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VASCULAR/INTERVENTIONAL RADIOLOGY
593

Endovascular Repair of Abdominal

Aortic Aneurysms: Vascular Anatomy,
Device Selection, Procedure, and
Procedure-specific Complications1
Yolanda Bryce, MD
Philip Rogoff, MD
Donald Romanelli, MD
Ralph Reichle, MD
Abbreviations: AAA = abdominal aortic an-
eurysm, EVAR = endovascular aneurysm repair
RadioGraphics 2015; 35:593–615
Published online 10.1148/rg.352140045
Content Codes:
1
From the Department of Radiology, Mount
Auburn Hospital, 330 Mount Auburn St, Cam-
bridge, MA 02138. Presented as an education
exhibit at the 2013 RSNA Annual Meeting. Re-
ceived April 29, 2014; revision requested July 18
and received August 4; accepted August 8. For
this journal-based SA-CME activity, the authors,
editor, and reviewers have disclosed no relevant
relationships. Address correspondence to Y.B.
(e-mail: ycdbryce@gmail.com).
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■Discuss important elements of vascular
anatomy pertinent to endovascular aneu-
rysm repair and device selection.
■■Describe the basic technique involved
in endovascular aneurysm repair.
■■List
complications of endovascular
aneurysm repair.
See www.rsna.org/education/search/RG.
Abdominal aortic aneurysm (AAA) is abnormal dilatation of the
aorta, carrying a substantial risk of rupture and thereby marked risk
of death. Open repair of AAA involves lengthy surgery time, anes-
thesia, and substantial recovery time. Endovascular aneurysm repair
(EVAR) provides a safer option for patients with advanced age and
pulmonary, cardiac, and renal dysfunction. Successful endovascular
repair of AAA depends on correct selection of patients (on the basis
of their vascular anatomy), choice of the correct endoprosthesis,
and familiarity with the technique and procedure-specific complica-
tions. The type of aneurysm is defined by its location with respect
to the renal arteries, whether it is a true or false aneurysm, and
whether the common iliac arteries are involved. Vascular anatomy
can be divided more technically into aortic neck, aortic aneurysm,
pelvic perfusion, and iliac morphology, with grades of difficulty with
respect to EVAR, aortic neck morphology being the most common
factor to affect EVAR appropriateness. When choosing among the
devices available on the market, one must consider the patient’s
vascular anatomy and choose between devices that provide suprare-
nal fixation versus those that provide infrarenal fixation. A success-
ful technique can be divided into preprocedural imaging, ancillary
procedures before AAA stent-graft placement, the procedure itself,
postprocedural medical therapy, and postprocedural imaging sur-
veillance. Imaging surveillance is important in assessing complica-
tions such as limb thrombosis, endoleaks, graft migration, enlarge-
ment of the aneurysm sac, and rupture. Last, one must consider the
issue of radiation safety with regard to EVAR.
©
RSNA, 2015 • radiographics.rsna.org

Introduction
Abdominal aortic aneurysm (AAA) is abnormal dilatation of the
abdominal aorta greater than 50% of the normal proximal segment,
or dilatation greater than 3 cm (1). It carries a considerable risk of
rupture and thereby a substantial risk of death. The risk of rupture in-
creases with increasing diameter: It has been reported as 1%–3% per
year when aneurysm diameter is 4–5 cm, 6%–11% per year when an-
eurysm diameter is 5–7 cm, and about 20% per year when aneurysm
diameter is greater than 7 cm (2). The factors associated with devel-
opment of AAA include advanced age, coronary artery disease, high
594 March-April 2015
TEACHING POINTS
■■ Aortic neck morphology greatly influences device delivery,
deployment, aneurysm exclusion, and long-term device func-
tion, since it is the proximal fixation site for the stent-graft and
the most important factor in determining a successful EVAR.
Unfavorable aortic neck anatomy is the most common reason
influencing contraindication to EVAR.
■■ Proximal aortic neck length is measured from the lowest renal
artery to the top of the aortic aneurysm, and its measurement
is important in determining suprarenal or infrarenal fixation.
■■ The morphology of the common femoral and iliac arteries is
important for vascular access and device introduction, as well
as adequate fixation at the distal attachment site and mainte-
nance of limb patency.
■■ The radiologist interpreting the postoperative CT scan should
analyze the stent-graft components with multiplanar imag-
ing to assess for subtle migration. Linked side-by-side unen-
hanced, arterial phase, and delayed contrast-enhanced im-
ages should be carefully studied for the presence of subtle en-
doleak and to exclude calcification within the sac mimicking
an endoleak. Measurement of sac volume is the optimal way
to monitor aneurysm sac size, instead of maximal sac diam-
eter on a single axial image. It can be difficult to distinguish
type 2 from type 1 or type 3 endoleak on CT images, and
any increase in sac size with a demonstrated endoleak should
prompt arteriographic imaging with an eye toward concur-
rent treatment.
■■ Type 2 endoleak is the most common type of endoleak,
occurring in about 20%–30% of patients and persisting in
10%–15% of patients after 6 months. These endoleaks occur
when there is retrograde flow of blood into the aneurysm sac
through branch vessels such as lumbar arteries or a patent
inferior mesenteric artery. These close spontaneously in about
half of patients.
cholesterol level, hypertension, and smoking (3).
The standard for aortic aneurysm repair has tradi-
tionally been an open surgical approach. Surgery
is indicated in an aneurysm with a diameter of 5.5
cm or greater, an aneurysm size that is 2.5 times
the normal aortic diameter, an aneurysm exceed-
ing a growth rate of 1 cm per year, a rupture, and
a symptomatic aneurysm, such as one with accom-
panying back pain, a potential warning sign of
impending rupture (4). The open surgical ap-
proach involves lengthy surgery time, anesthesia,
and substantial recovery time. Endovascular an-
eurysm repair (EVAR) provides a safer option for
patients of advanced age and with pulmonary,
cardiac, and renal dysfunction. A study conducted
by Schermerhorn et al (4) involving 22,830
patients showed a lower perioperative mortal-
ity rate among patients who underwent EVAR
compared with those who underwent open repair,
with the reduction of mortality rate being more
pronounced with increasing patient age (5). The
EVAR Trial 1 demonstrated a 30-day mortality
rate of 1.8% in EVAR patients and 4.3% in open
repair patients (6). Mortality and morbidity in
patients with moderate or severe chronic renal
radiographics.rsna.org
disease is lower after EVAR than after open re-
pair (7). Perioperative outcome in patients with
chronic obstructive pulmonary disease has also
been shown to be more favorable with EVAR (8).
Moreover, endovascular repair is associated with
fewer cardiac events in the perioperative period
than is open repair (9).
EVAR is defined as image-guided treatment of
an AAA by using a stent-graft device, also known
as an endoprosthesis. The device is placed within
the native abdominal aorta and is secured proxi-
mally and distally to the diseased aneurysmal
portion of the aorta, creating a new conduit for
blood flow and eliminating the AAA sac pres-
surization (4). Indications for EVAR are the same
as those for an open surgical approach; however,
contraindications are derived largely on the basis
of the patient’s vascular anatomy. The success of
the procedure is dependent on the correct selec-
tion of the patient on the basis of his or her vas-
cular anatomy, most important neck morphology,
as well as selection of the correct endoprosthesis
and familiarity with the technique and proce-
dure-specific complications (10). Postoperative
imaging surveillance is standard to confirm that
the device remains appropriately positioned and
that the aneurysm sac stabilizes or decreases in
size and to exclude endoleaks. It should be noted,
however, that operator experience is one of the
most important predictors of success (11).
Vascular Anatomy
An AAA is preliminarily defined by its location
relative to the renal arteries. A suprarenal AAA
involves the renal arteries and extends superiorly
so that the superior mesenteric artery and celiac
arteries arise from the aneurysmal aorta (Fig 1). A
juxtarenal aneurysm extends to the renal arteries,
with a normal-sized aorta superiorly (Fig 2). An
infrarenal AAA arises at least 10 mm below the
renal arteries (Fig 3). Endovascular repair is best
suited for infrarenal AAAs because the renal arter-
ies and superior mesenteric arteries are not in-
volved; with recent advances, however, EVAR may
also be used for juxtarenal aneurysms. Aneurysms
are also classified as a true aneurysms, usually fu-
siform, involving all three arterial layers (Fig 4a),
and pseudoaneurysms, usually saccular, involving
fewer than three walls (Fig 4b). Endovascular re-
pair can be used to address both true aneurysms,
usually resulting from atherosclerotic disease, and
pseudoaneurysms, usually caused by infection or
trauma. The vast majority of cases addressed with
EVAR are true aneusysms. In addition, aneurysms
may (Fig 5a) or may not (Fig 5b) involve the iliac
arteries. Iliac artery involvement makes endovas-
cular repair more complex. Size is also important
to note, as the larger the aneurysm, the less favor-
RG • Volume 35 Number 2 Bryce et al 595

Figure 1. Suprarenal aortic aneurysm. Schematic diagram (left), aortogram (middle), and computed tomographic (CT) angiogram
(right) in two patients demonstrate the aortic aneurysm extending above the renal arteries (arrow). SMA = superior mesenteric artery.

Figure 2. Juxtarenal aortic aneurysm. Schematic diagram (left), CT angiogram (middle), and three-dimensional rendition (right) of
an AAA in the same patient demonstrate the aneurysm extending just to the level of the renal arteries (arrows).

Figure 3. Infrarenal aortic aneurysm. Schematic diagram (left), CT angiogram (middle), and three-dimensional rendition (right) of
an AAA in the same patient demonstrate the aortic aneurysm extending 1 cm below the level of the renal arteries. Arrows = renal
arteries.

able the anatomy and the more complicated the
repair (12). However, anatomic aneurysm analysis
goes beyond these few factors.
A grading scale to analyze AAA anatomy was
developed by the Ad Hoc Committee for Stan-
dardized Reporting Practices in Vascular Surgery
of the Society for Vascular Surgery/American As-
sociation for Vascular Surgery in 2002 (12). The
grading scale factors taken into account include
aortic neck morphology, aneurysm morphol-
ogy, pelvic perfusion, and common iliac artery
morphology, which are fully described in Table 1.
These factors can be graded to provide a severity
score (14,15). Each factor is graded from 0 to 3,
with 3 being the most severe (Table 1).
Scoring is an aid in determining potential
clinical outcomes. Ahanchi et al (15) assigned
the number 14 to distinguish between low-score
596 March-April 2015 radiographics.rsna.org

Figure 4. True aneurysm and pseudoaneurysm. (a) Schematic diagram (left) and three-dimensional rendering (right)
of an AAA demonstrate a fusiform, or true, aneurysm (arrow). (b) Schematic diagram (left) and three-dimensional ren-
dering (right) of an AAA demonstrate an eccentric aneurysm, or pseudoaneurysm (arrow).

Figure 5. AAA with and without

iliac artery involvement. (a) Sche-
matic diagram (left) and CT angio-
gram (right) demonstrate an AAA
involving the common iliac artery
(arrows). (b) Schematic diagram
(left) and CT angiogram (right)
demonstrate an AAA that does not
involve the common iliac artery.
Blue arrows = normal-sized com-
mon iliac arteries, red arrow = nor-
mal-sized aorta caudal to the AAA.

and high-score groups, choosing the number 14 long, blood loss four times greater, 27% more
to ensure enough patients were in each group. use of contrast material, and substantially lon-
Compared with the low-score group, the high- ger hospital stays and higher costs. In addition,
score group experienced surgery times twice as the average number of endograft implants used
RG • Volume 35 Number 2 Bryce et al 597

Table 1: AAA Anatomy Severity Score Grading Scale

Attribute Absent: Score of 0 Mild: Score of 1 Moderate: Score of 2 Severe: Score of 3
Aortic neck
Length (mm) >25 15–25 10–15 <10
Diameter (mm) <24 24–26 26–28 >28
Angle (degrees) >150 150–135 135–120 <120
Calcification or 0 <25 25–50 >50
thrombus (%)
Aortic aneurysm
Aortic tortuosity index <1.05 1.05–1.15 1.15–1.2 >1.2
Aortic angle (degrees) 160–180 140–159 120–139 <120
Thrombus (%) 0 <25 25–50 >50
Aortic branch vessels No vessels 1 lumbar or infe- 2 vessels with <4- 2 vessels with inferior
rior mesenteric mm diameter mesenteric artery
artery diameter >4 mm
Pelvic perfusion Patent bilateral Single internal Single internal iliac Bilateral internal iliac
internal iliac iliac artery oc- artery occlusion artery occlusion
artery clusion and contralat-
eral internal
iliac artery >50%
stenosis
Iliac artery
Calcification None <25% vessel 25%–50% vessel >50% vessel length
length length
Diameter and occlusive >10 mm, no oc- 8–10 mm, no ste- 7–8 mm, focal <7 mm, stenosis
disease clusive disease nosis <7 mm in stenosis <7 mm in <7 mm in diam-
diameter, or >3 diameter and <3 eter and >3 cm in
cm in length cm in length length, more than
one focal stenosis
<7 mm in diameter
Iliac artery tortuosity <1.25 1.25–1.5 1.5–1.6 >1.6
index
Iliac artery angle 160–180 121–159 90–120 <90
(degrees)
Common iliac artery >30 20–30 10–20 <10
length (mm)
Iliac artery diameter <12.5 mm 12.5–14.5 mm 14.5–17 mm >17 mm

was three in the low-score group and four in the
high-score group. Intraoperative adjuncts were
required in 54% of patients in the low-score
group versus 80% in the high-score group; the
most common were distal limb extension and
access site adjuncts such as angioplasty and end-
arterectomy. Moreover, although both groups
had similar risk factors and comorbidities, hos-
pital stay lengths did differ, likely because of
increased surgery time, contrast material use,
blood loss, and adjunct procedures (16).
Aortic Neck Anatomy
Aortic neck morphology greatly influences de-
vice delivery, deployment, aneurysm exclusion,
and long-term device function, since it is the
proximal fixation site for the stent-graft and the
most important factor in determining a success-
ful EVAR (4,12,13). Unfavorable aortic neck
anatomy is the most common reason influenc-
ing contraindication to EVAR (17). Aortic neck
length, aortic neck tortuosity index, aortic neck
angle, aortic neck calcification or thrombus, and
aortic neck diameter are discussed in this sec-
tion; the grading system is depicted in Table 1.
Proximal Aortic Neck Length.—Proximal aortic
neck length is measured from the lowest renal
artery to the top of the aortic aneurysm (Fig 6),
and its measurement is important in determin-
ing suprarenal or infrarenal fixation. The shorter
the neck, the more complicated the procedure.
Generally, a 1.5-cm landing zone of normal
anatomy is required for infrarenal fixation (12).
Landing zone refers to the site at which the pros-
thesis is placed. If the landing zone is smaller,
suprarenal fixation, discussed below, may poten-
tially be used.
598 March-April 2015 radiographics.rsna.org

Figure 6. Aortic neck length. Schematic diagram (left) and CT angiogram (right) demonstrate measurement
of the aortic neck proximal to the AAA. Arrow = renal artery.

Figure 7. Aortic neck angle shown on schematic diagram (left) and CT angiogram (right).
The aortic neck angle is the angle in the dashed line denoting the central lumen between the
flow axis of the suprarenal aorta and the infrarenal neck.

Proximal Aortic Neck Angle.—The aortic neck
angle is drawn between the flow axis of the su-
prarenal aorta and the infrarenal neck (Fig 7)
(4). Angles greater than 150° are most favorable,
and angles less than 120° are most difficult with
regard to delivering and deploying the device to
the correct location. Operator experience is im-
portant when dealing with angles approaching
less than 120°.
Proximal Aortic Neck Calcification or Throm-
bus.—Aortic neck calcification or thrombus is
graded by the percentage of circumferential in-
volvement by calcification or thrombus thickness
of at least 2 mm (Fig 8, Table 1). Greater than
50% circumferential involvement is considered
severe; 25%–50% is considered moderate, and
less than 25% is considered mild.
Proximal Aortic Neck Diameter.—A diameter
greater than 28 mm is considered severe according
to the scoring system, as larger diameters usually
exceed the available stent-graft limit. Stent-grafts
are typically chosen to overestimate the proximal
and distal landing zone diameters by 10%–20%;
therefore, the proximal and distal neck diameter
cannot exceed 90% of the available maximal stent-
graft diameter (18). Aortic neck diameter is not
always uniform. The shape of the neck may be
straight, tapered, or reverse tapered. Tapered and
reverse tapered are defined as having greater than
3 mm diameter differences proximally and distally
(Fig 9). Reverse tapered—proximal greater than
distal—is associated with increased complication
(19). Aburahma et al (19) reported reverse tapered
to be a strong predictor of early type 1 endoleak.
The proximal aortic neck wall may also be bulging
in portions, affecting the seal between the stent-
graft and the aortic wall (20).
Aortic Aneurysm Morphology
Aortic aneurysm morphology influences stent-
graft delivery and deployment, risk of distal
embolization of thrombus, long-term device
performance, and exclusion or enlargement of
the aneurysm. Aneurysm tortuosity index, angle,
thrombus, and branch vessels are described
herein; the grading system is depicted in Table 1.
RG • Volume 35 Number 2
Aortic Aneurysm Tortuosity Index.—The aor-
tic tortuosity index is obtained by dividing the
distance along the central lumen line (L1 in Fig
10), between the lowest renal artery and the
aortic bifurcation, by the straight-line distance
from the lowest renal artery to the aortic bifur-
cation (L2 in Fig 10). A high tortuosity index
(>1.2) indicates that device delivery and deploy-
ment will be difficult.
Aortic Aneurysm Angle.—Aortic angle is the
most acute angle in the line through the central
lumen between the lowest renal artery and the
aortic bifurcation (Fig 11). As with high tortuos-
ity index, small angles make delivery and deploy-
ment of the device difficult.
Aortic Aneurysm Thrombus.—Aortic aneurysm
thrombus is classified in increments of 25%, as
described in Table 1. Thrombus is typically soft
and does not usually obstruct delivery of the de-
Bryce et al 599
Figure 8. Aortic neck thrombus
and calcification. Top row: Aortic
neck thrombus at least 2 mm thick
is shown on axial contrast mate-
rial–enhanced CT images. Bottom
row: Calcification is shown on axial
unenhanced CT images.
Figure 9. Diagrams show shapes
of the aneurysm neck. The neck
can be straight, tapered, or reverse
tapered; the latter two are defined
as a difference greater than 3 mm
in proximal and distal diameters.
vice. On rare occasions, however, thrombus may
break off and cause distal embolus.
Aneurysm Branch Vessels.—Aneurysm branch
vessels, mainly inferior mesenteric and lumbar
arteries, predispose patients to type 2 endoleak,
the most common type of endoleak. The number
of lumbar arteries and inferior mesenteric arter-
ies and their caliber form this portion of the grad-
ing system (Fig 12).
A second factor regarding branch vessels that
was not included in the grading system has to do
with accessory renal arteries, which may be oc-
cluded by the stent-graft. If a substantial percent-
age of a kidney is perfused by an accessory renal
artery, therapeutic attempts at renal artery revas-
cularization can be attempted. In addition, fenes-
tration of the stent-graft has been reported to spare
the accessory artery perfusion (21). Similarly, eval-
uation of the superior mesenteric artery is impor-
tant. If the inferior mesenteric artery is occluded, a
600 March-April 2015 radiographics.rsna.org

Figure 10. Aortic tortuosity index, demonstrated on schematic diagram (left) and CT angiogram (right). The
aortic tortuosity index is obtained by dividing the distance along the central lumen line (L1), between the low-
est renal artery and the aortic bifurcation, by the straight-line distance from the lowest renal artery to the aortic
bifurcation (L2).

Figure 11. Aortic aneurysm angle. Schematic diagram (left) and CT angiogram (right) show
the aortic angle as the most acute angle in the line through the central lumen between the
lowest renal artery and the aortic bifurcation.

diseased superior mesenteric artery can predispose Iliac Artery Anatomy

the patient to mesenteric ischemia. Revasculariza-
tion of the superior mesenteric artery, or use of a
fenestrated stent-graft, may be warranted.
Pelvic Perfusion
Pelvic perfusion is based largely on the patency
of the internal iliac arteries. When the stent-graft
is extended into the external iliac artery because
of a common iliac artery aneurysm or short
common iliac artery, the origin of the ipsilateral
internal iliac artery is occluded by the stent-graft.
If such a procedure will be performed, it is im-
portant to note contralateral internal iliac artery
patency to prevent pelvic ischemia (Fig 13) as bi-
lateral internal iliac artery occlusion significantly
increases the patient’s risk of pelvic ischemia. Pel-
vic ischemia manifests as buttock and thigh clau-
dication, impotence, perineal necrosis, and rectal
and colonic necrosis (22). Contralateral internal
iliac artery occlusion results in buttock claudica-
tion in as many as 28% of patients and erectile
dysfunction in 17% (23).
The morphology of the common femoral and
iliac arteries is important for vascular access and
device introduction, as well as adequate fixation
at the distal attachment site and maintenance of
limb patency. Common iliac artery calcification,
diameter, length, and pelvic perfusion grading
systems are depicted in Table 1.
Iliac Artery Diameter.—Stenotic or occlusive
disease prohibits delivery of the stent-graft.
A minimal outer diameter of 7 mm is usually
needed for main body device delivery, with a few
exceptions (24). The Endurant II (Medtronic;
Oak Brook, Ill) and Ovation Prime (TriVascular;
Santa Rosa, Calif) devices can potentially be
used in a patient with a smaller iliac artery. Cur-
rently, the Ovation Prime offers the lowest pro-
file; in other words, it requires the smallest outer
diameter. Stenotic arteries or occlusive disease
may be addressed with angioplasty and/or stent
placement. An outer diameter greater than 10
mm is favorable to a certain point, as the com-
RG • Volume 35 Number 2 Bryce et al 601

Figure 12. Aortic aneurysm branches. Schematic diagram (top left),

axial CT image (bottom left), sagittal CT image (bottom center), and
three-dimensional rendering (bottom right) of an AAA show aortic an-
eurysm branches. IMA = inferior mesenteric artery, green arrows = lum-
bar arteries, blue arrows = inferior mesenteric artery, orange arrow =
opacified portion of the aneurysm.

Figure 13. Pelvic perfusion.

(a) Three-dimensional rendering
from CT shows a right common
iliac artery aneurysm (orange ar-
row) with a patent contralateral
internal iliac artery. The pelvis can
be perfused by the contralateral il-
iac artery when the ipsilateral iliac
artery is occluded and the graft
limb is extended into the external
iliac artery. Yellow arrows = patent
internal iliac arteries. (b) Three-
dimensional rendering from CT
shows a left common iliac artery
aneurysm (orange arrow) with an
occluded contralateral internal
iliac artery (yellow arrow). The
pelvis will not be perfused by the
contralateral iliac artery when the
ipsilateral iliac artery is occluded
and the graft limb is extended
into the external iliac artery.

mon iliac artery diameter should typically be 2
mm smaller than the stent-graft limb diameter
(24). A dilated iliac artery affects the distal seal
zone, preventing successful fixation of the graft
limb. Iliac artery aneurysms occur in about 20%
of patients with AAA (25).
Iliac Artery Calcification.—As with iliac luminal
diameter, arterial calcification may also influence
device delivery. In addition, calcified plaque may
embolize. The severity is graded in increments of
25% (Fig 14). Calcification greater than 50% is
considered severe.
602 March-April 2015 radiographics.rsna.org

Figure 14. Iliac artery calcification. CT angiograms demonstrate iliac artery calcification, with
severity graded in 25% increments.

Figure 15. Iliac artery tortuosity index demonstrated on schematic diagram (left) and CT angiogram
(right). This index is obtained by dividing the distance along the central lumen line from the aortic bifur-
cation to the common femoral artery (L1) by the straight-line distance from the aortic bifurcation to the
common femoral artery (L2).

Iliac Artery Tortuosity.—The iliac tortuosity
index is determined by dividing the distance
along the central lumen line from the aortic
bifurcation to the common femoral artery (L1
in Fig 15 ) by the straight-line distance from
the aortic bifurcation to the common femoral
artery (L2 in Fig 15). An index of less than 1.25
is optimal, and an index of greater than 1.6 is
considered severe.
Iliac Artery Angle.—The iliac artery angle is the
angle line within the central lumen between the
aortic bifurcation and common femoral artery
(Fig 16). Larger angles are preferable. An angle
smaller than 90° is considered severe.
Iliac Artery Length.—Adequate length is needed
to ensure safe graft limb positioning and seal. If
the common iliac artery is too short, extension of
the aortic stent-graft into the external iliac artery,
which complicates the procedure, may be needed
to ensure successful graft limb positioning and an
adequate seal (24) (Fig 17). A length greater than
3 cm is considered ideal.
The Devices
There are two parts to the EVAR stent-graft
device: the delivery system for introducing and
deploying the stent-graft (Fig 18a) and the stent-
graft itself. The stent-graft is composed of a self-
expanding metallic stent framework with a high
RG • Volume 35 Number 2 Bryce et al 603

Figure 16. Iliac artery angle demonstrated on schematic diagram (left) and CT an-
giogram (right). The iliac angle is the angle line within the central lumen between the
aortic bifurcation and common femoral artery.

Figure 17. Iliac artery length. CT

angiogram demonstrates a right
common iliac artery that is 1.1
cm, likely inadequate for a landing
zone.

stances as described below. The AFX is slightly

different than the others, in that the graft material
is outside the self-expanding metallic stent frame-
work. Devices are bifurcated, with the ability for
a limb extension to extend the graft inferiorly and
an aortic cuff to extend the aortic component su-
periorly (Fig 18c).

outward radial force that allows attachment to the
artery wall (Fig 18b) and graft fabric that creates
a new conduit for blood flow and prohibits blood
from entering the aneurysm sac (Fig 18b).
The following devices are commercially
availablet: Zenith (Cook Medical), Endurant II
(Medtronic), AFX (Endologix), Excluder (Gore
Medical), and Ovation Prime (TriVascular). In
addition to appropriate aortic and iliac diameter
compatibility, each device requires adequate ac-
cess vessel diameter and optimal morphology. The
Zenith, Endurant II, AFX, and Ovation Prime can
be used for suprarenal fixation, which becomes
an important function to note in certain circum-
Proximal Fixation
To ensure adequate proximal fixation, a decision
must be made about suprarenal or infrarenal fixa-
tion. Infrarenal fixation describes placement of
the stent-graft immediately below the most inferi-
orly located renal artery. This is appropriate when
the aortic neck is sufficiently long (Fig 19).
A short aneurysmal neck (Fig 20a) will result
in radial force exerted over a smaller area, re-
sulting in a greater risk of inadequate seal, distal
stent-graft migration, and type 1 endoleak (4).
In such cases, suprarenal fixation can be used
(Fig 20b). Suprarenal fixation describes the
bare metallic stent component extending above
the fabric-covered stent-graft. The junction be-
tween the bare metallic stent and the stent-graft
is placed just below the renal arteries, and the
bare metallic stent extends superiorly. This al-
lows perfusion to the superior mesenteric artery
and renal arteries, which protrude through the
bare metallic stent. Suprarenal fixation endo-
prostheses often have more struts in the supe-
rior aspect of the stent-graft to help fixate the
device. In addition to utilization in AAAs with a
604 March-April 2015 radiographics.rsna.org

Figure 18. EVAR devices. (a) A delivery device, similar to that shown here (AFX Endovascular AAA System; Endologix, Irvine,
Calif), is used to introduce the endoprosthesis. The arrow denotes the proximal tip. (b) Image depicts five stent-grafts, or endo-
prostheses. From left to right, the devices are the Zenith (Cook Medical; Bloomington, Ind), Excluder (Gore Medical; Flagstaff,
Ariz), AFX (Endologix), Ovation Prime (TriVascular), and Endurant II (Medtronic). Orange arrow = bare metal stent of the supra-
renal fixation device, blue arrow = self-expanding metallic stent framework for outward radial force, gray arrow = graft material
that allows a new conduit for blood flow. (c) Limb extension and aortic cuff. Limb extensions and aortic cuffs extend the device
distally and proximally, respectively.

Figure 19. CT angiogram (left) and three-dimensional renderings (right) of an AAA repair demonstrate infrarenal fixation in this
patient with a sufficiently long aneurysmal neck. The stent-graft is positioned just below the renal arteries. Red arrows = renal artery,
black arrow = superior-most aspect of the stent-graft.

short aneurysmal neck, suprarenal fixation may is a theoretic increased risk of mesenteric isch-
also be used with circumferential thrombus or emia and renal dysfunction with this technique
calcification, severe angulation, and tapered or (27). Choke et al (27) reported that one patient
reverse-tapered neck configuration (26). There developed bowel ischemia out of 112 patients
RG • Volume 35 Number 2 Bryce et al 605

Figure 20. Suprarenal fixation in an AAA with a short aortic neck. (a) Three-dimensional rendering
(left) and CT angiogram (right) show an AAA with a 0.8-cm proximal aortic neck. Arrows = renal arteries,
arrowhead = proximal short aortic neck. (b) Three-dimensional renderings demonstrate suprarenal fixa-
tion. The junction between the stent-graft and the bare metal stent (white arrow) is placed just below the
renal arteries. The bare metal stent extends above the renal arteries (red arrows). The superior mesenteric
artery (green arrow) is seen to protrude through the bare metal stent.

who underwent suprarenal fixation. However, in
a study by Burke et al (28) of 95 patients, none
developed bowel ischemia. Moreover, a meta-
analysis (29) showed no definite medium-term
differences in renal function between patients
with infrarenal versus those with suprarenal de-
vice fixation.
A fenestrated stent-graft is another option in
patients with short aneurysmal neck anatomy.
For example, the Zenith Fenestrated device
(Cook Medical) has fenestrations and scallops
that accommodate aortic branches and poten-
tially can be used for a proximal neck length as
short as 4 mm. The chimney or snorkel technique
may also be used for juxtarenal aneursyms. The
chimney or snorkel technique involves parallel
graft placement into the renal arteries along-
side the main aortic endoprosthesis to maintain
flow to the covered branch vessels. With this
technique, a renal artery is accessed through a
brachial or axillary artery; a covered stent is de-
ployed, with the stent extending into the aorta
in a cranial direction. After the aortic stent-graft
components are deployed, dilation of the renal
conduit is performed simultaneously with the
aortic stent-graft by using “kissing balloons” to
preserve renal perfusion and attain an adequate
proximal aortic seal (30).
Distal Fixation
The landing zone for a stent-graft is usually the
common iliac arteries (Fig 21a). However, if
606 March-April 2015 radiographics.rsna.org

Figure 21. Fixation in the common iliac

arteries. (a) Three-dimensional rendering
from CT demonstrates a stent-graft with
fixation in the common iliac arteries (ar-
rows). (b) Three-dimensional rendering
from CT demonstrates a graft limb exten-
sion with fixation in the external iliac ar-
tery (arrow) with occlusion of the ipsilat-
eral internal iliac artery. The contralateral
internal iliac artery is patent.

Figure 22. Accessory renal artery, which complicates AAA repair. (a) CT angiogram demonstrates an accessory
renal artery (arrow) that markedly shortens the proximal aortic neck. (b) Angiogram obtained before emboliza-
tion shows the portion of the kidney perfused by the accessory renal artery.

there is a common iliac artery aneurysm or if
the common iliac artery is too short (less than
about 1.5 cm), the distal limb is extended past
the common iliac artery (Fig 21b). In such
cases, the internal iliac artery is occluded. As de-
scribed previously, if there is inadequate perfu-
sion to the pelvis from the contralateral internal
iliac artery, the patient is predisposed to pelvic
ischemia.
EVAR Technique
Preprocedural Imaging Technique
CT angiography is the method of choice for pre-
procedural planning of endovascular repair. The
imaging protocol should include an unenhanced
scan followed by a contrast-enhanced arterial
phase scan. The field of view should commence
above the celiac artery, include the aneurysm,
and end at the proximal thigh, where delivery
pathways for stent-graft hardware can be evalu-
ated. Imaging is easiest with a multidetector (16
or more detector rows) CT scanner that allows
thin sections in a reasonable breath-hold time.
Unenhanced images are used to evaluate arterial
wall calcification and to evaluate for possible in-
tramural hematoma in the acute setting (12).
Magnetic resonance (MR) imaging provides an
option for patients not able to receive iodinated
contrast material. T1-weighted three-dimensional
angiography provides the most information. In pa-
tients with poor renal function, unenhanced MR
imaging may be performed by utilizing a steady-
state free-precession sequence (12).
RG • Volume 35 Number 2 Bryce et al 607

Figure 23. Iliac artery occlusion, which complicates AAA repair. (a) Three-dimensional rendering from
CT shows a patent internal iliac artery (yellow arrow) that will be occluded by external iliac artery fixation.
Orange arrow = common iliac artery. (b) Three-dimensional rendering from CT in the same patient after
AAA repair with an external iliac limb extension (orange arrow). An embolization coil (yellow arrow) in the
internal iliac artery was placed before AAA repair. Black arrow = patent contralateral internal iliac artery.

Ancillary Procedures and suture-mediated arterial closure devices are

before AAA Stent-Graft Placement
Before AAA repair, certain interventions may be
warranted. An accessory renal artery (Fig 22)
that shortens the aortic neck and provides only a
small portion of vascularity to the kidney, a pat-
ent ipsilateral internal iliac artery with planned
external iliac artery fixation (Fig 23), or, as more
recently advocated at some institutions, a patent
inferior mesenteric artery may be embolized to
try to prevent a type 2 endoleak or retrograde
filling of the aneurysm sac (31,32). This may
be done on the day of or days before the AAA
repair. Moreover, if there is need to extend the
stent-graft into the external iliac artery because
of a common iliac artery aneurysm or a short
common iliac artery, or if an internal iliac artery
aneurysm necessitates occlusion, internal iliac ar-
tery embolization with coils and/or an Amplatzer
plug (AGA Medical, Plymouth, Minn) may be
done weeks before placement of the EVAR to
provide time for development of collaterals that
may mitigate pelvic ischemia (33).
Procedure
EVAR may be performed with general anes-
thesia—or possibly even with local or regional
anesthesia (4). A general approach is illustrated
in Figure 24. The common femoral artery is ac-
cessed in a retrograde fashion, traditionally by
surgical exposure via “cut-down” skin incisions
or, using a more recent technique, by percutane-
ous arterial puncture, where new smaller sheaths
used (4). The ipsilateral artery, by convention, is
the artery used to introduce the bifurcated main
body and attached limb of a modular device. The
contralateral artery is therefore used to introduce
the contralateral iliac limb. The optimal ipsilateral
artery is a larger-caliber artery, without substan-
tial stenosis, tortuosity, calcification, or thrombus
and with a satisfactory distal landing zone.
A full digital subtraction aortogram may
be used to confirm craniocaudal distance and
re-measure lengths; however, this view may be
omitted with good preoperative CT angiography
planning. Digital subtraction aortograms are lu-
minograms and often not a representation of the
aneurysm size, as the aneurysm may be partially
thrombosed. A measuring or calibrated pigtail
catheter is first introduced either in the contralat-
eral or in the ipsilateral artery and positioned just
distal to the subclavian artery in the proximal de-
scending thoracic aorta (Fig 24a). The ipsilateral
artery is used when it is necessary to confirm the
length of the ipsilateral stent-graft. A preliminary
digital subtraction arteriogram is acquired to doc-
ument the location of the renal arteries and ipsi-
lateral internal iliac artery to determine appropri-
ate main body device length (Fig 24b). A sheath
is then introduced over a stiff guidewire into the
ipsilateral artery for insertion of the main body of
the endoprosthesis. A “bareback” fixation proce-
dure may also be performed without the sheath,
such as with the Endurant device (Medtronic)
(4). A magnified or pseudomagnified angled or
608 March-April 2015 radiographics.rsna.org

Figure 24. Arteriograms depict the EVAR procedure. (a) A marking pigtail catheter is placed high enough to ensure opacification of
renal arteries in the arteriogram. In this case, the catheter was placed initially in the ipsilateral side. (b) Initial arteriogram is acquired
to locate the renal arteries and internal iliac arteries, in particular the ipsilateral artery. (c) Arteriogram obtained with undeployed
Excluder (Gore Medical) stent-graft just below renal arteries for infrarenal fixation. (d) Stent-graft is deployed just below the renal
arteries. (e) Contralateral sheath injected with contrast material to opacify the ipsilateral internal iliac artery. A marking pigtail catheter
is used to note the length between the gate and the internal iliac artery for contralateral limb placement. (f) Stiff wire is seen here
through the gate, after the gate was selected with a guidewire and angled catheter. (g) Arteriogram depicts a contralateral limb
stent-graft deployed and in a good location. (h) A balloon is used to dilate the superior aortic attachment. (i) Arteriogram after AAA
stent-graft placement shows patent renal arteries and internal and external iliac arteries and no endoleaks.

oblique view centered at the renal arteries im- anatomy with the goal of straightening the cranial-
mediately before main body device deployment caudal neck angle and optimizing visualization
is performed. The angle is determined by the of the renal artery orifices. With the help of the
RG • Volume 35 Number 2
magnification or pseudomagnification view at the
level of the renal arteries, the main body delivery
device is introduced over a stiff guidewire and po-
sitioned either for suprarenal or infrarenal fixation
(Fig 24c), with the fabric-covered portion just
distal to the lowest renal artery and the main body
carefully deployed to expose the contralateral gate
(Fig 24d). The stiff guidewire helps in straighten-
ing the aortic neck, aneurysm, or iliac artery in
the setting of severe tortuosity index or angle.
By using a sheath placed in the contralateral
femoral artery in a retrograde fashion, a guide-
wire and catheter are used to cannulate the gate,
the opening to the shorter contralateral limb,
which may be tedious and time consuming. A
pigtail catheter is usually then placed from the
ipsilateral side through the gate and either spun
within the main body or hooked over the flow
divider to confirm that the gate was successfully
cannulated (Fig 24e). An angiogram may be
obtained to determine the length of the contra-
lateral limb from the gate to the planned distal
attachment site before deployment of the graft.
The contralateral limb graft is then deployed
over a stiff guidewire (Fig 24f). When the graft
is deployed through the gate, there is a short
overlap between the main body and the contra-
lateral limb, depending on the device—usually
about 3 cm (Fig 24g). Optimal distal fixation is
1 cm proximal to the internal iliac artery (4). If
unfavorable anatomy precludes this, such as a
common iliac or external iliac artery aneurysm,
an iliac extension limb may be used in an overlap
fashion on both the ipsilateral and contralateral
sides. One “balloons” the points of overlap and
attachment sites (Fig 24h) using a compliant low-
pressure balloon either after deployment of each
component or at the conclusion of deployment of
all components, depending on the device used.
Intraprocedural angiography should be per-
formed to confirm the location, seal, and patency
of all graft components, to exclude endoleak, and
to assess the patency of renal arteries, mesenteric
arteries, and internal and external iliac arteries
(Fig 24i). Endoleak due to inadequate proximal
and distal fixation of the stent-graft (type 1) or
to device failure (type 3) should be corrected
immediately by overlapping the stent-graft with
another endoprosthesis piece. An aortic exten-
sion cuff may be used with modular bifurcated
graft devices if the proximal fixation is subopti-
mal. Moreover, narrowing or kinking of the graft
limbs, if present, should also be corrected im-
mediately with angioplasty or stent placement.
Last, if there is malposition of the stent resulting
in compromise of the renal artery or internal iliac
arteries, this may be corrected by placement of
an intravascular stent.
Bryce et al 609
There are variations to the described pro-
cedure for most available endoprostheses. The
Endologix device, however, has a deployment
method different from that described earlier. The
endoprosthesis rests on the native aortic bifurca-
tion and the device is built toward the infrarenal
or suprarenal fixation point. This endoprosthesis
is designed to preserve the anatomy at the aortic
bifurcation in a process called anatomic fixation.
Ballooning of the overlap and attachment sites is
not required because the graft, located outside
the metallic stent framework, quickly conforms to
the vessel wall.
In addition to the endovascular procedure,
surgical ancillary procedures may be performed,
including a cross-femoral bypass conduit to pro-
vide perfusion of the contralateral lower extrem-
ity in a patient with an aorto-uni-iliac stent-graft,
an internal iliac artery bypass in a patient at risk
for pelvic ischemia, endarterectomy in a patient
with severe atherosclerosis, and patch angioplasty
at a narrow arterial access site (4).
After the procedure, patients are usually hos-
pitalized for 3–5 days, most often in the intensive
care setting (34). A portion of this stay typically is
in a critical care setting.
Postprocedural Medical Therapy
Postoperative care includes medical management
and imaging. Antiplatelet therapy and statins are
usually routinely employed after AAA repair to
prevent graft-limb thrombosis and peripheral ar-
terial disease. In patients with existing peripheral
arterial disease, aspirin, clopidogrel, and statins
are usually prescribed (4).
Postprocedural Imaging Surveillance
Postprocedural surveillance is performed to detect
and characterize endoleak, to assess any change
in the caliber of the residual AAA sac; to note me-
chanical changes of the device such as migration,
kinking, or fracture; and to monitor the long-term
durability of the endoprosthesis (4).
CT is most often employed. A typical routine
for postprocedural surveillance is CT angiogra-
phy at 1 month, 6 months, and then yearly after
EVAR (35). The Society of Interventional Radiol-
ogy, Society for Vascular Surgery, European Soci-
ety for Vascular Surgery, and Cardiovascular and
Interventional Radiological Society of Europe
currently uniformly advocate lifelong imaging
surveillance (36). Surveillance with unenhanced
CT has been proposed after the initial post-
EVAR contrast-enhanced study (37). If the inter-
val volumetric change is 2% or less, surveillance
with unenhanced CT volumetric analysis can
be continued. However, if there is a volumetric
increase that exceeds 2%, contrast-enhanced CT
610 March-April 2015
should be performed immediately to evaluate for
an endoleak (37). In patients with renal failure,
unenhanced CT alone has been used.
The radiologist interpreting the postoperative
CT scan should analyze the stent-graft compo-
nents with multiplanar imaging to assess for sub-
tle migration. Linked side-by-side unenhanced,
arterial phase, and delayed contrast-enhanced
images should be carefully studied for the pres-
ence of subtle endoleak and to exclude calcifi-
cation within the sac mimicking an endoleak.
Measurement of sac volume is the optimal way
to monitor aneurysm sac size, instead of maxi-
mal sac diameter on a single axial image. It can
be difficult to distinguish type 2 from type 1 or
type 3 endoleak on CT images, and any increase
in sac size with a demonstrated endoleak should
prompt arteriographic imaging with an eye to-
ward concurrent treatment.
Contrast-enhanced MR imaging can be per-
formed with nitinol-based stents (35). Elgiloy
stents can obscure the lumen, and stainless-steel
stents can cause artifacts (35). Under optimal
conditions, MR angiography is at least as sensi-
tive as CT (38,39).
Complications of EVAR
Complications shared by both open repair and
EVAR include graft infection, pseudoaneurysm,
graft occlusion, and pelvic ischemia. Complica-
tions specific to or more commonly seen with
EVAR include limb thrombosis, endoleak, graft
migration, enlargement of the aneurysm sac, and
rupture (14).
Limb Thrombosis
Limb thrombosis may occur in as many as 5% of
patients (Fig 25) (40). Limb occlusion in the first
2 months is usually due to kinking in the hard-
ware of the unsupported stent-graft limb or ex-
tension of the small-diameter stent-graft into the
external iliac artery. Late occlusion may be due
to graft migration and dislocation of the stent-
graft components, which causes major turbulence
of hemodynamics and eventual thrombosis. This
can be addressed with thrombectomy, re-lining of
the stent-graft with another stent-graft, anti­co-
agulant therapy, or a surgical bypass graft (41).
Stent-Graft Migration
Researchers at the Cleveland Clinic (Cleveland,
Ohio) noted a 3.6% rate of device migration at
1 year (Fig 26) in 2003 (42). With more experi-
ence, planning, and device improvement, the rate
of this complication has improved. Stent-graft
migration takes place when there is inadequate
apposition of the stent-graft onto the arterial
wall, occurring either at initial placement or with
radiographics.rsna.org
Figure 25. CT angiogram demonstrates lack
of opacification of the thrombosed left limb
(arrow).
subsequent changes in aneurysm morphology.
Suboptimal anatomy or device selection predis-
poses patients to experience stent-graft migra-
tion. When a stent-graft migrates, endovascular or
open surgical revision is usually required.
Endoleaks
Endoleaks, the different types of which are de-
scribed individually later, are the most common
complication after EVAR (4). Researchers at
the Lifeline Foundation Registry for endografts
collected data from 1757 patients in the United
States and recorded a rate of 17% for endoleaks
(43). There are five types of endoleaks: Type 1
and type 3 endoleaks should be identified and
fixed during the procedure. Type 2 endoleaks
occur most commonly and are not immediately
detrimental.
Type 1 endoleak is a result of inadequate ap-
position between the stent-graft and native artery
at either the proximal or distal attachment site.
Therefore, the aneurysm sac is exposed to aortic
pressure and carries a high risk of rupture. This
endoleak is subdivided into type 1A, correspond-
ing to the proximal portion of the stent-graft (Fig
27a, 27d), and type 1B, corresponding to the dis-
tal portion of the stent-graft (Fig 27b, 27c).
Type 2 endoleak is the most common type,
occurring in about 20%–30% of patients and
persisting in 10%–15% of patients after 6 months
(44). These endoleaks occur when there is ret-
rograde flow of blood into the aneurysm sac
through branch vessels such as lumbar arteries
(Fig 28a, 28c) or a patent inferior mesenteric
artery (Fig 28a, 28b, 28d). These close spontane-
ously in about half of patients. Arteries contribut-
RG • Volume 35 Number 2 Bryce et al 611

Figure 26. Coronal (left) and axial (right) unenhanced CT images depict an endoprosthesis (arrows) dislodged
and floating within the aneurysm sac.

Figure 27. Type 1 endoleak. (a) Schematic diagram depicts type 1A and type 1B endoleaks. (b) Intraoperative
arteriogram obtained after stent-graft placement shows a type 1 endoleak emitting from the distal portion of
the graft. Arrow = blood opacifying the AAA sac. (c) Arteriogram demonstrates resolution of the type 1 endoleak
after an overlapping limb extension was placed on the right. (d) Coronal (left) and axial (right) CT angiograms
demonstrate opacified blood filling the aneurysm sac (black arrows) via the superior attachment site of the en-
doprosthesis. White arrows = top of stent-graft.

ing to a type 2 endoleak are often embolized with
coils or a liquid embolic agent (eg, ethylene–vinyl
alcohol copolymer [Onyx; Covidien, Plymouth,
Minn]) if they persist beyond 6 months, espe-
cially if the sac diameter increases or fails to
decrease as shown on follow-up images (43). For
example, as demonstrated in Figure 28d, a patent
inferior mesenteric artery supplying the aneu-
rysm sac can be accessed through the superior
mesenteric artery and marginal artery. If there is
612 March-April 2015 radiographics.rsna.org

Figure 28. Type 2 endoleak. (a) Schematic diagram depicts two varieties of type 2 endoleak, one with reversal of flow through a
lumbar artery and another through a patent inferior mesenteric artery (IMA). (b) CT angiogram demonstrates a type 2 endoleak (ar-
rowhead) closely related to a patent inferior mesenteric artery. (c) CT angiogram shows a type 2 endoleak (arrowhead) from lumbar
arteries. (d) Aortograms show a patent inferior mesenteric artery (black arrow) supplying the aneurysm sac, which was embolized
with coils (blue arrow).

Figure 29. Type 3 endoleak. (a) Schematic diagram depicts a type 3 endoleak. (b) CT
angiograms show an abnormal collection and stranding surrounding the aneurysm sac,
consistent with rupture. Extravasation of contrast material (arrows) from a limb of the
endograft is seen, which is consistent with a type 3 endoleak and which resulted in sac
rupture. (c) Aortogram obtained with limb cannulation shows extravasation of contrast
material when the culprit limb is cannulated.
RG • Volume 35 Number 2
Table 2: Predictors of Aneurysm Sac Growth after EVAR
Predictor Value
Patient age (y) >80
Proximal neck diameter (mm) 28–32 or >32
Proximal neck angle (degrees) <120
Iliac artery Only one > 20 mm
Follow-up Endoleak
Source.—Reference 44.
Note.—Table demonstrates statistically significant predictors of aneu-
rysm sac growth after EVAR.
difficulty cannulating the artery, a liquid embolic
agent may be injected directly into the aneurysm
sac under CT or fluoroscopic guidance.
Type 3 endoleak occurs through the body of the
stent-graft because of a tear in the graft or inad-
equate apposition or separation of the components
of the stent-graft (Fig 29). These endoleaks simi-
larly expose the aneurysm sac to arterial pressure
and must be addressed, usually by re-lining the
stent-graft with a new stent-graft component.
Type 4 endoleak is caused by too many pores
in the graft. These endoleaks occur intraprocedur-
ally and are transient, usually resolving after with-
drawal of anticoagulation therapy (Fig 30). With
newer devices, this is no longer a prominent issue.
Type 5 describes an endoleak with no demon-
strated cause and is also known as endotension. It
is a diagnosis of exclusion.
Sac Enlargement and Rupture
Schanzer et al (44) found certain factors to be
predictive of sac enlargement. These factors
include patient age older than 80 years, proximal
neck diameter of 28–32 mm, proximal neck di-
ameter greater than 32 mm, proximal neck angle
Bryce et al 613
Figure 30. Type 4 endoleak. (a) Sche-
matic diagram depicts a type 4 endoleak.
(b) Aortogram demonstrates slight opaci-
fication of the aneurysm sac (arrow) from
a type 4 endoleak.
smaller than 120°, only one common iliac artery
with a diameter greater than 20 mm, and endo­
leaks present at follow-up (Table 2) (45).
Sac enlargement leads to sac rupture (Fig 29b).
The EUROSTAR registry data demonstrated an
aneurysm rupture rate of 0.4% at 1 year, 2.5% at
2 years, and 3.3% at 4 years (46). May et al (47)
reported a rupture rate of 2.3% by 17 months.
Radiation Safety
One final drawback to the EVAR procedure is
radiation exposure. Radiation exposure during
the procedure is influenced by patient size and
technique, such as fluoroscopy time, distance
of the x-ray tube to the skin surface, x-ray unit
used, size of the radiation field, normal- versus
high-dose continuous dose rate, use of pulse fluo-
roscopy, and beam attenuation between the tube
and skin surface (48). Badger and colleagues (48)
saw a weak correlation between aneurysm size
and radiation dose as time was increased to can-
nulate the gate in larger aneurysms. Weerakkody
et al (49) demonstrated that radiation exposure
exceeded 2 Gy in 29% of EVAR patients, 2 Gy
being the threshold for deterministic skin effects
614 March-April 2015
(50). Perhaps more important, however, in addi-
tion to the dose acquired during the procedure
itself, patients undergo lifelong yearly follow-up
CT examinations, which increase the burden of
radiation exposure and have important stochas-
tic implications. Kalef-Ezra et al (47) calculated
that within the 1st year alone, a patient receives
an effective dose of about 62 mSv, which is 30
times higher than the dose received from annual
background radiation (48). By matching the age
distribution data of the study by Kalef-Ezra et al
with the excess lifetime mortality data from the
National Academy of Sciences, and thereby as-
suming a risk factor of 4% per sievert, the excess
mortality due to radiation-induced carcinogenesis
from the procedures carried out in the 1st year
was estimated to be one in about 400 (48). After
10 years, that number increases to one in about
155 (48). However, aneurysms tend to occur
in older patients, with a 10-year survival rate of
about 44% (51). Radiation exposure is some-
thing to keep in mind when dealing with younger
patients.
Good technique, including wearing proper
attire such as a lead apron, a thyroid shield, and
glasses; proper angulation of the tube such that
one stands on the side of image intensifier to
avoid scatter; the use of pulse mode; and decreas-
ing the radiation field, also decreases exposure to
the interventionalist and staff. Lipsitz et al (51)
reported an annual effective eye dose to an inter-
ventionalist of 2–7 mSv and effective hand dose
of 5–18 mSv. Ho and colleagues (52) reported
that a vascular specialist would have to perform
2500 EVARs to exceed the 50 mSv/y limit rec-
ommended by the International Committee on
Radiation Protection.
Conclusion
EVAR is a procedure that has revolutionized
AAA repair, making intervention safer in high-
surgical-risk patients. Knowledge of the individ-
ual’s vascular anatomy, appropriate technique,
follow-up care, and potential complications is
essential for the success of EVAR, not only for
physicians performing the procedure, but also
for those interpreting pre- and postprocedural
imaging studies.
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