Intraluminal grafting of a bifurcated artery

Description: TECHNICAL FIELD [Detailed description of the invention]

Intracavitary transplantation of bifurcated arteries Field of invention The present invention relates to a method of positioning an intracavitary implant in a bifurcated blood vessel such as an artery. To. Background technology Human arteries can easily develop an inflatable sac known as an aneurysm after a disease. As is well known, this aneurysm is prone to rupture. Traditionally, aneurysms are basic surgical Treated with graft replacement. This coping is risky to the patient and often Is impractical due to other pre-existing illnesses in the patient. These days , Intracavitary placement of intracavitary grafts that bridge the aneurysm, and thereby active arteries Many proposals have been made to isolate the tube from the aneurysm sac. Such a hand One of them is disclosed in Australian Patent Application No. 78835/94. If the aneurysm extends from a single artery to one or more bifurcated arteries, such intracavities Difficulties arise in the placement of the graft. In this case, the so-called "trouser transfer" "Plant" must be used. In such a graft, a single tubular body Branches downstream into two smaller tubular bodies. This intention is a single The tube body is located in a single artery, and there are two small tubular bodies each Placed in a bifurcated artery (see, eg, US Pat. No. 5,360,443, Barone) Is to do so. In practice, effective placement of trouser-like grafts is non-existent It turned out to be always difficult. Disclosure of invention According to the first aspect, the present invention locates an intracavitary implant in a bifurcated blood vessel in a patient's body. In the method of deciding, this vessel is a single pre-branch that bifurcates into a pair of post-branch vessels. Including blood vessels, this method involves the following steps: (a) First intraluminal graft, which contacts the peripheral wall of the pre-branch vessel at the first end Tubular part that can be expanded until it becomes, and first and second tubular transplants at the second end Has a body with a bifurcation to one stretched portion) through one post-branch vessel The step of complete introduction into the pre-branch vessel; (b) Intra-second cavity containing an inflatable tubular body with upstream and downstream ends The graft is introduced into one post-branch vessel and the upstream end is one of the first intraluminal grafts. Within or surrounding the tubular graft extension of the Transfer the second graft until the downstream end is within the one post-branch vessel. Move and to the tubular body of the second intraluminal implant, the tubular implant extension and the The process of forming a fluid delivery engagement with a blood vessel; and (c) Intra-third cavity containing an inflatable tubular body with upstream and downstream ends The implant is introduced into the other post-branch vessel and the upstream end is of the first intracavitary implant. Being in or surrounding the other tubular graft extension And the third until the downstream end is within the other post-branch vessel. And to the tubular body of the third intracavitary implant, the tubular implant The step of forming a fluid delivery engagement between the stretched portion and the blood vessel. In a preferred embodiment of this aspect of the invention, the first intraluminal implant is the first. Introduced through one of the above-mentioned post-branch vessels, and the above-mentioned second intraluminal graft, It is introduced through the blood vessel after bifurcation on the other side. Next, the third intraluminal graft is the first. It is introduced through one of the blood vessels after bifurcation. Instead of first positioning the bifurcated graft, one of the "legs" of the graft It is possible to place first and then position the bifurcated graft. Therefore, the first In two aspects, the invention positions the intracavitary implant into a bifurcated vessel in the patient's body. This vessel is a single pre-branch vessel that branches into a pair of post-branch vessels. This method includes the following steps: (a) Intra-first cavity containing an inflatable tubular body with upstream and downstream ends The implant will be introduced into one post-branch vessel and the downstream end will be in contact with the vessel. The process of inflating until sea urchin; (b) Second intraluminal graft, which contacts the peripheral wall of the pre-branch vessel at the first end Tubular part that can be expanded until it becomes, and first and second tubular transplants at the second end Has a body with a bifurcation to one stretched portion) is completely placed in the post-branch vessel The second graft is introduced into the other post-branch vessel until it is placed. The first end of the vessel is inflated until it comes into contact with the wall of the prebranch vessel, and One tubular implant extension is formed with a fluid delivery engagement with the first intracavitary implant. Process; and (c) Intra-third cavity containing an inflatable tubular body with upstream and downstream ends The implant is introduced into the other post-branch vessel and the upstream end is of the second intracavitary implant. Being in or surrounding the other tubular graft extension And the third until the downstream end is within the other post-branch vessel. To the tubular body of the third intracavitary implant, and then transfer the tubular to the tubular body of the third intracavitary implant. A step of forming an elongated portion of a plant, the blood vessel, and a fluid delivery engagement. In a further aspect, the present invention presents an intracavitary implant in a bifurcated blood vessel in a patient's body. This vessel is a single branch that branches into a pair of post-branch vessels. Including pre-branching vessels, this method involves the following steps: (a) Intra-first cavity containing an inflatable tubular body with upstream and downstream ends The implant is introduced into one post-branch vessel, and at least the downstream end is with the vessel. The process of inflating until contact; (b) Second intraluminal graft, which contacts the peripheral wall of the pre-branch vessel at the first end Tubular part that can be expanded until it becomes, and first and second tubular transplants at the second end It has a body with a bifurcation to one stretched part and the other tubular graft stretched part. Longer length with one tubular graft extension), said one post-branch blood The second intraluminal graft is introduced into a tube and the first end is within the pre-branch vessel. Yes, and the other tubular graft extension removes the first intracavitary graft Pass through the first intraluminal implant until it is closed, and then the first of the second implant. The end is inflated until it comes into contact with the wall of the prebranch vessel, and the one A fluid transfer attachment with the first intracavitary implant is formed in the extended portion of the tubular implant. Process to make; and (c) Intra-third cavity containing an inflatable tubular body with upstream and downstream ends The implant is introduced into the other post-branch vessel and the upstream end is of the second intracavitary implant. Being in or surrounding the other tubular graft extension And the third until the downstream end is within the other post-branch vessel. And to the tubular portion of the third intracavitary implant, the tubular implant The step of forming a fluid delivery engagement between the stretched portion and the blood vessel. In each of the above aspects, the method further comprises the following steps: (d) Further intracavitary including an inflatable tubular body with upstream and downstream ends The graft is introduced into one and / or the other post-branch vessel, with the upstream end Move more implants until within the downstream end of the intracavitary implant, and further Into the tubular body of the implant, with and surrounding the downstream end of the implant in the post-branch vessel The step of forming a fluid delivery engagement with a post-branch vessel. In one embodiment of the further aspect, the first intraluminal implant is combined into one of the above. The above steps of positioning the blood vessel after bifurcation include the following steps in order: (a) Pass the first fine guide wire through the one post-branch vessel and Preferably at least the step of guiding into the pre-branch vessel; (b) Place the first fine catheter sheath on the first fine guide wire. In addition, the step of guiding the catheter sheath to at least enter the pre-branch vessel; (c) Step of pulling out the first fine guide wire; (d) The second relatively rigid guide wire is attached to the first fine catheter sea. Insert the guide wire through the thread until it enters at least the pre-branch blood vessel. About; (e) Step of pulling out the first fine catheter sheath; (f) A second relatively large diameter catheter sheath with the second guide wire Above, the step of guiding the catheter sheath to at least into the pre-branch vessel ; (g) A non-inflated balloon adjacent to the first end and around the balloon A first delivery catheter having the downstream end of the arranged first intraluminal implant. Catheter sheath on the second guide wire and larger in the second diameter The process of guiding within; (h) Position the first delivery catheter, thereby placing the first implant in the implant. The process of keeping the blood vessels in the blood vessel after branching; (i) Partially pull out the second catheter sheath and remove the first intraluminal implant. Release process; and (j) Inflate the balloon, thereby causing the downstream end of the first intraluminal implant. A step of inflating the blood vessel wall after branching until the downstream end is engaged. The invention according to the invention is where a single blood vessel bifurcates into two blood vessels (eg, the ilium). It is typically used in the aorta, which branches into an artery. Like found in the aortic arch It can also be used where there are multiple vessels branching from a single vessel. In a particularly preferred embodiment of the above aspect of the invention, the intracavitary implant is an austra. It has the characteristics of the implant described in Rear Patent Application No. 78835/94. Contents of this patent Is incorporated herein by reference. Hereinafter, the present invention is a typical application for positioning a trouser-shaped implant into a bifurcated artery. Described with reference to. However, in the method according to the present invention, a trouser-shaped implant is placed in the body. It can be used to position in any bifurcated vessel. As such a blood vessel In addition to arteries, include veins, trachea and tracheal twigs, and bile ducts. The tubular body of the implant used in carrying out the present invention is a balloon catheter. Inflatable, but at least one of the tubular parts of the first intraluminal graft , Can be formed with a self-expanding stent. Such a stent holds the tubular part Can act to receive the tubular body of the second and third intraluminal implants. In an intracavitary graft, each of the tubular graft extension ends in the artery upstream of the bifurcated artery. It is preferable to have a length that can be tied. In this configuration, a separate tubular transplant Pieces are used to engage each tubular extension with its connecting distal artery. another In the configuration, the intracavitary graft is one long enough to project into the first distal artery. Includes a tubular stretched portion of. In this case, the other tubular extension portion is the above two. Terminates at a branch, and the second tubular graft is with the anterior extension and the second distal artery. To combine. A brief description of the drawing FIG. 1 has an aortic aneurysm bridged by an intraluminal implant according to the invention. Partially clipped central view of the patient; FIG. 2 shows an implementation with a tubular intraluminal implant used in the method described with reference to FIG. It is a front view of the aspect; FIG. 3 is a cross-sectional view of the intracavitary graft of FIG. 2 opposite to the longitudinal direction; FIG. 4 is a detailed elevation view of one end of the intracavitary graft of FIG. 2; FIG. 5 is a detailed perspective view of the first end of the intracavitary implant of FIG. 4, the end of the implant. How the alternating crests of wire radiate outward while inserting the implant Indicates whether it is pushed in the direction; 6 and 6a are placed on the delivery catheter used in the practice of the method of the invention. It is a vertical cross-sectional view of two possible embodiments of a bifurcated implant to be made; Figure 6b shows a bulge adjacent to the free end of the catheter and guide wire, respectively. An enlarged view of a stretchable balloon, the balloon is inflated; FIG. 6c is a longitudinal sectional view of the device of FIG. 6b, with the balloon not inflated. I; Figure 6d shows a guide wai with an inflatable umbrella adjacent to its free end. Simplified cross section of Yar; Figure 6e shows a simplified stand of a guide wire with solid beads at its free end. It is a face view; Figures 7a-7i show the steps in implementing one method according to the invention; 8a-8e show the steps of implementing another method according to the invention; Figures 9a-9f show a simplification of yet another intraluminal implant used in the method according to the invention. It is a side elevation FIG. 10 shows a tubular transfer placed on a delivery catheter that can be used in the practice of the present invention. It is a vertical sectional view of an embodiment with a plant piece. Preferred aspects for carrying out the present invention Bifurcated or trouser-shaped graft containing three intracavitary grafts 10, 10a, and 10b The piece bridges and occludes an aortic aneurysm that extends at least into the left iliac artery. Adapted to transfemorally insert into the patient to be possible To. As shown in FIG. 1, the aorta 11 is connected to the left and right iliac arteries 13 and 12. Great movement Aneurysms are located between renal arteries 14 and 15 and iliac arteries 12 and 13, with few aneurysms Also extends below the left iliac artery 13. Each intracavitary implant (as shown in Figures 2-5) is a pleated tube of polyester fabric. Can include 16. Polytetrafluoroethylene, polyurethane, and combinations thereof Other materials, including mixes, may be used. Tube 16 is separated by a plurality of pipes along its length. Reinforced by spaced stainless steel wires 17 (each of these) Each can have a generally closed sinusoidal shape depicted). Wire 17 is preferred Or as thin as possible, and typically 0.3-0.4 mm in diameter. Wire 17 Are malleable and can be bent into any desired shape, i.e. they are any parenchyma Since they do not have elasticity in a certain range, they are more likely to expand due to their own elasticity. Rather, it should be physically inflated into contact with the aorta. wire 17 is each woven into the fabric of tube 16, with alternating crests of each wire 17 of tube 16. On the outside, the rest of the wire 17 is on the inside of the tube (described below herein). Except for the wire 17a at the end where it is placed). The end of each wire 17 is the tube 16 Arranged on the outside and twisted together to form the tail 18. Alternate wire 17 The tail 18 is bent to extend in the opposite longitudinal direction along the outer surface of the tube 16. .. If desired, the wire 17 is a two-part having a coupling tail 18 on each side of the tube 16. Can be formed in minutes. The wire 17a at the end protrudes from each end of the tube 16 and thus theirs. Alternating crests of wire extend longitudinally beyond the end of tube 16. Wa at the end Ear 17a preferably has an amplitude of about 6 mm and 6-8 around the 22 mm diameter implant. It has a wavelength such that the crests are arranged. The next two adjacent wires 17 is preferably disposed as close as possible to the terminal wire 17a, and It has an amplitude of 4 mm and 5 mm, respectively. These wires are typically end First has the same wavelength as the wire 17a of. Then, over the entire graft, Wires 17 are spaced 15 mm apart, have an amplitude of 6 mm, and end wires It has a first wavelength that is substantially the same as 17a. An aneurysm extends from the aorta 11 to or beyond the bifurcation of the iliac arteries 12 and 13. So a single tubular graft will allow blood to flow into each of the iliac arteries 12 and 13. Not enough to bridge the aneurysm while holding. Rather than using a single tubular graft Rather, in the method of the invention, three separate implants 10, 10a, and 10b are used. Will be done. At the downstream end of the first one of graft 10 (as illustrated in Figure 1), a bifurcation In preparation, a pair of tubular grafts 10 form graft extension portions 19a, 19b. Tubular transplant The one-sided stretched parts 19a, 19b can be passively inflated by the bloodstream, or Can be actively expanded by the expansion of the rune or by the self-expansion of the spring Can be. As best illustrated in Figures 9a-f, they extend into the iliac arteries 12 and 13, respectively. Graft portions 10a and 10b adapted so that they have a common diameter at the upstream end. Each has. The upstream end is a transition adapted to be located inside the aorta 11. It is interlocked at each of the extension parts 19a and 19b of the plant piece 10. Preferably, this The interlock is due to the friction between the upstream ends and the extension portions 19a and 19b, respectively. Inflation or spring of the balloon at the upstream end so that there is an engagement that occurs Achieved by self-expansion of. In addition to having a straight cylindrical tube, the downstream ends of graft portions 10a and 10b The diameter of 35 is the iliac artery (graft parts 10a and 10b are implanted inside it) It may have a variable diameter to match the diameter of the). Diameter changes can be seen in short step-down sections 31 (see Figure 9c) or steps. By puup part 32 (see Figure 9d) or by graft part 10a or 1 Regions of tapers 33 and 34 extending along the length of 0b (see Figures 9e and 9f) Can be given by. Next, one method of positioning the intracavitary implant is described with reference to FIGS. 7a-7i. To do. In performing this method, an incision or puncture is made to flow from the corresponding iliac artery. Exposing one femoral artery (eg, ipsilateral) and using Seldinger needle technique , 0.035 inch diameter tip flexible (floppy tipped) flexible guide wire, Insert through the femoral artery and then enter the aorta 11 so that it crosses the aneurysm Insert it into the iliac artery 12 and pass it through. Then 8French hemostatic sheath suppresses bleeding To introduce on this wire. Introducing an angiographic catheter to the patient blood Angiography is taken and the location of renal arteries 14, 15 and other relevant anatomical structures of the patient Makes it possible to show. Then, Amplatz's very rigid (AES) guide wire 23 (0.035 inches in diameter) Pass through the aorta 11 through an angiographic catheter (see Figure 7a). Angiography After retracting the tatel, leave the rigid guide wire 23 in situ. Then A rigid wire, preferably a 24 French catheter sheath 21 and a mantle needle into the aorta 11. -Introduce on 23 (see Figure 7a). Next, the balloon catheter 24 is seamed. Introduced in Su 21. As shown in FIG. 6, the balloon catheter 24 is a delivery catheter, which is , 1st and 2nd tubular graft extension 19a, 19b separated from bifurcation point 40 The first through the bifurcated graft 10 with, as well as the first tubular graft extension 19a In the direction of, then in the second different direction into the second tubular graft extension 19b Prepackaged with a thin catheter 25 containing an extending guide wire 26. Catheter 24 and thin catheter 25 when placing implant 10 in a blood vessel The role of ensuring accurate positioning of the wheel 25 and guide wire 26 In a common catheter sheath 56 that plays, it can bind together under graft 10. Tubular In addition to being slidable through the graft extension 19a, 19b Le 25 was anchored in place at graft 10 prior to insertion of graft 10 into the blood vessel. obtain. Catheter 26 can be sutured, glued, or woven into the body of implant 10. .. Although the guide wire 26 is shown inside the catheter 25 in FIG. 6, the guide wire 26 is shown inside the catheter 25. Only -26 can be placed in the first and second tubular graft extension 19a, 19b. Can be easily predicted. In another configuration illustrated in Figure 6b, the guide wire 26 is positioned within a tubular channel 22 formed within the body of implant 10. To. After packaging the implant 10 around the balloon 20, the balloon is placed in the aorta 11. Before placing the Tether 24, the groove 22 has the guide wire 26 in the first and second tubular. Make sure it remains in place at the desired location in the graft extension 19a, 19b It plays a role of keeping. If the balloon catheter 24 is positioned at the desired location inside the aorta 11, Sheath 21 is partially retracted, releasing graft 10 and inflating balloon 20 (See Figure 7b). Inflatation of balloon 20 of catheter 24 is the first transplant Inflate the upstream end of piece 10 and above the aneurysm but downstream of renal arteries 14 and 15. , It causes an engagement with the aortic wall at its upstream end. The first graft 10 is Length such that the tubular graft extension 19a, 19b is completely located inside the aorta 11. Have. The balloon 20 is then contracted, but the balloon catheter 24 is It is left in place for a time beinng (see Figure 7c). Baloo The contraction of the 20 causes the blood to inflate each of the tubular graft extension parts 19a and 19b. Allows the plant piece 10 to flow downwards. The thin catheter 25 is preferably 3 French and the guide wire 26 is preferred. Moreover, it is a non-kinking substance, so the guide wire 26 is the catheter 25. Can extend downstream with respect to (see Figure 7c). Guide wire 26 is good Further, it comprises a nitinol core having a hydrophilic coating. The method illustrated in Figure 7 At the tip of the catheter 25 and the guide wire 26, a small inflatable It has 50 and 55 balloons, respectively. For details on balloons 50 and 55, see Figures 6 and 6b. And 6c are illustrated in detail. Balloons 50 and 55 are inflated and catheter 25 and guide wire 26 are transported and guided by blood flow to the opposite iliac artery 13. Help to do that. Balloon 50 adjacent to each free end of catheter 25 and guide wire 26 , 55 enlarged views are provided by FIGS. 6b and 6c. Catheter 25 has two It has cavities 52 and 53. The guide wire 26 passes through the first lumen 52. Second The end of the lumen 53 is sealed and a small hole 51 is formed on the outer surface of the catheter 25. To. The latex balloon 50 is annularly adhered to the outer surface of the catheter 25 at 50a. To. When the balloon 50 is inflated, a liquid or gas will pass through the hole 51. The balloon 50 is injected downward into the second lumen 53 so as to inflate. Similarly The guide wire 26 has a lumen 54, which descends from the free end of the guide wire 26. Air can be infused to inflate the balloon 55 placed in the section. Inflatable balloons are preferred, but other inflatable devices may be recognized. For example, in another embodiment, the catheter 25 and the guide wire 26 Runes 50, 55 can be replaced by inflatable umbrellas. Ann available An example of a Brera type is illustrated in Figure 6d. Arranged at the free end of the guide wire 26 It is Umbrella 70. Umbrella 70 (This is the inflated shape shown in Figure 6d (Shown in the form) is a wire 71 that extends through the lumen 73 in the guide wire 26. Inflated by. Joint stay 72 when retracting wire 71 Wire 71 stays to inflate Umbrella 70 It is attached to 72. Umbrella 70 is on guide wire 26, but on catheter 25 It can be easily recognized that a similar configuration can be used. For further alternatives The balloon 55 on the guide wire 26 is epoch, as illustrated in FIG. 6e. It can be replaced with small solid beads 80 of a substance such as resin or titanium. Bi The 80's preferably has a larger profile than the guide wire 26. .. As soon as the catheter 25 is placed in the desired position in the blood vessel in a particular application At the free end of the catheter, the balloon 50 engages with the wall of the blood vessel. Then inflate the catheter 25 further until it is fixed in the desired position in the blood vessel. It is hoped that the idwire 26 will provide additional fixation while passing through the blood vessel. I'm sorry. Once the guide wire 26 is correctly placed in the contralateral femoral artery, its thigh movement A cut is made in the pulse (which is fastened at the intersection) and an arteriotomy is made. guide Guide wire 26 if wire 26 is completely guided to the opposite femoral artery Withdraws the guidewire through an incision or puncture made in the artery It is easily recovered by this. Guide wire 26 completely squeezes into the opposite femoral artery If not idled, snare or similar device, opposite femoral movement Can be introduced through the pulse, to grab the guide wire 26 and retrieve it Pull back to the site of the incision or puncture. Once the guide wire 26 is recovered, it is thin Catheter 25 is then retracted via the same side and the other The Teter 27 climbs the guide wire 26 through the opposite femoral artery, which is the first Go inside the graft 10 and reach at least the top of the second tubular graft extension 19b Supplied until it reaches (see Figure 7d). Thin guide wire 26 Is then retracted, and a thicker guide wire 30 connects the opposite femoral artery It is inserted through the catheter 27. Catheter 27 is then removed and then The catheter sheath 21a preferably has 24 French and the mantle needle is rigid. Introduced on the guide wire 30 (see Figure 7e). Prior to extension of the guide wire 26 to the opposite iliac and femoral arteries, the catheter -Tel sheath (which can be similar to catheter sheath 21) is the opposite femoral movement Any that can extend upstream through the veins and iliac arteries and can be present in these arteries The twists and turns can be reduced, thus facilitating the guidance of the guide wire 26 through it. Second balloon catheter 24a (second tubular implant 10a) as illustrated in FIG. (Package on this), then through the catheter sheath 21a, fully so The upper end of the implant enters the interior of the second tubular graft extension 19b, and its lower end It is introduced until it is inside the iliac artery at the end of the iliac artery. On catheter 24a In the balloon 20a, the upper end of the implant 10a is rubbed against the second tubular extension 19b. It is inflated to engage (see Figure 7f). On catheter 24a The inflatable balloon 20a passes through the artery 12 on the ipsilateral side of the first balloon catheter 24. Support graft 10a while retracted. Then, the catheter 24a Rune 20a is contracted, and catheter 24a is positioned with a third implant 10b. In place to continue to support graft 10,10a in the artery while being squeezed Be held. The catheter sheath 21a is then removed (see Figures 7f and 7g). ), And a third balloon catheter (tubular graft 10b packaged on top) (The third balloon catheter 10b can be identical to that illustrated in FIG. 10) Is introduced into the sheath 21 of the guide wire 23. Partially pull sheath 21 After squeezing, its upstream end should be inside the first tubular graft extension 19a This is advanced until, and then placed. Positioned on the third balloon catheter The implanted third implant 10b is therefore the first tubular at its upstream end. Contact with the graft extension 19a, and at its downstream end with the right iliac artery 12. The contact is pushed forward (see Figure 7h). Here, the rigid guide wires 23 and 30 are retracted, and the opposite incision is made. Or the puncture is sutured. A second angiography test is then performed, and the graft The hemostatic sheath 21 pulls when 10, 10a, and 10b are properly positioned and functioning. It is tucked in and the right thigh is closed by suturing. As a result, illustrated in Figure 7i As such, a trouser-shaped graft that bridges the aneurysm functions. Next, see Figures 8a-8e for different methods for positioning intracavitary implants. Here, similar features have the same reference numbers as in the previous figure. Shown in Figure 7 In the practice of this method, an incision or puncture is made and the corresponding intestine is used, as in the case of the method. Exposing one femoral artery (eg, ipsilateral) flowing from the bone artery, and Seldinger Using needle technology, a flexible flexible guide wire with a tip of 0.035 inch diameter, Insert through the femoral artery and then enter the aorta 11 so that it crosses the aneurysm Insert it into the iliac artery 12 and pass it through. Then, 8French hemostatic sheath suppresses bleeding Introduce on this wire to control. Introducing an angiographic catheter and suffering Angiography of the person is taken and the location of renal arteries 14, 15 and other relevant of the patient Allows to show anatomical structure. Then Amplatz's very rigid (AES) guide wire 23 (0.035 inches in diameter) Through an angiographic catheter through the aorta 11 (see Figure 8a). Vascular structure After retracting the shadow catheter, leave the rigid guide wire 23 in situ. Next Then, preferably, a 24 French catheter sheath 21 and a mantle needle are placed in the iliac artery 12. Introduce on rigid wire 23 (see Figure 8a). Then the balloon catheter A cell 24a (eg, shown in FIG. 10) is introduced into the sheath 21. in this case, The balloon catheter 24a is prepackaged with the tubular implant 10b. Kate When positioning the tell 24a within the iliac artery 12, the catheter sheath 21 is partially Pull out to release the graft 10b, then inflate the balloon 20a (figure) See 8b). Inflatation of balloon 20a on catheter 24a is graft 1 Inflate the downstream end of 0b and it against the wall of iliac artery 12 below the aneurysm To engage. The balloon 20a is then contracted and the catheter 24a is retracted. Pull out. The catheter sheath 21 is then passed through the implant 10b, and the aorta 11 Introduce on the rigid guide wire 23 inside. Then balloon catheter 24 (For example, shown in FIG. 6) is introduced into the sheath 21. Balloon catheter 24 The bifurcation point 40, two tubular graft extension parts 19a, 19b, thin catheter Pre-packaged with bifurcated graft 10 with 25 and guide wire 26 .. Balloon catheter with or with graft 10 positioned on it -Tel 24 passes through tubular implant 10b and is positioned within the aorta 11. .. As soon as the balloon catheter 24 is positioned within the aorta 11, the catheter Partially pull out sheath 21, release graft 10, and with catheter 24 The balloon 20 can be inflated. Inflatation of balloon 20 is above the aneurysm However, the upstream end of graft 10 with respect to the aortic wall downstream of renal arteries 14 and 15. Inflate (see Figure 8c). Of graft 10 extending into graft 10b The tubular implant extension portion 19a, when used in the method of the present invention, is a tubular implant extension portion. Longer than min 19b. And this is the proper movement of the balloon catheter 24 When positioned within vein 11, the graft extension 19a overlaps the graft 10b and And the tubular implant extension 19b ensures that there is no implant 10b. Then , Withdraw the balloon 20 and partially pull it to the upstream end of the tubular implant 10b Cut out. Here, it is re-expanded so that the tubular graft extension portion 19a expands and overlaps. It comes into contact with the graft 10b, and in that way the graft 10 A fluid delivery engagement is formed between and 10b. The thin catheter 25 and guide wire 26 are then placed on top with reference to FIG. It can be arranged towards the downstream end in a manner similar to that described. Correct the guide wire 26 Immediately after being placed in the femoral artery on the opposite side, it is fixed with a cross-cl. An amp) and a cut down is made on the femoral artery that has been arteriotomized. Next Now, the free end of the guide wire 26 has been recovered as described above and this In position a thin catheter 25 can be pulled out through the same flank. Then another category -Tell 27, it is inside the first graft 10 and at least the graft extension Guide wire through the contralateral femoral artery until it reaches the apex of 19b Go up 26 and proceed. Then pull out the thin guide wire 26 and then Insert a thicker guide wire 30 into the catheter 27 through the contralateral femoral artery Enter (see Figure 8d). Then remove catheter 27 and catheter -Telshes 21a (preferably 24 French) and mantle needle, see Figure 7. Introduce on the rigid guide wire 30 in a manner similar to that described in the light. Then a third balloon catheter packaged with a second tubular implant 10a Through the catheter sheath 21a (having the characteristics of the catheter shown in FIG. 10) , Introduced until its upper end is completely within the tubular graft extension 19b To do. The balloon on the third balloon catheter is then placed on top of the implant 10a. Inflate the end so that it engages with the graft extension 19b by friction. Then , Inflate the balloon on the third balloon catheter, and balloon catheter Withdraw through the contralateral femoral artery (see Figure 8e). Baru on catheter 24, which remains inflated at the upstream end of graft 10b, then 20 is contracted and the balloon catheter 24a is completely withdrawn. Then Take the catheter sheath 21a, guide wire 23 and guide wire 30 Remove and suture the contralateral incision or puncture. As described above Here, a second angiography test is performed, and grafts 10, 10a and 10 If b is properly positioned and functioning, pull out the hemostatic sheath 21 and then The ipsilateral femoral artery is closed by suturing. As a result, it is similar to that shown in Fig. 7i. Bon-shaped implants work. Position grafts 10, 10a and 10b shown in Figures 8a-8e into bifurcated vessels Further modifications of the method follow the positioning of the tubular implant 10b within the right iliac 12. , Delivery catheter 2 that delivers graft 10 through left iliac artery 13 to aorta 11 May include the introduction of 4. Graft 10 is desired between grafts 10 and 10a, and Immediately after being placed where proper binding is made, graft 20b is then placed in the left ilium. Positioning of the trouser-like implant, introduced through artery 13 and properly placed Is complete. Various methods of surgery include general anesthesia, epidural anesthesia, or where appropriate. It can be performed using only local anesthesia. A number of changes and / or modifications have been extensively described in the spirit or scope of the invention. What can be done in the present invention as shown in a particular embodiment without departing from , Can be understood by those skilled in the art. Therefore, all of these embodiments are considered exemplary and limited. It should be considered that it should not be regarded as a target.