evar---what we need to know before we start jia xin, guo wei, liu xp, yin tai, xiong jiang
TRANSCRIPT
EVAR---WHAT WE NEED TO
KNOW BEFORE WE START
Jia Xin, Guo Wei, Liu XP,
Yin Tai, Xiong Jiang
www.vasc.cn
• EVAR EndoVascular Aortic Repair
• EVR EndoVascular Repair
• SG Stent-Graft
• TEVAR Thoracic EndoVascular Aortic Repair
• PTA Percutaneous transluminal angioplasty
SHAPE
Renal A
Lumbar A
Mesentery A
Iliac A
Collaterals
ETIOLOGY
Atherosclerosis
Inherent
Autoimmunity
Infection
Trauma
Others
High Risk
Age>65 y
Gender: M > F (4:1)
Family (1° M): 20%
SMOKING: > 10 y
Peripheral Aneurysm
femoral, popliteal, thoracic Hypertension
Diabetic negative
Race
Clinical Manifestations
M/F 5 : 1(> 60y )
Infrarenal AAA 90%,
Extending to Iliac 66%
Pain; AVF ;Embolism
Pulse Mass
DIAGNOSIS
• Duplex-US
• CTA
• MRA
• DSA
• IVUS
• X- ray
INDICATION
• DIAMETER
• EXPANSION
RATE
• SYMPTOM
• Shape, Age, Life expectancy, Comorbidity
• DIAMETER AND RUPTURE
1 yr rupture risk :
4 - 4.9cm 1.1%
5 - 5.9cm 3.3%
6 - 6.9cm 9.4%
7 - 7.9cm 24% Law et al 1994
5 yr rupture risk:
4cm 5 - 13%
5cm 25 - 38% Vardulaki 1998
OR RESULTS
Mortality
• Best modern individual series 3.5%
• State/community 10.3%
• High risk patients 7.0%
• Patients>80years 10.0%
• High+extra-anatomic bypass 16.0%
Peri-Op Complications
--MI 2%-8%
--All pulmonary 8%-12%
--Reduced renal function 5%-12%
--Dialysis 1%-6%
70% 5 years survival for elective AAA repair
JUAN PARODI
INSTITUTO
CARDIOVASCULAR
DE BUENOS AIRES
ARGENTINA
FIRST HUMAN ELG1989
EVAR History
我国 EVAR的历史 1992年 医院专家开始关注 EVAR国际发展动向
1994年 医院成立 EVAR技术攻关协作组
1995年 协作组前往阿根廷、美国、英国等参观访问
1996年 规划军队九五攻关重点课题
1997年 临床应用 Vanguard腔内治疗 AAA取得成功
1998年 首例 Talent治疗胸主动脉瘤
首例 Talent胸腹主动脉瘤的杂交手术
首例 Talent治疗主动脉夹层
1999年 完成重大医疗保健任务
At least 80At least 80 international conference international conference
with EVAR symposium in the past with EVAR symposium in the past
decadedecade
Important magzines and index
EVAR as first choice in many
centers
Endovascular
Open Surgical
Advantage
Indication for EVAR
Same to OR generally
Anatomy requirements
Landing zone; Access
Proximal
Distal
Access
Anatomy Requirements
• Suitable access (diameter at least 7mm) .
• Proximal landing >15mm ;distal >20mm.
• Angulation <45 - <60°
Pre-OP Assessment
• Measurement:
• Cross section
• MIP
• 3D VR
• Sizing protocol
Proximal
Distal
Collateral
Access
1
2
3
4
Key Points
• Diameter—Cross section
• Length– VR or MIP
• Catheter with marker
Proximal landing zone
• Anatomy – Diameter
– Length
– Morphology
– Angulation
– Thrombus
– Calcification
Each one can affect the final decision
Proximal Neck
• Measure at different
levels
• Spot accessary renal
artery
Taper Neck
• Maximal diameter
+10%
Diameter
measurement a
b
• outer-outer
membrane
• (a+b) / 2
•11•22•33
•nn
length=NX
Layer thickness
Length Assessment
Measure with marker
catheter
• Proximal neck
– length(?)
– angulation(?)
Distal Landing
• Aorta bifurcation
Diameter>20mm
Otherwise, AUI
• Iliac artery
– CIA length, diameter
– Angulation and
calcification
– EIA IIA
CIA
Measure diameter and
length
– Landing length>20mm
– Cover as long as
possible(to prevent
late aneurysm)
• When aneurysm involve CIA
– EIA as landing zone
– IIA
• Embolizaion
• 40% buttock claudication
• Erectile dysfunction
EIA
• Angulation
• Calcification
• Diameter at least 7mm
• Mainbody through the bigger
and straighter side( C
curve better than S curve)
Choose SG
• Neck diameter
• SG diameter=neck diameter + 10-20%
注意 :
• If diameter between two references,
choose the bigger
• If length between two references, choose
the smaller
Pre-OP Protocol
◊ General picture (aneurysm and landing zone)
◊ Choose access; C cuve> S
curve ( 20/22/24F) ◊ familiar with SG
● plan A and B ◊ For small access, female,
prepare CIA conduit
ENDOLEAK
Post-EVAR
Plan:3 、 6 、 12month、 every year
Duplex-US 、 CT、 DSA、 MR
Clinic consultant
Follow UP
THANKS
www.vasc.cn