An endurant ii stent graft system was implanted for the endovascular treatment of a 51mm abdominal aortic aneurysm.It was reported during the index procedure an endurant limb model etlw1616c124ej - v30805780 was unintentionally implanted in the eia landing zone instead of the left cia landing zone. the sentrant sheath tip was pressed in an attempt to push up the periphery of the stent graft, but it did not go up.On the final contrast imaging , the peripheral blood vessels at the access site did not touch so the physician performed a repair by implanting an artificial blood vessel and bare stent on the peripheral side near the incision that had been opened.As per the physician the cause of the inaccurate delivery was as a result of user error.The unintended eia landing occurred due to misalignment between the marking position and the blood vessel during stent graft placement. the access vascular vessel was damaged because the sheath was pressed in order to push it up.No additional clinical sequalae was provided and the patient will be monitored.
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