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How to do Aortic Intervention

: Tips and Tricks


Veera Suwnaruangsri, MD.
Pruesttipong Kaviros, MD.
Maharat Nakhon Ratchasima Hospital
Instruction for Use = IFU
(Endurant stent graft)

• Neck length 10-15mm ; infrarenal angulation <60˚


• Neck length >15mm ; infrarenal angulation 60-75˚
• Distal fixation length ≥ 15mm
• Aortic diameter 19-32mm
• Aortic bifurcation ≥ 20mm
• Common iliac artery diameter 8-25mm
• 60-70% of AAA can be performed standard EVAR
Standard EVAR(IFU)
How to advance the main-body ?
How to advance the main-body ?
How to advance the wire
into the contralateral gate ??

• Contralateral retrograde access


• Up and over technique
• Brachial access
How to advance the wire into the
contralateral gate ??
How to advance the wire into the
contralateral gate ??
Difficult Anatomy and Out of IFU

• Angulated neck
• Reverse conical neck
• Short neck
• Aortic mural thrombus
• Narrow aortic bifurcation
• Severe tortuosity of iliac artery
• Thoracoabdominal aortic aneurysm (TAAA)
Difficult cases : Out of IFU
 Technical success was achieved in all cases.
 Similar mortality, morbidity, technical success, clinical
success, complications, and reinterventions rates.
 Estimated 1-year freedom from type I endoleak was
100% in the IFU group vs 93.3% in the OL patients
(P=0.01) @ 1 year.

J Vasc Surg 2011;54:300-6


 Similar outcome in challenging neck and in favorable
neck.
 No postoperative or 30-day type I endoleak.
 The duration of procedures, intraoperative contrast
use and radiation exposure time were similar in both
groups.

Eur J Vasc Endovas Surg 2012;44:274-279


 Technical success was achieved in 97% and 100% of
the patients with hostile and friendly anatomy : No
significant
 30-day mortality : 2% in both group.
 30-day morbidity : 15% and 7%
 Early type I endoleak occurred in 2% and 1%

J Vasc Surg 2013;57:527-38


 type I endoleak at 1 year : 10% and 1%
 device-related reintervention at 1 year : 5% in both
groups.
 Aneurysm-related mortality at 1 year : 4% and 0%

J Vasc Surg 2013;57:527-38


Angulated neck

• Type I-a endoleak


• Difficult to remove the device
• ??? Accuracy of deployment
• Renal artery coverage
• Need for aortic extension with aortic cuff
Advance to wire into renal artery
Inflated balloon for changing the neck angle
Brachial-femoral through and through wire
Brachial-femoral through and through wire
Partial coverage renal artery with
renal stenting (bare BES)
Partial coverage renal artery with
renal stenting (bare BES)
Reverse conical neck
(>2-4mm in 10mm)
Oversize 10-20% of max. diameter
 The Endurant stent-graft can be utilized with
acceptable results in more challenging neck
anatomies, such as those with a reverse taper, as long
as there is adequate oversizing of the stent-graft.

J Endovase Ther. 2013;20:514-522


Short neck
(<10mm)
Short neck
: Open repair
: Hybrid repair
( bypass, banding aortic neck )
: Fenestrated EVAR
: Chimney EVAR
: Sandwich technique
: Periscope technique
Fenestrated EVAR

Customized f-stent graft , take time 6-8 wk


Fenestrated EVAR
• f-EVAR is a good technique but the limitations are

: time consuming ( 6-8 wk )


: down-going renal artery
: angulation > 45 °
: small and tortious iliac artery
: severe iliac occlusive disease
Chimney EVAR Periscope technique
Chimney EVAR

• Emergency or urgency condition


ruptured AAA, symptomatic AAA, large AAA >
7cm(6cm)
• High surgical risk for open repair
Anatomy should be considered for
ch-EVAR are:

• short neck < 10mm


• short with angulated neck
• reverse tapering neck
• proximal para-anastomotic aneurysm
(previous open repair)
• juxtarenal or suprarenal aortic aneurysm
(degenerative,infected aneurysm)
Anatomy should be considered for
ch-EVAR are:

• thoracoabdominal aneurysm
• persistent type Ιa endoleak (previous standard
EVAR)
• aortoenteric fistula
• adequate distal landing zone
How to select the chimney graft?

1.Covered balloon expandable stent


: high radial force
: kingking
2.Covered self expanding stent
: less vessel trauma
: more flexibility
: less radial force
: stent collapse, occlusion
3.Composite stent
: covered BES with bare-SES
:covered SES with bare-BES
Limitations of ch-EVAR
• Multiple ch-grafts >2: more chimney grafts, more
gutters and more chance of
: type Ιa endoleak
: aortic occlusion
• Kinking or compression
: stenosis or occlusion
• Up-going renal artery : difficult to advance the wire
: periscope technique
Risk factors of type Ιa endoleak in
chimney EVAR
: Short gutter < 15mm. (The longer the length of the gutter,
the greater the chance for spontaneous thrombosis of the flow channel.)
: High blood pressure
: Antithrombotic therapy(Clopidogel and aspirin)
: Severe calcified neck : poor conformation
between calcified aorta and aortic stent graft
How to perform ch-EVAR?

• A covered stent is deployed parallel to the main


aortic stent graft
• Brachial or axillary access
• Oversize 20-30% : more than standard EVAR
• Neck length 15-20mm
• Kissing balloon
• Clopidogel and aspirin for 6 mo.
Chimney-EVAR (Rt. Renal a.)
Chimney-EVAR(SMA & Lt. renal a.)
Chimney&Periscope-EVAR
3 chimney-EVAR
Sandwich technique
Gutter: peri-graft channels

More chimney grafts, more gutters and more chance of type Ia endoleak
Sandwich technique
Aortic mural thrombus
(>50%)
Balloon dilatation
(neck)
Narrow aortic bifurcation
The problems of narrow aortic
bifurcation and narrow aorta ??
• Arterial dissection and disruption
• Stent graft compression and collapse
• Iliac limb occlusion
• Difficult to advance the wire into the contralateral
gate

** Current recommendations : 20 mm at the aortic


bifurcation.
J Vas Surg2015;62:1140-7
Three options

• Open repair
• Aortouniiliac stent graft (AUI)
• Bifurcated stent graft
(off-label technique)
• 231 AUI-EVAR patients
• Patency@3 yr : 91%
• Patency@5 yr : 83%
• Wound complications : 11%
(groin hematoma4%, seroma3%, superficial wound
infection3%)
• Fem-fem bypass graft occlusion : 4%

J Vas Surg2003;38:498-503
• Aortic bifurcation diameter < 18mm
• Early mortality rate =1.8% , morbidity rate =11%
• Bifurcated stent grafts(106) : diameter : 16±3mm
• Stent graft primary patency@1,5 yr : 99%, 96%

• Aortouniiliac stent grafts : diameter : 14±2mm


• Stent graft primary patency@1,5 yr : 100%,83%

J Vas Surg2015;62:1140-7
A B C

Up and over
technique

J Vas Surg2015;62:1140-7
Narrow aortic bifurcation
Kissing balloon and bare BES
Kissing balloon and bare BES
AAA with AIOD
PTA and partially deployed MB
Iliac limb compression; kissing balloon
Iliac limb compression; kissing bare BES
Severe tortuosity of iliac artery

• Iliac limb kinging


• Iliac limb occlusion
• Difficult to advance the sheath , stiff wire
• Risk of ruptured iliac artery
Severe tortuosity of iliac artery
: stenting with bare-SES
Severe tortuosity of iliac artery
: stenting with bare-SES
Severe tortuosity of iliac artery
: stenting with bare-SES
Combination of Viabahn and Endurant
Combination of Viabahn and Endurant
Brachial-femoral through and through wire
Thoracoabdominal
aortic aneurysm
(TAAA)
Thoracoabdominal aortic aneurysm(TAAA)

• Open repair
• Hybrid repair
• Totally endovascular repair
o T-branch
o Sandwich technique
Review of the literature
• Operative mortality and morbidity of standard open repair for
TAAA have improved significantly at selected centers, but the
overall national data of mortality rate approaching 20%.

• The hybrid repair for TAAA offers an alternative technique as it


avoids a thoracotomy, high aortic cross clamping, single lung
ventilation, and prolong visceral and renal ischemia.

• The performance of the procedure under stable hemodynamic


conditions reduces the risk of paraplegia or paraparesis.
• The meta-analysis for 30-day/in-hospital mortality
rate was 14.3%
• mean follow-up period : 34.2 months.
• SCI : 7% , irreversible paraplegia : 4.4%
• Endoleak : 21.1%.
• Respiratory complication : 7.8%
• Cardiac complications : 4.6%.
Ann Cardiothorac Surg 2012
Hybrid repair : TAAA
CHA
Right common iliac artery-to-
Rt renal a. right renal artery-to-common
hepatic artery bypass

PTFE, 8mm

Rt CIA
Left common iliac artery-to-
left renal artery-to-SMA
bypass
No endoleak
CHA
Lt renal a.

Rt renal a. SMA

SMA
• CTA at one month
showed
• no endoleak
• no bypass grafts
occlusion
• dissection of right
external iliac artery.
• The patient denied for
iliac stenting. dissection
Sandwich tech : TAAA
Sandwich tech : TAAA
Thank you for your attention

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