FR2979228A1 - UNIVERSAL AORTIC ENDOPROTHESIS - Google Patents

Abstract

The present invention relates to a stent (1) comprising: a main tubular stent (10) having an inner surface (20), at least one side leg (100), the side leg (100) comprising a tubular leg body (110) and a leg stent (120), the leg stent (120) being at least partially covered by the tubular leg body (110), the proximal end (111) of the lateral leg (100) comprising a collar (30) extending substantially towards the distal end (112) of the lateral leg (100), characterized in that the lateral leg (100) is inserted into an orifice (130) of the main tubular stent (10), such that the flange (30) bears against the inner surface (20) of the main tubular stent (10). The present invention further relates to a leg, a stent assembly method, an insertion system, and an endoprosthesis assembly kit.

Description

GENERAL TECHNICAL FIELD The present invention relates to the field of aortic stents.

STATE OF THE ART Aneurysm is a localized dilation of the wall of an artery. Its usual shape is that of a bag, its diameter can reach several centimeters. We speak of aneurism when there is loss of parallelism between the edges of the vessel and that the caliber of this one is greater than 2 times normal. It can be manifested by secondary signs, especially the compression of nearby organs, but most often its presence in itself is not problematic. These are the complications he can cause that are dangerous. Due to the change in the caliber of the artery, the blood flow, which was normally laminar, becomes turbulent at the level of the aneurysm. This turbulence can lead to the formation of a thrombus (blood clot) that can one day break off later and go to cause a serious embolism (by plugging a smaller artery downstream) But the essential risk is that of the rupture of aneurysm, resulting in massive bleeding. The death occurs most often in a few tens of minutes.

If all the arteries can be affected, the aorta is frequently affected. It is the largest artery of the human body. While its normal diameter is 1.5 cm to 2.5 cm, it can sometimes exceed 13 cm in the presence of an aneurysm. All the aneurysms of the aorta increase inexorably in size over time and the risk of rupture becomes significant as soon as the diameter of the aorta exceeds 5 cm. In case of rupture, death occurs in 75 to 90% of cases.

However, if an aneurysm is detected in time, it can be prevented by vascular surgery. However, it is extremely heavy and risky to operate on the aorta. Since the early 1990s, a less invasive treatment with stent placement from the femoral artery has been proposed: endoluminal repair. The stent is a stent (a meshed metal device commonly called spring) covered by a waterproof wall (also called "stent graft" or "stent graft" in French), unfolded inside the artery at the location of the aneurysm. It isolates the latter from the blood, and recreates a cylindrical section of artery in its place. Now, as can be seen in FIG. 1, the aorta A has the particular shape of a butt. It is divided into two parts, the abdominal aorta Al (lower part, below the diaphragm) and the thoracic aorta A2 (upper part, above the diaphragm). Treating the aneurysms on the rectilinear portions of the thoracic aorta A2 (descending thoracic aorta A21 and ascending thoracic aorta A23) is relatively well known since a cylindrical stent is sufficient. Two parts of the aorta are difficult to equip with an endoprosthesis: the abdominal aorta Al and especially the aortic arch A22. Indeed, the abdominal aorta bifurcates in two left iliac arteries Al 1 and right Al2; and three major vessels (the brachiocephalic arterial trunk, the left primary carotid artery, and the left subclavian artery) leave the upper surface of the aortic arch Al2, almost at right angles. European patent EP1159024 discloses a Y-shaped abdominal stent which adapts to the geometry of the abdominal aorta Al. This stent in fact comprises a structure in which two tubular sleeves are inserted longitudinally in a main body, the corresponding tubular sleeves at the iliac arteries Al let Al2. This stent can not be adapted to the aortic arch A22, from which the branches leave laterally at right angles. International patent application WO2007 / 028086 describes a thoracic endoprosthesis adapted to the aortic arch A22 through the presence of "windows" in the wall of the stent in front of the three vessels, these windows allowing the blood to pass. However, this stent can treat only the aneurysms located in the lower part of the A22 aortic arch, and not those located at the junction with the three vessels, in the upper part. In addition, the installation of this stent is delicate, since it is cylindrical in appearance: it must be ensured that it does not rotate when it is inserted, otherwise the windows will not face the vessels. which would instantly put the patient at risk of death.

The patent application FR1150285 describes a new thoracic "T" endoprosthesis that can treat all thoracic aortic aneurysms, and provides complete satisfaction. However, this endoprosthesis must almost be made to measure in some cases of aneurysms placed between the major vessels of the arch requiring a stent with several legs. There is also a portion of the aorta where no endoprosthesis can still treat aneurysm alone: this is the branching zone with the renal arteries A13. The solution is to surgically reconnect these arteries higher or lower (depending on the position of the aneurysm) on the aorta. It would be interesting to have a "universal" stent, which can treat all the aortic aneurysms, whatever their size and position, whether abdominal or thoracic, with ease and without extra cost.

PRESENTATION OF THE INVENTION The present invention aims to enable all aortic aneurysms to be treated with maximum safety, while reducing the complexity of the surgical procedure. The present invention thus relates to an endoprosthesis comprising: a main tubular stent having an inner surface, at least one lateral leg, the lateral leg comprising a tubular leg body and a leg stent, the leg stent being at least partially covered by the tubular leg body, the proximal end of the lateral leg comprising a collar extending substantially towards the distal end of the lateral leg, characterized in that the lateral leg is inserted into an orifice of the main tubular stent , so that the flange rests on the inner surface of the main tubular stent.

According to other advantageous and non-limiting characteristics: the main tubular stent comprises a main tubular body and at least one stent, the at least one stent being at least partially covered by the main tubular body, and the main tubular body being laminated teflon ® or dacron ®; the stent comprises a plurality of side jambs; - The collar of the side jambs is sutured to the tubular leg body; the flange comprises a flange body having a truncated cone shape, and a flange stent, the flange stent being covered by the flange body; - The collar comprises a crimping wire defining the distal end of the collar; the flange body consists of a circular sector with flanks joined by a suture; the tubular body of the lateral jamb (s) and / or the collar body is made of laminated teflon® or dacron®; - The outer diameter of the unfolded main tubular stent is between 20 and 42 mm; the length of the unfolded main tubular stent is between 100 and 150 mm; - The outer diameter of the unfolded tubular body of each side jamb is between 4 and 16 mm. A second aspect of the invention relates to a lateral leg of an endoprosthesis according to the first aspect of the invention, comprising a tubular leg body and a leg stent, the leg stent being at least partially covered by the tubular body of the stent. jamb, characterized in that the proximal end of the lateral leg comprises a flange extending substantially towards the distal end of the lateral leg. A third aspect of the invention relates to a method of assembling a stent according to the first aspect of the invention, characterized in that it comprises steps of: (a) Placing a main tubular stent, (b) inserting a lateral leg into an opening of the main tubular stent, (c) moving the lateral leg towards its distal end so as to rest the collar on the inner surface of the tubular stent, (d) Inflation of a balloon in the leg so as to unfold it. According to other advantageous and nonlimiting features: the method comprises several times the succession of steps (b) to (d) so as to assemble several legs to the main tubular stent; - The method further comprises between steps (a) and (b) an additional step of perforating the main tubular stent so as to create the orifices; the lateral leg is held in a folded position and the collar is held pressed against the lateral jamb by a sheath during step (b), the method further comprising a step of releasing the lateral leg by removing the sheath just before step (c); - The lateral leg is maintained in a folded position and the flange is maintained pressed against the side jamb by a sheath during step (b), the method further comprising a step of releasing the collar by partial withdrawal of the sheath just before step (c), and a step of releasing the side jamb by removing the remainder of the sheath just after step (c); - The collar has an opening angle of between 20 and 30 ° at the beginning of step (c).

A fourth aspect of the invention relates to a system for inserting the flange of a side jamb according to the second aspect of the invention into an orifice of a main tubular stent, further comprising a sheath, a balloon and a guide. integral with the balloon, the lateral leg being mounted on the balloon, the sheath enclosing the lateral leg so as to maintain the stent jamb folded and maintain the flange (30) pressed against the side jamb. A fifth aspect of the invention relates to a kit for assembling a stent according to the first aspect of the invention, characterized in that it comprises a main tubular stent and at least one side jamb according to the second aspect of the invention. invention, the at least one side jamb being mounted on an insertion system according to the fourth aspect of the invention. PRESENTATION OF THE FIGURES Other features and advantages of the present invention will appear on reading the description which follows of a preferred embodiment. This description will be given with reference to the accompanying drawings in which: - Figure 1 previously described is a diagram of the aorta; FIG. 2 is a diagram of an endoprosthesis according to the invention; FIG. 3 is a diagram of the collar of an endoprosthesis according to the invention; FIG. 4 is a perspective view of an endoprosthesis according to the invention; FIG. 5 is a diagram of an endoprosthesis fenestration device according to the invention; FIG. 6a is a diagram of a first embodiment of a system for inserting the collar of a lateral leg of a stent according to the invention in the folded position; FIG. 6b is a diagram of a first embodiment of a system for inserting the collar of a lateral jamb of a stent according to the invention in a semi-unfolded position; FIG. 7a is a diagram of a second embodiment of a system for inserting the collar of a lateral leg of a stent according to the invention in the folded position; FIG. 7b is a diagram of a second embodiment of a system for inserting the collar of a lateral leg of a stent according to the invention in an unfolded position; Figure 8 is a schematic of an endoprosthesis according to the invention at a limb positioned in the left subclavian artery; - Figure 9 is a diagram of an endoprosthesis according to the invention with two legs positioned in the renal arteries. DETAILED DESCRIPTION OF THE INVENTION The stents commonly used in vascular surgery have various forms. As explained above, it is known to produce endoprostheses at one or more side jambs. The surgeon who wishes to treat a patient thus chooses a stent whose shape is adapted to the location of the aneurysm, and then implants it in the patient's aorta. In view of the multiplicity of possible locations, it is therefore necessary to have a plurality of stents. In addition, two people will never have exactly the same aorta, and one stent may be suitable for one person, but may not be suitable for another even if they have the same aneurysm. The universal aortic endoprosthesis of the invention is a "kit" stent, which the surgeon assembles to measure for his patient. Thus, from standard bricks, the surgeon can fabricate any aortic stent. As will be detailed below, these bricks are a main tubular stent 10, and one or more side jambs 100. Structure of the assembled stent A stent 1 according to the invention is shown in Figure 2. It thus comprises a stent tubular main 10, intended to be placed in the aorta, and which typically consists of a "stent graft" described above. It then advantageously comprises a main tubular body and at least one stent, the at least one stent being at least partially covered by the main tubular body, the main tubular body being made of a biocompatible material forming a sealed envelope, the tubular body thus recreating a cylindrical and insulating vessel the sac that forms the aneurysm of the bloodstream. The main tubular body is thus advantageously but not exclusively limited to laminated teflon® or dacron®, these materials being commonly used in simple stents. In addition, the outer diameter and the length of the unfolded main tubular stent 10 are advantageously selected between 20 and 42 mm and between 100 and 150 mm, respectively, in order to adapt perfectly to the morphology of the patient's aorta. . The invention is however limited to particular dimensions or materials. Those skilled in the art will know how to adapt it according to the case. The stent or stents are for example Z-stents® (stent consisting of a series of cylindrical elements formed by a zigzagging metal wire) of chromium and cobalt alloy. The size of its mesh is proportional to its diameter. The stent 1 according to the invention furthermore comprises at least one lateral leg 100. This lateral leg 100, visible from the side and from above respectively in FIG. 2 and in particular in FIG. 4, itself has a structure of FIG. stent: it comprises a tubular leg body 110 and a leg stent 120, advantageously respectively similar to the main tubular body and the at least one stent of the main tubular stent 10. The leg stent 20 is thus for example also a Z-stent® (fine mesh in view of the smaller diameter). In addition, the leg stent 120 is at least partially covered by the tubular leg body 110, and especially the proximal end 111 of the lateral leg 100 comprising a collar 30 extending substantially towards the distal end 112 of the side jamb 100 when it deviates from the tubular leg body 110. 20 jamb collar The collar 30, detailed more specifically in Figure 3, has in other words a skirt shape. This form, described for example in International Patent Application WO 2004/000167, is known to improve the seal between the edge of a blood vessel and the stent in some cases. Note that it can extend both outwardly of the stent and outward. In the endoprosthesis according to the invention, the collar 30 has another use: the lateral jamb 100 is in effect as shown in FIG. 2 inserted in an orifice 130 of the main tubular stent 10, so that that the flange 30 bears on the inner surface 20 of the main tubular stent 10. In other words, the flange 30 acts as a locking element of the leg 100, and constitutes what can be seen as the "barbels" of a harpoon. It is thus very easy to bring the collar 30 into the orifice 130 (the flange 30 naturally flattening), but it can not come out of it because the support on the inner surface 20 increases the angle of opening of the collar 30. It would be necessary to make it out apply a strong traction to return the collar 30 in the manner of an umbrella. The assembly formed of the flange 30 and the tubular leg body 110 may be made in one piece. Alternatively, the flange 30 of the lateral leg 100 is sutured to the tubular leg body 110. The suture must ensure the tightness of the junction between the body of the leg 100 and the flange 30. As shown in Figure 2, this suture is advantageously offset about 1 mm from the proximal end 111 of the leg 100 (offset 35). in order to increase the surface of the band of the tubular leg body 110 on which the suture bears, and therefore to strengthen it, while allowing the variation of the opening angle of the collar 30. As can be seen in the figure 3, the flange 30 (when intended to be sutured to the tubular leg body 110) advantageously comprises a flange body 32 (which is advantageously still similar to the tubular bodies described above) having a truncated cone shape, and a collar stent 31, the flange stent 31 being covered by the flange body 32. This flange stent 31 25 makes it possible to stiffen the flange 30, and to make it possible to transfer force from the zone of contact with the internal surface 20 to the body of the leg 100. It may advantageously consist of a deformed Z-stent® in order to take the conical shape (for example by tightening one of its ends, the stent being naturally cylindrical ). The flange 30 may further comprise a crimping wire 34 defining the distal end of the flange 30, in other words a wire including metal which circles the contour of the free end of the flange 30 and rigidifies it. The crimping wire 34 also corresponds to the zone of contact between the flange 30 and the inner surface 20 of the main tubular stent 10. The rigidity of the wire prevents the flange 30 from being damaged or torn during the assembly of the stent 1, during which the flange is "plated" against the wall 20 (see below). The truncated cone shape can be obtained by realizing the flange body 32 from a circular sector (in other words a piece of a disk having for edge two diameters of the disk and two arcs) to the flanks joined by a suture 33. A circular sector is indeed the boss of a cone. Lateral leg structure Once mounted on the main tubular stent 10, the leg 100 as shown in the figures orthogonally part of the body of the main tubular stent 10, hence a T-shape. However, the stent does not have an endoprosthesis. is not limited to this angle: the leg 100 may not be perfectly cylindrical, the proximal end 111 being cut "obliquely" with respect to the distal end 112. The axis of the collar 30 then deviates from a given angle of the axis of the remainder of the leg 100, and thus once assembled the stent 1 sees the leg 100 deviate from the same given angle relative to the perpendicular to the axis of the main tubular body 10.

The stent 1 according to the invention may thus be both a "Y" stent and a "T" stent. It is therefore particularly suited not only to the treatment of aneurysms at the level of the aortic arch, from which the three major arteries (the brachiocephalic arterial trunk, the left primary carotid artery, and the left subclavian artery) proceed to right angle, and the treatment of aneurysms at the junction with the renal arteries, but also the treatment of aneurysms in the abdominal aorta. As explained, the main tubular stent 10 is in fact placed in the aortic arch, and the leg 100 is in one of the other arteries. Thanks to this structure, the stent 1 has excellent stability, low risk for the patient and above all, as we have just seen, the treatment of all the aneurysms of the aorta. The tubular leg body 110 and the flange body 32 are advantageously chosen as the main tubular body made of laminated teflon® or dacron®. In addition, the outer diameter and the length of the unfolded leg tubular body 110 are advantageously chosen between 4 and 16 mm and between 10 and 35 mm respectively, depending on the artery in which the leg 100 is positioned, in order to perfectly adapt to the morphology of arteries from the aorta of any patient. The invention is however not limited to particular dimensions or materials. Those skilled in the art will know how to adapt it according to the case. In a particularly preferred manner, the stent 1 may comprise two or even three legs 100. It is sufficient if there are as many orifices 130 as necessary, the orifices 130 being placed in the right places. Particularly preferably, firstly the diameter and the length of the tubular leg bodies 110a, 110b and possibly 110c of the different legs 100a, 100b and possibly 100c, respectively are adapted to the plurality of arteries in which they are located. commit. A custom multi-leg endoprosthesis can effectively treat any aneurysm with a simple surgical procedure, there is no need to intervene on the aorta. One can even consider the use of stents 1 according to the invention generally in the body and not only at the level of the aorta. EXAMPLES FIG. 8 shows an example of a stent 1 at a leg 100 placed in the left subclavian artery. Clearly, the flange 30 of the leg 100 in the open position pressed against the inner surface 20 of the main tubular stent 10. In addition, the axes of the legs 100 are not necessarily parallel and can be completely shifted depending on the area of the aneurysm. In particular, Figure 9 shows a stent 1 with two legs 100 diametrically opposed, inserted into the renal arteries. In a second aspect, the invention relates to a lateral leg 100 of an endoprosthesis as described above. An example of a leg 100 alone is visible in FIG. 4. As explained, a leg 100 comprises a tubular leg body 110 and a leg stent 120, the leg stent 120 being at least partially covered by the tubular leg body 110 , characterized in that the proximal end 111 of the lateral leg 100 comprises a collar 30 extending substantially towards the distal end 112 of the lateral leg 100.

It is indeed possible to market for the surgeons jambs 100 alone, so that they combine them with conventional stents that they can use as main tubular stents 10 by making the orifices 130 as a function of the position of the aneurysm to be treated and the anatomy of the patient.

The invention relates, according to a third aspect, to a method of assembling a stent according to the invention. This method is particularly advantageous in that it can be implemented under any conditions, including directly inside the patient, remotely! This innovative method is characterized in that it comprises steps of: (a) Placing a main tubular stent 10, (b) Inserting a lateral leg 100 into an orifice 130 of the main tubular stent 10 (c) moving the lateral leg 100 towards its distal end 112 so as to bear the collar 30 on the inner surface 20 of the tubular stent 10, (d) Inflation of a balloon 201 in the leg 100 in order to unfold it.

The succession of steps (b) to (d) can also be implemented several times so as to assemble several legs 100 to the main tubular stent 10. The idea of the method is therefore to first put and deploy the main tubular stent 10, for example in the aorta, and then come to bring the legs 100 in folded form so that the flange 30 can enter the hole 130 without requiring the slightest force. Thus, advantageously, the lateral jamb 100 is held in a folded position and the flange 30 is held pressed against the lateral jamb 100 by a sheath 202 during the insertion step (b) as can be seen in FIG. 6a. . Two alternatives exist later: one can either free all the side jamb 100 by removing the sheath 202 just before the step (c) of displacement back, but preferably this withdrawal is in two steps. Thus, the method first comprising a step of releasing the flange 30 by partially removing the sheath 202 just before step (c), and then a step of releasing the lateral jamb 100 by removing the remainder of the sheath 202 just after step c. Thus, at the moment of the step (c) of displacement behind the leg 100, the sheath 202 is in an intermediate position shown in FIG. 6b. In this position the flange 30 is free, and is no longer pressed against the tubular leg body 110, while the rest of the leg 100 is still held folded, the leg stent 120 being clamped under the sheath 202. This is that the diameter of the leg remains minimal, it can slide in the hole 130 without any resistance, while having the distal edge of the flange 30 (at the crimping wire 34). When the leg 100 is retracted backwards, it moves first rectilinearly until the collar 30 touches the inner surface 20. If we continue to pull, the collar 30 deforms and opens more and more like an umbrella. The opening angle, advantageously initially between 20 and 30 ° at the beginning of step (c) that is to say before contact, increases, and can reach more than 80 °. The contact surface, and thus the stability of the jamb, increases. It should be noted that this opening increases the diameter, and thus the periphery, of the circle defining the distal end of the collar 30, in other words the crimping wire. 34. This is why the crimping wire is advantageously pleated and curled up on itself when the flange 30 is in the pressed state against the tubular leg body 110, and gradually stretched during the opening of the flange. in contact with the inner surface 20. The total length of the crimping wire is set to correspond to the maximum open position which is the most stable. The remainder of the leg 100 is then released by removing the remainder of the sheath 202, which has the effect of allowing the diameter of the tubular leg body 110 to increase slightly by elasticity of the leg stent 120 (the stents are generally wholly or partially self-supporting). unfoldable, but one can consider memory-shape materials, stents unfoldable to the application of an electrical voltage, or even pre-inflation of the balloon 201 ... Those skilled in the art will adapt the process to the use of different modes of guidance and / or deployment of stents). The tubular leg body 110 and the edge of the orifice 130 come into contact, which locks the leg 100 in translation in the orifice 130, and thus prevents the collar 30 from moving.

The final step (d) sees the inflation of a balloon 201 (visible folded in Figures 6) in the jamb 100, which has the effect of finishing unfolding by substantially increasing its diameter. The edge of the orifice 130 is bitten into the tubular leg body 110. The orifice 130 is deformed, this ensures a perfect fit and tension ensuring contact. The tightness of the assembly is thus foolproof, and this at two levels for a double security: at the orifice 130 as explained, but also at the contact surface between the flange 30 and the inner surface 20 of the main tubular stent 10.

It is important to note that the sequence of steps of inserting the leg 100 into the orifice 130 and then moving the lateral leg 100 towards its distal end 112 does not necessarily imply that the leg "advances" then "retreats. ".

For example it is conceivable that the leg is mounted on the balloon 201 in the opposite direction to that shown in Figures 6. This embodiment is visible in Figures 7a and 7b. The leg 100 is in this case brought to the port 130 through the inside of the main tubular stent 10 and inserts in the opposite direction to that described above (starting with the distal end 112). The collar 30 never passes through the orifice 130. Once the tubular leg body 110 has penetrated into the orifice 130, the sheath 202 is removed (the leg 100 mounted upside down, the collar 30 is released last It is therefore only possible to release all the jamb 100 at once). The collar 30 being released, the step (c) of contacting the flange 30 with the inner surface 20 is implemented. The leg 100 moves well in the same direction as in the first case, ie from the proximal end 111 to the distal end 112: it only "retreats" during all the implementation of the method, even if for the person who makes the assembly is rather a "push" and not a "pull". This embodiment has an advantage: the main tubular stent 10 and then the leg 100 are fed via the same artery. It therefore requires no access to the artery in which it will eventually be installed. This is very useful in the case of difficult access short arteries without a dangerous and unattractive incision, for example the renal arteries (see Figure 9): the latter, connecting the aorta to the kidneys, measure only a few centimeters and are deeply buried in the abdomen. Principle of in-situ fenestration The assembly of the stent according to the invention requires, as explained, orifices 130 situated opposite the arteries in which a leg 100 is placed. The surgeon can prepare his main tubular stent prior to implantation from a standard stent without holes, and pierce the openings 130 according to the imaging performed on the patient. Alternatively, in a very ingenious and particularly preferred manner, the invention proposes that the process according to the invention comprises between steps (a) and (b) an additional step of perforation of the main tubular stent 10 so as to create the or the orifices 130, in other words that the embodiment of the orifices 130 (or "windows" of the main tubular stent 10) is performed in situ, that is to say on a standard main tubular stent 10 without Port 130 already set up and deployed. Although surprising, this idea has many advantages. Thus, it is possible for the position of the orifices 130 to be adapted in the most perfect manner to the patient, hence a tailor-made adjustment of the struts 100, without the surgeon having to make any measurement or even observation of the positions. lateral arteries in which the legs 100 are intended to be inserted. Indeed, it is the arteries themselves that serve as a guide to a fenestration device 11 developed to be used in combination with the stents 1 according to the invention. Endoprosthesis Fenestration Device The aforementioned stent fenestration device 11 comprises a flexible elongate tube 2 provided at its distal end with a hollow needle 4, the tube 2 and the needle 4 being traversed by a common channel 3 , and a guide 5 able to slide in the channel 3.

It is represented in FIG. 5. As can be seen in this figure, it also advantageously comprises an introducer 6, in which the tube 2 is slidable. The introducer 6 is an object commonly used for catheter placement, and which also makes it easy to introduce the fenestration device 11 into the patient's artery. This is in particular a long non-peelable introducer, that is to say a cylindrical sheath whose length can sometimes exceed 100 cm. The device 11 corresponds to a removably movable cutting tool on a "rail" which is the guide 5, advantageously a standard wire of diameter 0.035, inside the introducer 6 which protects the walls of the crossed vessels of any The tube 2 which slides on this guide 5 is advantageously a probe having a diameter between 4 and 5 French (a unit commonly used to measure the diameter of the catheters, also called "Charrière", and one-third of a millimeter), the diameter of the channel 3 being chosen so that the displacement on the guide 5 is possible without particular resistance, and the diameter of the introducer being also chosen so that the displacement of the tube 2 is possible without particular resistance. The material of the tube 2 is advantageously a material having a rigidity lower than that of the material of the guide 5, typically a flexible biocompatible plastic. This is advantageously also the case for the introducer 6.

The hollow needle 4 is the organ of the fenestration device 11 which in particular allows the perforation of the main tubular stent. By hollow needle is meant for example a beveled syringe needle having an elliptical edge cutting at least one level of its highest point (in this case the orifice 130 is created by stretching the fibers of the stent 10 in force from the initial piercing, and pushing a possible wire stent of the main tubular stent 10 that the needle 4 would encounter.This embodiment is of interest if a low port 130 is desired. dimension), and advantageously over almost its entire periphery (a "hinge" is formed at the untrenched area). Indeed, if the needle 4 was sharp on all its periphery, a "confetti" corresponding to the disk of cut material would fall into the aorta. Such a needle is provided with a channel substantially coinciding with the channel 3 of the tube 2. This allows that the end of the guide 5 can also slide through the hollow needle 4 until protruding from the end thereof. . In such a configuration (guide 5 protruding from the needle 4), the needle can not stitch even though it would protrude from the end of the introducer 6. The needle 4 is therefore safely movable along the guide 5 in the artery of the patient through the introducer 6 to the main tubular stent 10. It is sufficient, to make the needle 4 operational, slightly remove the guide 5 so that the pointed end of the needle 4 is again prominent. This hollow needle 4, of an outside diameter substantially coinciding with that outside the tube 2, advantageously has a length of between 8 and 10 mm. The perforation is done applying a thrust force on both the tube 2 and the guide 5. The latter serves as a "carrier" force: the fact that it is very rigid that the force is almost fully communicated from the distal end of the device 11 to the needle 4. Fenestration method The fenestration device 11 described above allows the implementation of a method of fenestration of a tubular stent 10. This method comprises steps of (a) Placement of the stent 10, (b) Introduction of the guide 5 until the endoprosthesis 10 is reached at the desired fenestration point, (c) Displacement of the tube 2 on the guide 5 to the stent 10, (d) Removing the guide 5 so that it no longer protrudes from the hollow needle 4, (e) Applying a thrust on the device 11 so as to pierce the stent 10 into an orifice 130. We find the steps mentioned in the previous section. Following step (e), the fenestration method advantageously further comprises a step (f) of reintroduction of the guide 5 until it passes through the orifice 130 created, in other words to reposition the guide 5 in the channel 3 until the needle 4 is no longer protruding, and then until the guide 5 enters the orifice 130 and thus enters the tubular stent 10. The method fenestration may further comprise a step (g) of removal of the tube 2, so that a system of insertion of the flange 30 of a leg 100 can be introduced into the orifice 130 to assemble the jamb 100 to the main tubular stent 10.

According to a fourth aspect, the invention relates to a system for inserting the flange 30 of a side jamb 100 into an orifice 130 of a main tubular stent 10 that can be used for the implementation of the invention. in particular steps (b) to (d) of the assembly method described above. This system allows the introduction of the lateral leg 100 folded into the vascular system of the patient to the main tubular stent already in place, its remote guidance to the point of deployment (in particular an orifice 130) and its introduction and its release at this point after deployment.

This insertion system visible in FIG. 6 further comprises the leg 100, the sheath 202 mentioned above, a balloon 201 (also mentioned above) and a guide 203 integral with the balloon 201, the lateral leg 100 being mounted on the balloon 201, the sheath 202 enclosing the lateral jamb 100 so as to maintain the stent 120 leg folded and maintain the flange 30 pressed against the side jamb 100. The guide 203, for example a conventional guide diameter 0.035 inch, is preferably longitudinally traversed by a carrying guide on which he can move. In a particularly advantageous embodiment, this carrying guide is the guide 5 of a fenestration device 11: once the fenestration has been performed (during step (g) of the fenestration method), the tube 2 is removed but not the guide 5, and the insertion system is mounted on this guide 5. The intervention is all shortened. The guide 203 makes it possible to move the ball 201, and thus the jamb 100 crimped to the balloon 201 (as long as the stent of the leg 120 is folded, it encloses the balloon 201). The three elements move in one piece. In this state, only the sheath 202 can move relative to them. The guide 203 thus allows the displacement of the leg 100 necessary during step (c) of the method according to the invention. By keeping the guide 203 fixed relative to the sheath 202, the movement of the leg 100 is controlled both in propulsion and in traction. Just let the sheath 202 move relative to the guide 203 to cause its controlled removal from the surface of the leg 100 and thus the release of the flange 30 and all the jamb 100.

After the inflation of the ball 201 and the complete deployment of the leg 100, the balloon 201 is deflated and the leg 100 detaches. It is then fully released and the guide 203 can be removed by taking the ball 201. The invention is however not limited to this particularly advantageous insertion system, and one skilled in the art will know how to use known systems. Assembly kit According to a fifth aspect, the invention relates to a kit for assembling a stent as described above, characterized in that it comprises a main tubular stent 10 and at least one side jamb 100, the less a side jamb 100 being mounted on an insertion system also described above. This kit, which can be marketed in sterile packaging, contains all the elements necessary to assemble a stent 1 according to the invention. It could also be marketed with the stent fenestration device 11. Complete placement of the stent The placement of a stent 1 according to the invention using the method or methods described above requires only a few tiny incisions: a lower incision (at the level of the femoral artery) and possibly a incision in the high way (in one or more arteries 25 to access the arteries in which a leg 100 will be inserted, for example the carotid artery, one of the humeral arteries ...), but it is possible to do without of this second incision in some cases as explained previously. It is performed by an operator. The pose, a particularly advantageous embodiment of which will now be described, begins with femoral introduction of a delivery guide and then the folded main tubular stent. This is placed in the patient's aorta at the required location using known methods. Then the free end of the guide 5 of the fenestration device 11 is introduced either by the second incision, or by the first in the case of a pose with a single incision. It should be noted that in the case of a single incision, it remains preferred to make the orifices 130 before placing the main tubular stent 10. Indeed, if the main tubular stent 10 is in a straight section l aorta from which the lateral artery where to place the leg 100 is substantially orthogonal, it is possible to create the orifice 130 only coming from this lateral artery and therefore from another incision. The device 11 inserted into the aorta would indeed move tangentially to the wall of the main tubular stent 10 without coming into contact with it. In the example of a leg 100 to be inserted into an artery of the aortic arch, the guide 5 is inserted by a high route by means of an introducer 6 (which is then peeled), until it touches the wall endoprosthesis 10 already installed in the aortic arch. The following process of fenestration of the stent is implemented. Once the orifice 130 obtained with the guide 5 is introduced, the leg 100 is in turn introduced by high way mounted on its collar insertion system 30, the guide 203 (the guide on which the balloon 201 is crimped) is threaded on the guide 5. The leg 100 is guided to the aorta. This step and all others are advantageously monitored by medical imaging, the guides being radio-opaque. The method of assembling the stent 1 from the main tubular stent 10 and the leg 100 described above can then be put in place. The sheath 202, the guide 203 and its deflated balloon 201, and finally the guide 5 are then successively removed from the incision in the high lane.

The stent 1 is then completely put in place. It is possible to repeat, via another incision, the steps of fenestration and then insertion of a collar 30 in the case of multiple jambs 100. Such an operation lasts only a few minutes and presents almost no danger to the patient, unlike the heavy surgical procedures hitherto necessary in the case of many aortic aneurysms.

Claims (14)

REVENDICATIONS1. An endoprosthesis (1) comprising: a main tubular stent (10) having an inner surface (20), at least one side leg (100), the side leg (100) comprising a tubular leg body (110) and a leg stent (120), the leg stent (120) being at least partially covered by the tubular leg body (110), the proximal end (111) of the lateral leg (100) comprising a collar (30) extending substantially direction of the distal end (112) of the lateral leg (100), characterized in that the lateral leg (100) is inserted into an orifice (130) of the main tubular stent (10), so that the collar (30) is supported on the inner surface (20) of the main tubular stent (10). 2. Endoprosthesis according to the preceding claim, wherein the main tubular stent (10) comprises a main tubular body and at least one stent, the at least one stent being at least partially covered by the main tubular body, and the body tubular main being laminated Teflon or dacron O. 3. Endoprosthesis according to one of claims 1 to 2, comprising a plurality of side jambs (100a, 100b) 4. Endoprosthesis according to one of claims 1 to 3, wherein the flange (30) of the side jamb (s) (100) is sutured to the tubular leg body (110). The stent of claim 4, wherein the flange (30) comprises a truncated cone shaped flange body (32) and a flange stent (31), the flange stent (31) being covered by the flange stent (31). flange body (32). The stent of claim 5, wherein the flange (30) comprises a crimping wire (34) defining the distal end of the flange (30). 7. Endoprosthesis according to one of claims 5 to 6, wherein the flange body (32) consists of a circular sector to the flanks joined by a suture (33). 8. Endoprosthesis according to one of claims 5 to 7, wherein the tubular body (110) of the side jamb (s) (100) and / or the flange body (32) is laminated teflon ® or dacron ®. 9. Endoprosthesis according to one of claims 1 to 8, characterized in that the outer diameter of the main tubular stent (10) unfolded is between 20 and 42 mm. 10. Endoprosthesis according to one of claims 1 to 9, characterized in that the length of the main tubular stent (10) unfolded is between 100 and 150 mm. 11. Endoprosthesis according to one of claims 1 to 10, characterized in that the outer diameter of the tubular body (110) unfolded from each side jamb (100) is between 4 and 16 mm. A lateral stent (100) of a stent according to one of claims 1 to 11, comprising a tubular leg body (110) and a leg stent (120), the leg stent (120) being at least partially covered by the tubular leg body (110), characterized in that the proximal end (111) of the lateral leg (100) comprises a collar (30) extending substantially towards the distal end (112) of the lateral leg (100). A system for inserting the flange (30) of a side jamb (100) according to claim 12 into a port (130) of a main tubular stent (10), further comprising a sheath (202), a balloon (201) and a guide (203) integral with the balloon (201), the lateral leg (100) being mounted on the balloon (201), the sheath (202) enclosing the lateral leg (100) so as to hold the stent leg (120) folded and maintain the flange (30) pressed against the side jamb (100). 14 stent assembly kit according to one of claims 1 to 11, characterized in that it comprises a main tubular stent (10) and at least one side jamb (100) according to claim 12, the at least one side jamb (100) being mounted on an insertion system according to claim 13.