STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY

SINGLE CENTER EXPERIENCE

Dr Rajendra Kumar Premchand M.D., D.M,D.I.U.

Senior consultant Interventional cardiologist

Director, KIMS Hospitals,

Hyderabad, India

EVAR-Single Centre Experience

• Total cases-50

• Mean age -63

• 45 M: 5 F

• Risk factors- SM-15, DM-15, HTN-15, CKD-5

• Thoracic- 18, abdominal-19, thoraco-abdominal- 7, Dissection-4.

• Chimney- 5, hybrid -3, on table fenestration-3

Approach to Aortic Aneurysm

Case -1 Type B Dissection Acute -EVAR

• 52 yrs male

• HTN+, chronic smoker

• C/O- sudden onset chest pain and abdominal discomfort radiating to back.

• O/E- feeble pulses in both L/L.

• ECG- Sinus tachycardia

• Echo- Normal LV function

• CT Aortogram- Type B aortic dissection starting below LSCA and extending distally into B/L CIA, left EIA with thrombus.

Case -1 EVAR – Aortic dissection Type B

Pre - EVAR Post - EVAR

Medtronic 36 mm stent graft x 2

Case 2-Hybrid EVAR to Acute Aortic dissection Type B

• 52 yrs male

• HTN+, Chronic smoker

• S/O chest pain radiating to back associated with worsening dyspnea

• CXR- widened mediastinum

• Echo- Good LV function

• CT Angiogram- Type B aortic dissection with DTA aneurysm and mildly dilated aortic root

Type B Aortic aneurysm LCCA / LSCA arising from aneurysm

Case 2-Hybrid EVAR to Acute Aortic dissection Type B STRATEGY Bypass graft to Rt Carotid & LSCA from LT Carotid artery

f/b EVAR

COOK 36 MM COVERED STENT

CASE 3 - Hybrid aortic arch debranching

• 69 yrs old male

• Chronic smoker (30 pack years)

• Non-diabetic , Non hypertensive

• Being worked up for Squamous cell carcinoma tongue

• Incidentally diagnosed to have Thoracic aortic aneurysm

CASE 3 - Hybrid aortic arch debranching

STRATEGY

Case -4 EVAR with on table Fenestration +

stent to LSCA

• 82 yrs male

• Hypertensive, dyslipidaemic & non diabetic

• S/P CABG (1996) x 3 (LIMA LAD, SVGRamus & PLB)

• DOE class II-III and chest pain (atypical)

• CXR- wide mediastinum s/o Thoracic AA

• CT scan- 4.2 x 5.1 Saccular aneurysm in arch/isthmus after the origin of LSCA with mural thrombus and burrowing in lung parenchyma.

Case -4 EVAR with on table Fenestration +

stent to LSCA

ZENITH TZ2 36 X 77 mm , LSCA- 8 X 38 mm Advanta V12

Case -5 Multilayer Flow Modulator device for

Thoracoabdominal aneurysm Case history

• 54yr male

• HTN , HLP,Non-DM.

• Severe back pain -6 days.

• On evaluation USG abd showed aortic aneurysm.

• CT aortogram - aneurysm of distal descending thoracic

and upper abdominal measuring 5.5*29 mm (fusiform )

with mural thrombus along posterior and lateral walls

with celiac artery stenosis.

Case -5 Multilayer Flow Modulator device for

Thoracoabdominal aneurysm

• Issues:

Aneurysm involving major

branches:

– Hypogastric artery

– celiac artery

– Superior mesenteric

artery

– Renal arteries.

Case -5 Multilayer Flow Modulator device for

Thoracoabdominal aneurysm

Prerequisite - side

branch stenosis should

not be >50%. Celiac

artery stenting

(hippocampus renal

stent) via LBA

MFM

(28*180)

deployed

slowly ~ 15

min

MFM - Principle

• Eliminates erratic flow vortices by redirecting the flow into laminar flow.

• Patency of side branches- The side branches act as a vacuum, augmenting

the lamination which results in shrinkage of the aneurysm and increased

side branch flow.

• Rapid endothelialization makes it quickly embedded within the aortic

wall.

• The effect of peak wall stress is grossly diminished.

Treat aneurysm rather than

excluding it.

Case -6 EVAR to Thoracic aneurysm presenting as

Hoarseness of voice

• 62 yrs male

• HTN+, DMII, Chronic smoker

• C/O Hoarseness of voice since 10 months

• Referred from ENT b/s of abnormal CXR and diagnosed to have Lt RLN palsy.

• CT Chest- 4.2 x 5.5 saccular thoracic aneurysm with diffuse atherosclerosis.

Case -6 EVAR to Thoracic aneurysm presenting as

Hoarseness of voice

VALIANT 32 X 32 X 100mm

Pre - EVAR Post - EVAR

Case -7 Hypertensive emergency with leaking

AAA

• 57 yrs old male

• Chronic smoker (38 pack years), hypertensive

• Presented with abdominal discomfort in gastroenterology department

• USG abdomen- 4 x 3.8 cm saccular abdominal

aortic aneurysm with eccentric thrombus.

• CECT abdomen – 5.2 x 5.8 saccular abdominal aneurysm with eccentric mural thrombus.

Case -7 Hypertensive emergency with leaking

AAA

Case -8 Infrarenal AAA extending into B/L CIA

• 60yr, Doctor By Occupation Non- HTN, Non DM

• Post CABG- 15 yrs back., continues to smoke.

• Epigastric symptoms , back ache-

• On evaluation-

– USG ABD – Infra Renal AAA

– CT angio- Infra renal AAA (8.6mm diameter)

• Diagnosis- symptomatic infra renal AAA and

aneurysm of bilateral CIA

Case -8 Infrarenal AAA extending into B/L CIA

Main body (cook 24*96)deployed

across the aneurysm infrarenally

Two Lt sided Extension

limbs

24*56

12*73

24*73

Deployment of Rt & Lt extension limbs

Case -8 Infrarenal AAA extending into B/L CIA

Case -9 Traumatic Aortic Laceration

• 68 years, male

• H/O RTA

• Traumatic aortic laceration

with leak into pleural cavity

• Lung contusion with hemothorax

• Cerebral contusion SAH

STRATEGY Emergency EVAR

Case -9 Traumatic Aortic Laceration

Pre - EVAR Post - EVAR

• After stent graft- ICD placed for hemothorax • Conservative management of SAH • Recovered sensorium over 3 days

Valiant thoracic stent graft 36-36 C 150TE

Post - EVAR

Case -10 Sub Acute Type B Aortic dissection with SMA Occlusion

• 45 yrs male

• HTN+, Chronic smoker

• C/O- Acute onset tearing type of abdominal pain radiating to back and chest associated with malena 3-4 episodes.

• O/E- Pulse 116/min , feeble in B/L L/L ; BP- (RUL) 190/114 mmhg and 70 systolic in B/L L/L

• ECG- Sinus tachycardia

• CT Angio- Dissection flap starting just below LSCA & extending upto Rt EIA and Lt CFA; SMA Total occlusion seen

Case -10 Acute Type B Aortic dissection with SMA Occlusion

STRATEGY Emergency EVAR + SMA Stenting

SMA Stented with 8 x 80 mm Luminex Bard stent 32 x 200 mm COOK stent graft in DTA

• 1 year follow up- Patient asymptomatic • CT Angio – DTA stent graft and SMA stent patent

Troubleshooting complications :

Complications

• Paraparesis- 4

• Renal failure- 2

• Endovascular leak-1

• brachial artery complications- 2

• Common iliac rupture -2

• Death during procedure-1

• During hospital stay-1

• Death at 30 days-2.

Post dilation of the stent grafts with CODA balloon (10-35)

Flaring of struts due to excessive dilatation

Patient developed hypotension (SBP- fell from140 to 90 mm Hg)

STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR

• Check aortogram showing rupture of Rt CIA.

• CODA Balloon inflation to decrease the blood loss by

occluding the stent graft

Balloon inflation in RT extension limb

Balloon inflation in Main stem infrarenally to work on Rt CIA

Strategy ? Surgery ?covered stent ?? How to prevent endoleak

10:42 PM

STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR

10:40 PM

Internal iliac artery selectively engaged with Diagnostic JR & 7 Coils deployed – [(8-10)*1,(3-4)*2,(5-8)*4]

10:45 PM

Rt Int Iliac

Deployment of another Rt sided Extension limb

Final Angio- No leak & well contained aneurysm

STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR

• The sheath which was oversized to EIA diameter (6mm) led to the avulsion of the Right common iliac artery and Rt external iliac artery .

• POBA was done and 2 stents were deployed across the lesion till the femoral head but flow could not be restored.

• Hence PTFE graft was done anatomizing Right CIA and RT Common femoral artery after ligating the internal iliac artery.

• Pt developed retroperitoneal leak due to peri PTFE graft oozing induced by overzealous heparin usage , managed conservatively.

The approximate size of

peripheral access artery

should be atleast 8mm to

prevent avulsion of arteries.

Avulsion of Right CIA and Right EIA

Avulsion of LT CIA Covered with another stent

Avulsion of Left common Iliac Artery

Conclusions

• Anatomical challeges-

small arteries, calcification( No Data to support)

• Most of the procedures- Out of pocket expense

• Not uniformly remursable

• DCGI- challenges in approving new devices

• Only few Centres are doing these procedures

• Intervenitonal cardiologist/radiologist/Vascular surgeon/ CT surgeon.

STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY

Dr Rajendra Kumar Premchand M.D., D.M,D.I.U.

Senior consultant & Interventional cardiologist

Director, KIMS Hospitals,

Hyderabad, India