title: Classification of gutter type in parallel stenting during endovascular aortic aneurysm repair.
abstract: Gutters can be described as the loss of continuous apposition between the main body of the endograft, the chimney stent graft, and the aortic wall. Gutters have been associated with increased risk of type IA endoleaks and are considered to be the Achilles' heel of chimney endovascular aneurysm repair (ch-EVAR). However, there is no classification yet to classify and quantify gutter types after ch-EVAR.
  
  
  
  Different gutter types can be distinguished by their morphologic appearance in two- and three-dimensional views and reconstructed slices perpendicular to the center lumen line.
  
  
  
  Three main categories are defined by (1) the most proximal beginning of the gutter, (2) the length of gutter alongside the endograft, and (3) its distal end. Type A gutters originate at the proximal fabric of an endograft, type B gutters originate as loss of apposition of the chimney stent graft in the branch vessel, and type C gutters start below the fabric of the endograft. To determine eventual changes of gutter size during follow-up computed tomography angiograms (CTAs), measurements may be performed with dedicated software on the follow-up CTA scan to assess the extent of gutters over the aortic circumference, ranging from 0° to 360° of freedom, together with the maximum gap between the endograft material and the aortic wall as it appears on reconstructed axial CTA scan slices.
  
  
  
  The proposed gutter classification enables a uniform nomenclature in the current ch-EVAR literature and a more accurate risk assessment of gutter-associated endoleaks. Moreover, it allows monitoring of eventual progression of gutter size during follow-up.
authors.affiliation: MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands. Electronic address: s.overeem@antoniusziekenhuis.nl.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Overeem
authors.affiliation: MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands.
authors.forename: Johannes T
authors.initials: JT
authors.lastname: Boersen
authors.affiliation: MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Richte C L
authors.initials: RCL
authors.lastname: Schuurmann
authors.affiliation: MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands.
authors.forename: Erik
authors.initials: E
authors.lastname: Groot Jebbink
authors.affiliation: MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.
authors.forename: Cornelis H
authors.initials: CH
authors.lastname: Slump
authors.affiliation: Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands.
authors.forename: Michel M P J
authors.initials: MMPJ
authors.lastname: Reijnen
authors.affiliation: Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Jean-Paul P M
authors.initials: JPM
authors.lastname: de Vries
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D000072226:Computed Tomography Angiography; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D021621:Imaging, Three-Dimensional; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011857:Radiographic Image Interpretation, Computer-Assisted; D015607:Stents; D009626:Terminology as Topic; D016896:Treatment Outcome