Download - Endovascular aneurysm repair ( EVAR)
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Endovascular aneurysm repair (EVAR)
Dr Ranjith MPSenior Resident
Department of CardiologyGovernment Medical college
Kozhikode
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Introduction
Endovascular aneurysm repair (EVAR) is a relatively new method of treating aortic aneurysms
Performed by inserting graft components folded and compressed within a delivery sheath through the lumen of an access vessel, usually the common femoral artery
Upon deployment, the endograft expands, contacting the vessel wall proximally and distally to exclude the aortic aneurysm sac from aortic blood flow and pressure
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Introduction
The main advantages over open repair are
Avoidance of long incisions in the thorax or abdomen No cross-clamping of the aorta Less blood loss Lower incidence of visceral, renal, and spinal cord ischemia Less peri-operative mortality Earlier return to normal activity
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Indications for repair
Abdominal aortic aneurysm : Symptomatic (tenderness or abdominal or back pain,
evidence for embolization, rupture)AAA Aneurysm size ≥5.5 cm AAA that has expanded by more than 0.5 cm within a six-
month interval
Thoracic aortic aneurysm Width >6 cm rapidly enlarging diameter (>5 mm of growth over 6m) symptoms such as chest pain, and diagnosis of aortic
rupture or dissection
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1. Endovascular repair of abdominal aortic aneurysm
2. Thoracic endovascular aneurysm repair (TEVAR)
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Endovascular repair of abdominal aortic aneurysm
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Anatomic considerations
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Anatomic considerations
Abdominal aorta is the most common site of arterial aneurysm
Defined as aneurysmal - diameter of the dilated region is increased more than 50 percent relative to normal aortic diameter
The normal diameter of the aorta at the level of the renal arteries is approximately 2.0 cm (1.4 to 3.0 cm)
An aortic diameter greater than 3.0 cm - aneurysmal
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Anatomic considerations
Infrarenal – originates below the renal arteries
Juxtarenal – originates at the level of the renal arteries
Suprarenal – originates above the renal arteries
AAAs most often occur in the segment of aorta between the renal and IMA
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Anatomic considerations
Approximately 5 percent involve the renal or visceral arteries
Up to 40 percent of AAAs are associated with iliac artery aneurysm
Majority of endovascular aneurysm repairs are performed on aneurysms affecting the infrarenal aorta and iliac arteries
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Preoperative planningAortoiliac imaging
Needed to define the anatomy, determine the feasibility of endovascular repair, and choose the size and configuration of endograft components
CT angiography with 3-D reconstruction preferred
2D CT- aortic diameter measurements will be overestimated if the aorta is angulated and the longitudinal axis is not perpendicular to the imaging plane
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Preoperative planningAortoiliac imaging
The use of DSA is limited - cannot evaluate the true lumen diameter, extent of thrombus, plaque, or degree of calcification
MR angiography can be used but gadolinium administration in the setting of renal dysfunction is a relative contraindication
MRA fails to depict vessel wall calcification, which has implications for vascular access
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MeasurementsAortic neck diameter
Aortic diameter at the lowest renal artery
The required endograft diameter = 15 to 20% more of measured aortic neck diameter
Over-sizing the endograft 15 to 20% provide sufficient radial force to prevent device migration
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MeasurementsAortic neck diameter
Devices up to 36mm diameter are available
Over-sizing may lead to kinking of the device, which can form a nidus for thrombus formation or endoleak
Over-sizing may result in incomplete expansion of the endograft with infolding & inadequate seal, and can also be associated with intermediate and long-term neck expansion
Under sizing- inadequate seal
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Conical/reverse tapered aortic neck
A conical neck is present when the diameter of the aorta 15 mm below the lowest renal artery is ≥10 percent larger than the diameter of the aorta at the lowest renal artery
Potential Solutions Rejection Oversizing Supra-renal Fixation Balloon-expandable Stent Fenestrated or Branched Endograft
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MeasurementsAortic neck length
The distance from the lowest renal artery to the origin of the aneurysm
Should be at least 10 to 15 mm to provide an adequate proximal landing zone for endograft fixation
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MeasurementsAortic neck angulation
The angle formed between points connecting the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation
Ideally, the aortic neck angle should be < 600
Angles that are greater lead to difficulties in implantation, kinking, endoleak, and the potential for distal device migration
Angle >600 is generally considered to be a contraindication
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Measurements
Iliac artery & access vessel morphology
Should have no significant stenosis ,mural thrombus, calcification and tortuosity
CIA is the preferred distal attachment site
When the EIA is used for distal fixation the hypogastric artery need to be embolized to prevent back bleeding into the aneurysm sac
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Measurements
Iliac artery & access vessel morphology
EIA diameter of 7 mm is needed to allow safe passage of the endograft delivery sheath.
CIA measure between 8 and 22 mm, and the length of normal diameter CIA into which the limbs of the endograft will be fixed should measure at least 15 to 20 mm to achieve an adequate seal
Diffuse narrowing or significant calcification - an iliac conduit can be created
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Preoperative planning- Other anatomic considerations
Renal artery anomalies - up to 30% have accessory renal arteries &commonly originate from the lumbar aorta
Exclusion of an accessory renal vessel by an endograft can lead to partial renal infarction
Renal arteries often arise from the aneurysmal aortic segment
The inferior mesenteric artery arise from the aneurysm
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Ideal case for EVAR
Proximal neck length >10mm
Diameter <28mm
Aortic neck angulation ≤60
Iliac artery diameter >7mm and < 15mm Minimal to moderate tortuosity No mural thrombus at attachment sites Minimal calcification
No associated mesenteric occlusive disease
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Endografts (Stent-graft)
Fabric-covered stent
There are significant variations in endovascular graft design
Three types of components are common to all: A delivery system Main body device Extensions (limb)
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EndograftsDelivery system
Typically delivered through the femoral artery, either percutaneously or by direct surgical cutdown
If the femoral artery is too small to accommodate the delivery system, access can be obtained by suturing a synthetic graft to the iliac artery (ie, iliac conduit) through a retroperitoneal low abdominal incision
The size of the delivery system varies depending upon the device diameter
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EndograftsMain device
The main body device is usually bifurcated
Endovascular grafts rely primarily upon outward tension in the proximal graft to maintain the positioning of the graft
Fixation systems may also include barbs or a suprarenal uncovered extension
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EndograftsExtensions
Bifurcated abdominal aortic grafts require adjunctive placement of iliac artery limbs to complete the graft
Iliac limbs on the main body device vary in length depending upon whether the graft is a 2 or 3 component graft
Two-component grafts have one short and one long iliac limb Three-component devices have two short limbs
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Stent-graft design
Six stent-graft systems are currently approved by FDA
1. AneuRx (Medtronic, Inc., Minneapolis, MN)
2. Talent (Medtronic, Inc., Minneapolis, MN)
3. Endurant (Medtronic, Inc., Minneapolis, MN),
4. Excluder (W.L. Gore and Associates, Flagstaff, AZ)
5. Zenith (Cook, Inc., Bloomington, IN)
6. Powerlink (Endologix, Irvine, CA)
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Endografts
Figure FDA-approved endovascular stent graft devices in use(A) AneuRx® device - This graft is a modular bifurcated stent graft composed of a nitinol exoskeleton and polyester lining. It is deployed just below the renal arteries and relies on radial force to fix the device into place. Distal and proximal extension cuffs are available. (B) The Gore Excluder -Also a modular bifurcated device, with a nitinol exoskeleton and a polytetrafluoroethylene graft. It has proximal barbs to anchor into the proximal infrarenal aorta. (C) The Powerlink®system- A unibody device made of polytetrafluoroethylene and a cobalt chromium alloy endoskeleton. It has a long main body and sits on the anatomic bifurcation. (D) The Zenith® device-The bare proximal stents allow for suprarenal fixation. The device also has barbs to allow for more secure attachment into the suprarenal aorta. It is modular bifurcated with a stainless steel exoskeleton.
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Endografts
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Endografts
Endurant® - The Endurant® endograft is a modular, bifurcated device composed of a multifilament polyester fabric with an external self-expanding support structure of M-shaped electro-polished nitinol stents. Proximally, it has a suprarenal nitinol stent with anchoring pins for suprarenal fixation. The graft design is intended to treat aneurysms with more challenging anatomy (eg, neck angulation)
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Advanced devices and techniques
Useful when aneurysmal disease is more extensive, involving the visceral vessels proximally or associated with common or hypogastric artery aneurysms
Fenestrated – Fenestrated endografts have openings in the fabric of the endograft, which allow flow into the visceral arteries. Can be used when the proximal aortic neck is short (ie, <10 mm)
Fenestrated Zenith® device with Palmaz stents designed for the treatment of juxtarenal abdominal aortic aneurysms
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Advanced devices and techniques
Branched – Branched grafts have a separate small graft sutured to the basic endovascular graft for deployment into a vessel to preserve flow into it. Branched grafts have been designed to accommodate the hypogastric (ie, internal iliac) and renal arteries
Model of an aorto-iliac aneurysm repair with a bifurcated aortobiiliac stent and a branched iliac extension device
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Advanced devices and techniques
Chimney grafts technique- a stent placed parallel to the aortic stent-graft
Used to preserve perfusion to branch vessels
Complications - type I endoleak
In the absence of available fenestrated or branched grafts, chimney grafts remain a feasible endovascular option for high-risk patients
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Choice of graft
There are no clear advantages of one stent-graft design over another
The choice is based upon multiple factors, including patient anatomy, operator preference, and cost
Bifurcated grafts are most often chosen, but are not appropriate for patients with unilateral severe iliac stenosis or occlusion.
Unilateral iliac stenosis - unibody (nonbifurcated) grafts, also known as aorto-uni-iliac (AUI) devices, are used
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Choice of graft AUI devices are used when contralateral iliac access or gate
cannulation impossible, and for the treatment of some ruptured aneurysms for control of hemorrhage
To provide adequate perfusion to the contralateral lower extremity - a femoro-femoral crossover bypass
Aorto-uni-iliac (AUA) Device
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Preparation
Antithrombotic therapy - moderate to high risk for DVT.The incidence of DVT following EVAR was 5.3 percent in spite of pharmacologic thromboprophylaxis
Antibiotic prophylaxis - A first generation cephalosporin or, in the case of a history of penicillin allergy, vancomycin, is recommended
Prevention of contrast-induced nephropathy
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Procedure
Gaining vascular access
Placement of arterial guidewires and sheaths
Imaging to confirm aortoiliac anatomy
Main body deployment
Gate cannulation (bifurcated graft)
Iliac limb deployment
Graft ballooning
Completion imaging
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Procedure
Anesthesia - can be performed under GA or local anesthesia with conscious sedation
Vascular access — Bilateral femoral access is needed - via surgical cutdown or percutaneously
Small caliber iliac vessels - iliac conduit or internal endoconduit
Graft deployment
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Procedure
Once vascular access is established and landmarks for positioning the device are obtained with aortography, the main device is positioned with particular attention paid to the location of the opening for the contralateral iliac limb (“contralateral gate”)
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Procedure
The aortic neck is imaged
A slight degree of craniocaudal and left anterior oblique angulation may improve imaging of the renal ostia
With the proximal radiopaque markers of the graft positioned appropriately
The body of the graft is deployed to the level of the contralateral gate
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Procedure
The aortic neck is imaged
A slight degree of craniocaudal and left anterior oblique angulation may improve imaging of the renal ostia
With the proximal radiopaque markers of the graft positioned appropriately
The body of the graft is deployed to the level of the contralateral gate
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Procedure
A guidewire is advanced through the contralateral access site into the contralateral gate.
Gate cannulation is confirmed by placing a pigtail catheter over the guidewire into the main body of the graft, removing the guidewire and confirming that the pigtail catheter rotates freely within the main body of the graft; if it does not, the catheter is assumed to be in the aneurysm sac
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Procedure
Once the contralateral guidewire is positioned within the main body of the endograft, the deployment of the endograft at the neck of the aneurysm is completed followed by deployment of the contralateral, then ipsilateral iliac artery limbs (depending on the type of graft)
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Procedure
Once the endograft components are in place, the attachment sites and endograft junctions are gently angioplastied with a compliant or semi-compliant balloon
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Procedure
Completion aortography is performed to evaluate the patency of the renal arteries and evaluate for endoleak
Guidewire access is maintained throughout the procedure but is particularly important when removing the main graft body device sheath since disruption of the access vessels by an oversized sheath may not become apparent until after sheath has been removed
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Troubleshooting “jailing the contralateral gate”
Deployment of the main body of the device with the gate low in the aneurysm sac or below the aortic bifurcation can lead to a situation in which the contralateral gate does not open up when the device is deployed
In some cases, pushing the device upward will allow the gate to flare open
Many currently available endovascular graft devices allow recapture of the graft to reorient the gate opening
If the gate of the graft cannot be moved more superiorly, conversion to an AUI configuration or open conversion may be needed
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Troubleshooting Handling endoleak
Endoleak is a term that describes the presence of persistent flow of blood into the aneurysm sac after device placement
Five types of endoleaks are described
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Endoleak Classification
Type I - Persistent flow at proximal(a) or
distal(b) attachment sites
Type II—retrograde flow from side branches Inferior mesenteric lumbar arteries
Type III - graft defect
Type IV - graft porosity
Type V - continued aneurysm sac expansion without a demonstrable leak on any imaging modality
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Endoleak
Untreated type I or III endoleaks are at high risk of rupture and a rupture rate of 3.37%
Type II are the commonest endoleaks, affecting up to 43% of cases, associated with a low (0.52%) risk of rupture and a significant rate of spontaneous closure. Treatment is required only for endoleaks that persist for more than a year in an aneurysm of increasing size
Type IV endoleak typically resolves in 24 hours. It has not been associated with any long-term adverse events and does not require any treatment
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Endoleak Treatment
Type Endovascular Open surgery
Type I Moulding balloon angioplastyGiant Palmaz stent Stent-graft cuff/ extension
External banding of aneurysm neckSurgical conversion
Type II Trans-arterial embolisation Trans-lumbar injection
30% decrease
Type III Angioplasty/ stenting of junctionsSecondary graft placement
Open conversion
Type VCo-axial graft(‘re-lining’) Evacuation of hygroma
Open conversion
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Postoperative care
Ambulation is resumed on the first postoperative day
peripheral pulse exam should be assessed at regular intervals
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EVAR complicationsDeployment related
Failed deployment
Bleeding
Hematoma
Lymphocoel
Infection
Embolization
Perforation
Arterial rupture
Dissection
Device relatedStructural failure
Implant relatedEndoleaks
Limb occlusion/stent-graft kink
Sac enlargement/proximal neck dilatation
Stent migration
AAA rupture
Infection
Buttock/leg claudication
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EVAR complications
Systemic Cardiac Pulmonary Renal insufficiency, contrast-induced neuropathy Deep vein trombosis Pulmonary embolism Coagulopathy Bowel ischemia Spinal cord ischemia
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EVAR complications Postoperative device migration
Device movement of >10 mm relative to anatomic landmark with the use of 3-D CT reconstruction or any migration leading to symptoms or requiring intervention
Multifactorial: Aortic neck length, angulation, nonparllel aortic neck, thrombus in the aortic neck
Short neck and late neck dilatation after EVAR is a major cause of concern because of the potential loss of proximal fixation and seal
Complications Endoleak Aneurysm expansion & rupture
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EVAR complications Postoperative device migration
A case series of in 130 patients treated for AAA (AneuRx® & Zenith®)
With AneuRx®, device migration- in 14 of 130 patients. Freedom from device migration was 96, 90, 78, and 72%t at 1,2,3,&4yrs respectively
The initial neck length was shorter in patients with migration compared with patients who did not demonstrate migration (22 vs 31 mm). Aortic neck dilation (≥3 mm) occurred in 22%. Twelve of the 14 patients underwent secondary procedures (13 endovascular, 1 open conversion)
With Zenith®, freedom from device migration was 100, 98, 98, and 98 percent at 1,2,3 & 4 yrs, respectively. The single patient with stent migration did not require treatment
Tonnessen BH et al. J Vasc Surg 2005; 42:392.
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Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
Superstiff-Guidewire Technique: Maneuvers like bending the guidewire before introduction, in order to align it with the axes of the aneurysm and the neck, could be helpful.
Also of benefit is the use of a superstiff guidewire,such as the 0.035-inch Lunderquist or the 0.035-inch Amplatz® in combination with slow and controlled deployment of the endograft
Useful in patients with severe infrarenal neck angulation, short infrarenal necks, or both
A 0.035-inch superstiff guidewire is bent to conform theendograft to tortuous infrarenal aortic neck anatomy
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Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
Combination Technique Using the Palmaz XL Stent with the Excluder Stent-Graft:
Used in patients who have complicated infrarenal neck anatomy
The permanent deployment of the Palmaz® XL stent in the infrarenal neck before permanent deployment of the Excluder endograft
This technique has been shown to offer a reliable mode of Excluder fixation and prevention of distal migration
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Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
Endowedge Technique with Excluder Stent-Graft
Useful in short infrarenal neck anatomy
Juxtarenal sealing during endograft placement
Technique enables the scalloped proximal 4 mm of the Excluder endoprosthesis to be wedged against the renal angioplasty balloons, which are placed via the brachial approach
The first 2 to 3 rings of the endograft are slowly deployed (flowering technique), and then the device is advanced upwards against the inflated renal balloons for the completion of deployment
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Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
Kilt Technique :
In patients who have funnel-shaped aortic necks
An aortic cuff is deployed in the distal infrarenal seal zone before the main body is deployed
The proximal end of the Excluder contains barbs, which enable the device to remain above the aortic extension and thereby prevent distal migration
Careful inflation of an angioplasty balloon of the appropriate size then achieves the proximal seal of the prosthesis
![Page 60: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/60.jpg)
Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
Anatomic Fixation with the Powerlink Stent-Graft
![Page 61: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/61.jpg)
Latest Advances in Prevention of Distal Endograft Migration and Type 1 Endoleak
The Aorfix Endovascular AAA Repair System : currently undergoing clinical trial. The proximal part of the Aorfix has incorporated nitinol clips for active fixation of the device to the aortic wall
The Anaconda device: undergoing clinical trials .This is the only graft system that enables repositioning of the graft after deployment. It is highly flexible and has good torque control
![Page 62: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/62.jpg)
Postoperative Surveillance
30 Days: CTA and X-ray Abdomen PA + lateral
6 Months: CTA can be omitted if no prior endoleak and good component overlap
1 Year: CTA and X-ray Abdomen PA+lateral
If no endoleak and stable/shrinking AAA Annual doppler US with plain radiographs CTA if increasing diameter or new endoleak
![Page 63: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/63.jpg)
all mortality aneurysm mortality0
3
6
9
EVAR 1
• 30-day operative mortality: 1.8% with endovascular repair vs. 4.3% with open repair
• All-cause death rate: 7.5/100 person-yrs vs. 7.7/100 person-yrs, respectively
• Aneurysm-related death rate: 1.0/100 person-yrs vs. 1.2/100 person-yrs, respectively
• Late ruptures only occurred in the endovascular repair group
Trial design: Patients with an abdominal aortic aneurysm were randomized to endovascular repair (n = 626) vs. open repair (n = 626). Median follow-up was 6 years.
Results
Conclusions• Among patients with abdominal aortic
aneurysm, endovascular repair associated with lower operative mortality with similar long-term all-cause mortality
• Greater overall frequency of complications after endovascular repair
EVAR Trial Investigators. N Engl J Med 2010;Apr 11:[Epub]
(p = 0.72) (p = 0.73)
Endovascular repair Open repair
per 1
00 p
erso
n-ye
ars 7.5 7.7
1.0 1.2
All-cause death Aneurysm-related death
![Page 64: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/64.jpg)
EVAR 2
all mortality aneurysm mortality0
12
24• 30-day operative mortality: 7.3% with
endovascular repair• Rupture rate in the no repair group: 12.4/100
person-yrs• All-cause death rate: 21.0/100 person-yrs with
endovascular repair vs. 22.1/100 person-yrs with no repair
Trial design: Patients with an abdominal aortic aneurysm ineligible for surgery were randomized to endovascular repair (n = 197) vs. medical management (n = 207). Median follow-up was 3.1 years.
Results
Conclusions
EVAR Trial Investigators. N Engl J Med 2010;Apr 11:[Epub]
(p = 0.97) (p = 0.02)
Endovascular repair No repair
per 1
00 p
erso
n-ye
ars
21.0 22.1
3.6
7.3
All-cause death rate
Aneurysm-related death rate
• In patients with abdominal aortic aneurysm, ineligible for open surgery repair, endovascular repair is associated with relatively high operative mortality
• Aneurysm-related deaths reduced from endovascular repair; but no reduction in all-cause mortality
![Page 65: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/65.jpg)
survival reintervention60
70
80
90
DREAM
• Survival: 69% with endovascular repair vs. 70% open repair (p = 0.97)
• Freedom from reintervention: 70% vs. 82% (p = 0.03), respectively
• In the endovascular repair group, common causes for reintervention were thrombo-occlusive disease, endoleak, and graft migration
• In the open repair group, a common cause for reintervention was treatment of incisional hernia
Trial design: Patients with an abdominal aortic aneurysm were randomized to endovascular repair (n = 173) vs. open repair (n = 178). Median follow-up was 6.4 years.
Results
Conclusions• Among patients with abdominal aortic
aneurysm, endovascular repair results in similar long-term survival as open repair; however, this approach results in the need for significantly more reinterventions
De Bruin JL, et al. N Engl J Med 2010;362:1881-9
(p = 0.97) (p = 0.03)
Endovascular repair
Open repair
%
Survival Freedom from reintervention
69 70 70
82
![Page 66: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/66.jpg)
OVER
• 30-day mortality ↑ with open repair (2.3% vs. 0.2%, p = 0.006); no difference at 2 years (9.8% vs. 7.0%, p = 0.13)
• MI: 2.7% vs. 1.4%, p = 0.14; stroke: 0.9% vs. 1.6%, p = 0.38
• Procedural time, duration of hospital stay ↓ in EVAR arm (p < 0.001)
Trial design: Patients with unruptured AAA were randomized to endovascular repair (EVAR) or open surgical repair. Patient follow-up was a mean of 1.8 years.
Results
Conclusions
Lederle FA, et al. JAMA 2009;302:1535-42
(p = 0.13)
Open repair(n = 437)
EVAR(n = 444)
Mortality at 2 years
• Mid-term outcomes similar with EVAR and open repair for unruptured AAA; length of stay and procedural time was shorter for EVAR
• Results are contrary to two other published trials; long-term results are awaited
0
10
20
% 9.8
7.0
2.71.4
%
0
20
MI at 1 year
(p = 0.14)
10
![Page 67: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/67.jpg)
Review of EvidenceEVAR vs OSR
![Page 68: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/68.jpg)
Thoracic endovascular aneurysm repair (TEVAR)
![Page 69: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/69.jpg)
Introduction
TEVAR refers to the percutaneous placement of a stent graft in the descending thoracic or thoracoabdominal aorta in patients with aortic aneurysms
Preoperative planning
![Page 70: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/70.jpg)
Conduct of the operationProcedure is typically done under GA
A lumbar drain is placed in the L3-L4 disc space for drainage of CSF in cases where extensive coverage of the thoracic aorta is anticipated where interruption of contributing blood supply to the artery of Adamkiewicz is high
Lumbar drainage of cerebrospinal fluid to decrease the pressure in the subarachnoid space and increase the spinal cord perfusion pressure
![Page 71: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/71.jpg)
Anatomic considerations
The thoracic aorta is of larger caliber than that of the infrarenal aorta so needs larger diameter stent grafts
There is high force of blood flow in the thoracic aorta so requires a longer seal zone (20 mm both proximal and distal)
Hybrid approach- for proximal aneurysm
![Page 72: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/72.jpg)
Stent Grafts
Gore-TAG device -made of e-PTFE and an exoskeleton made of nitinol. The proximal and distal ends of the graft have scalloped flares
Medtronic Talent thoracic stent graft system . It is made of two components, a proximal straight tubular stent graft with a proximal bare stent & a distal tapered tubular stent graft with an open web proximal configuration & closed web distal configuration It consists of a woven polyester graft with a nitinol endoskeleton. studied in the VALOR I trial
![Page 73: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/73.jpg)
Stent Grafts
The Cook TX2 stent graft is a two-piece modular endograft system made of proximal and distal tubular endografts. The proximal endograft is covered and has stainless steel barbs, allowing for active fixation to the aortic wall. The distal component has at its distal end a bare metal. The TX2 is made of Dacron fabric covered by stainless steel Z-stents.
The Bolton Relay stent graft is an investigational device
![Page 74: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/74.jpg)
Perioperative complications
Perioperative stroke has ranged from 4 percent to 8 percent
The risk of spinal cord ischemia - 3 to 11 percent
Visceral ischemia can occur with coverage of the celiac axis
![Page 75: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/75.jpg)
Review of Evidence
![Page 76: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/76.jpg)
Review of Evidence TEVAR vs OSRVALOR 1 trial
5-year outcomes of TEVAR using the Vascular Talent Thoracic Stent Graft System in pts considered low or moderate risk for OSR
195 patients, prospective, nonrandomized, multicenter study
Freedom from all-cause mortality - 83.9% at 1 yr & 58.5% at 5yrs
Freedom from aneurysm-related mortality (ARM) was 96.9% at 1 year and 96.1% at 5 years
The 5-year freedom from aneurysm rupture was 97.1% and the 5-year freedom from conversion to surgery was 97.1%
The incidence of stent graft migration was ≤1.8% in each year
The 5-yr freedom from secondary endovascular procedures -81.5%
![Page 77: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/77.jpg)
42 nonrandomized studies - 5,888 patients (38 comparative studies, 4 registries)
Conclusion: TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery
Sustained benefits on survival have not been proven
![Page 78: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/78.jpg)
MCQ
![Page 79: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/79.jpg)
MCQ.1
False statement regarding AAA is
A. AAA that has expanded by more than 0.5 cm within a six-month interval is an indication for EVAR
B. More than 15% percent involve the renal or visceral arteries
C. Up to 40 percent of AAAs are associated with iliac artery aneurysm
D. Majority of endovascular aneurysm repairs are performed on aneurysms affecting the infrarenal aorta and iliac arteries
![Page 80: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/80.jpg)
MCQ.2
Incorrect matching is?
A. Aortic neck diameter - Aortic diameter at the lowest renal artery
B. Aortic neck length - The distance from the lowest renal artery to the aortic bifurcation
C. Ideal aortic neck angle less than 60º- EVAR feasible
D. Iliac artery diameter >7mm and < 15mm – EVAR feasible
![Page 81: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/81.jpg)
MCQ.3
Fill in the blanks
Post operative stent migration in EVAR defined as Device movement of more than ------------- mm relative to anatomic landmark or any migration leading to symptoms or requiring intervention
A. 5
B. 10
C. 15
D. 20
![Page 82: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/82.jpg)
MCQ.4
False statement about endograft is
A. There are no clear advantages of one stent-graft design over another
B. The main body device is usually bifurcated
C. Endovascular grafts rely primarily upon outward tension in the distal graft to maintain the positioning of the graft
D. Fixation systems may also include barbs or a suprarenal uncovered extension
![Page 83: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/83.jpg)
MCQ.5
An 88-year-old man who presented with tearing mid abdominal pain 4 months after EVAR. DSA taken. What is your diagnosis ?
A. Type 1 Endoleak
B. Type 2 Endoleak
C. Type 3 Endoleak
D. Endotension
![Page 84: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/84.jpg)
MCQ.6
What is the most appropriate treatment
in the above case ?
A. deployment of covered stent over defect
B. Regular follow up by CT scan
C. Open surgical repair
![Page 85: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/85.jpg)
MCQ.7
Correct order of stent deployment in EVAR of AAA
A. Endograft at the neck of the aneurysm →contralateral limb → ipsilateral iliac artery limbs
B. Contralateral limb → Endograft at the neck of the aneurysm →ipsilateral iliac artery limbs
C. contralateral limb→ Ipsilateral iliac artery limbs→ Endograft at the neck of the aneurysm
![Page 86: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/86.jpg)
MCQ.8
False statement regarding EVAR is
A. A femoro-femoral crossover bypass may be needed in aorto uniiliac device
B. EVAR has better short term prognosis than OR
C. EVAR is better than OR in terms of long term prognosis
D. EVAR can be done under regional anaesthesia
![Page 87: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/87.jpg)
MCQ.9
False statement is?
A. MR angiography Is the investigation of choice in pre EVAR work up
B. The required endograft diameter = 15 to 20% more of measured aortic neck diameter
C. DSA cannot evaluate the true lumen diameter
D. 2D CT- aortic diameter measurements will be overestimated if the aorta is angulated
![Page 88: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/88.jpg)
MCQ.10Images of a thoracic pseudo aneurysm repair procedure. What is your
comment about the stent length?
A. Adequate size
B. Under sized
C. Over sized
![Page 89: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/89.jpg)
MCQ.1
False statement regarding AAA is
A. AAA that has expanded by more than 0.5 cm within a six-month interval is an indication for EVAR
B. More than 15% percent involve the renal or visceral arteries
C. Up to 40 percent of AAAs are associated with iliac artery aneurysm
D. Majority of endovascular aneurysm repairs are performed on aneurysms affecting the infrarenal aorta and iliac arteries
![Page 90: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/90.jpg)
MCQ.2
Incorrect matching is?
A. Aortic neck diameter - Aortic diameter at the lowest renal artery
B. Aortic neck length - The distance from the lowest renal artery to the aortic bifurcation
C. Ideal aortic neck angle less than 60º- EVAR feasible
D. Iliac artery diameter >7mm and < 15mm – EVAR feasible
![Page 91: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/91.jpg)
MCQ.3
Fill in the blanks
Post operative stent migration in EVAR defined as Device movement of more than ------------- mm relative to anatomic landmark or any migration leading to symptoms or requiring intervention
A. 5
B. 10
C. 15
D. 20
![Page 92: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/92.jpg)
MCQ.4
False statement about endograft is
A. There are no clear advantages of one stent-graft design over another
B. The main body device is usually bifurcated
C. Endovascular grafts rely primarily upon outward tension in the distal graft to maintain the positioning of the graft
D. Fixation systems may also include barbs or a suprarenal uncovered extension
![Page 93: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/93.jpg)
MCQ.5
An 88-year-old man who presented with tearing mid abdominal pain 4 months after EVAR. DSA taken. What is your diagnosis ?
A. Type 1 Endoleak
B. Type 2 Endoleak
C. Type 3 Endoleak
D. Endotension
![Page 94: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/94.jpg)
MCQ.6
What is the most appropriate treatment in the above case ?
A. deployment of covered stent over defect
B. Regular follow up by CT scan
C. Open surgical repair
DSA obtained after deployment of covered stent over defect shows no further contrast leakage.
![Page 95: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/95.jpg)
MCQ.7
Correct order of stent deployment in EVAR of AAA
A. Endograft at the neck of the aneurysm →contralateral limb → ipsilateral iliac artery limbs
B. Contralateral limb → Endograft at the neck of the aneurysm →ipsilateral iliac artery limbs
C. contralateral limb→ Ipsilateral iliac artery limbs→ Endograft at the neck of the aneurysm
![Page 96: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/96.jpg)
MCQ.8
False statement regarding EVAR is
A. A femoro-femoral crossover bypass may be needed in aorto uniiliac device
B. EVAR has better short term prognosis than OR
C. EVAR is better than OR in terms of long term prognosis
D. EVAR can be done under regional anaesthesia
![Page 97: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/97.jpg)
MCQ.9
False statement is?
A. MR angiography Is the investigation of choice in pre EVAR work up
B. The required endograft diameter = 15 to 20% more of measured aortic neck diameter
C. DSA cannot evaluate the true lumen diameter
D. 2D CT- aortic diameter measurements will be overestimated if the aorta is angulated
![Page 98: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/98.jpg)
MCQ.10
Images of a thoracic pseudo aneurysm repair procedure. What is your comment about the stent length?
A. Adequate size
B. Under sized
C. Over sized
![Page 99: Endovascular aneurysm repair ( EVAR)](https://reader033.vdocuments.net/reader033/viewer/2022061423/568164c9550346895dd6e370/html5/thumbnails/99.jpg)