area and radius measurements of the infrarenal aorta just proximal to the sealing mechanism, as well at the site of stenosis, were measured from 3D reconstructions of the 1-month postoperative computed tomographic angiograms. Based on Poiseuille's law, the predicted pressure drop was calculated for each patient based on the length of the stenosis. Invasive blood pressure measurements at 3 levels (proximal to the inflatable rings, halfway inside the stenosis, and distal to the stenosis) were obtained in 10 patients intraoperatively. Ankle-brachial index (ABI) values preoperatively were compared to those after the procedure for all patients to assess the clinical impact of this phenomenon.
  
  
  RESULTS
  Median internal cross-sectional area at the site of the stenosis was significantly reduced compared to the area just proximal to the O-rings [57% reduction: 123 mm(2) (range 28-254) vs. 283 mm(2) (range 177-531), respectively; p<0.001]. The same was observed for the radius [6.5 mm (range 3-9) vs. 9.5 mm (range 7.5-13), respectively; p<0.001]. Based on the median 15 mm length of the stenosis (range 13-17) observed in the study population, a median pressure drop of 0.13 mmHg (range 0-0.25) along the stenosis was calculated. Invasive blood pressure measurements indicated a non-significant pressure change along the stenosis (e.g., 0.7 mmHg between the proximal level and halfway inside the stenosis). ABI remained practically unchanged postoperatively.
  
  
  CONCLUSIONS
  The advantages of the Ovation device's unique sealing mechanism come at the expense of a median area inflow stenosis of ∼ 60%. This stenosis does not cause a hemodynamically significant pressure drop. Future modification of the graft ring design may be needed in order to reduce this stenosis.
authors.affiliation: 1 Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece.
authors.forename: Christos V
authors.initials: CV
authors.lastname: Ioannou
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Kontopodis
authors.forename: Eleni
authors.initials: E
authors.lastname: Metaxa
authors.forename: Yannis
authors.initials: Y
authors.lastname: Papaharilaou
authors.forename: Efstratios
authors.initials: E
authors.lastname: Georgakarakos
authors.forename: Alexandros
authors.initials: A
authors.lastname: Kafetzakis
authors.forename: Elias
authors.initials: E
authors.lastname: Kehagias
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Tsetis
mesh_terms: D000368:Aged; D055109:Ankle Brachial Index; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D062186:Arterial Pressure; D001783:Blood Flow Velocity; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D006115:Greece; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012039:Regional Blood Flow; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: abdominal aortic aneurysm; aortic stenosis; endograft; endograft planning; endovascular aneurysm repair; hemodynamics; stent-graft; stent-graft oversizing