Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR...
Transcript of Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR...
![Page 1: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/1.jpg)
Anatomical challenges in
EVAR
M.H. EL DESSOKI, MD,FRCS PROFESSOR OF VASCULAR SURGERY
CAIRO UNIVERSITY
![Page 2: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/2.jpg)
Disclosure
Speaker name:
.................................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
![Page 3: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/3.jpg)
– Proximal landing zone issues 64%
– Distal landing zone issues – Access issues
Unsuitability for EVAR
Schanzer A, et al.. Circulation. 2011
![Page 4: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/4.jpg)
Hostile Proximal Landing Zone
• Neck length </=10 mm • Focal bulge in the neck >3 mm • More than 2-mm reverse taper within 1 cm below the
renal arteries • Neck thrombus > or =50% of circumference • Neck wall calcification >50% of circumference • Angulation > or =60 degrees within 3 cm below renal
arteries.
Ionel Droc, Dieter Raithel and Blanca Calinescu. Abdominal Aortic Aneurysms - Actual Therapeutic Strategies. Yasuo Murai, ISBN 978-953-51-0730-9, Published: August 29, 2012
![Page 5: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/5.jpg)
Neck Angulations
Angle between the suprarenal aorta and the neck (>45°& <60°)
Angle between the neck and aneurysm angle (>60° and <75°)
L1 Length of the non-
aneurysmal aortic neck (distance between D1a and D1b) > 1.5 cm
β L1
D1a
D1b α
![Page 6: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/6.jpg)
Hostile Neck
• Hostile neck can result in:
– Inadequate seal (Proximal type I endoleak) – Distal migration
![Page 7: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/7.jpg)
Management Of Type IA Endoleak
• Active intervention – Ballooning – Palmaz Stent – Endoanchoring – Extension – Wrapping – Embolization
• Conservative (*)
(*) F. B. Gonçalves et al. Spontaneous Delayed Sealing in Selected Patients with a Primary Type-Ia endoleak After Endovascular Aneurysm Repair. European Journal of Vascular and Endovascular Surgery. Volume 48, Issue 1, July 2014, Pages 53–59
![Page 8: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/8.jpg)
Palmaz Stent Advantages • Simple technique • Fast implantation • Less expensive • Short learning curve • Suprarenal fixation
Disadvantages • Dilatation <28mm • Fixed diameter • No active fixation
![Page 9: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/9.jpg)
Endoanchoring• Aneurysm Treatment
Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) study
– 2-year period, 319
patients were enrolled at 43 sites
– first-time EVAR (primary
arm, 242 patients) vs those with proximal neck complications remote from the time of an initial EVAR
![Page 10: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/10.jpg)
6.7%
20%
![Page 11: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/11.jpg)
Sac EmbolizationOnyx® is a liquid embolic
agent that allows for: A slow controlled injection and
delivery method. The ability to stop and start the
injection. Excellent visibility. Control angiography during
embolic injection.
![Page 12: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/12.jpg)
![Page 13: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/13.jpg)
Stent Migration
• Migration is defined as a distance increase greater than 5 mm between distal renal and top end of the graft during the follow-up period (*)
• Factors that can lead to migration
– Type of fixation – Initial proximal fixation length – Dilation and elongation of the infrarenal aortic neck – Poor iliac fixation (**)
(*) Litwinski RA1, Donayre CE, Chow SL, Song TK, Kopchok G, Walot I, White RA.The role of aortic neck dilation and elongation in the etiology of stent graft migration after endovascular abdominal aortic aneurysm repair with a passive fixation device.J Vasc Surg. 2006 Dec;44(6):1176-81. (**) E.J. Waasdorp et al. The Association between Iliac Fixation and Proximal Stent-graft Migration during EVAR Follow-up: Mid-term Results of 154 Talent Devices. Eur J Vasc Endovasc Surg (2009) 37, 681-687
![Page 14: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/14.jpg)
Aburahma AF et al, J Vasc 2011
![Page 15: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/15.jpg)
![Page 16: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/16.jpg)
European Journal of Vascular and Endovascular Surgery Volume 46 Issue 1 July/2013
“Mid-term outcomes are comparable with those achieved in patients with standard suitable anatomy using the same devices” “Mandatory continued follow-up is needed to justify aggressive use of standard EVAR outside the IFU during EVAR”
![Page 17: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/17.jpg)
Unsuitability for EVAR
– Proximal landing zone issues 64%
– Distal landing zone issues
– Access issues
Schanzer A, et al.. Circulation. 2011
![Page 18: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/18.jpg)
Distal Landing Zone
• Measurements – Length 15 mm – Diameter >7 mm and < 22 mm
• Problems in Landing Zone – Tortuous – aneurysmal iliac arteries – Diseased or stenosed vessels
• Effect – Endoleak – Limb occlusion
![Page 19: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/19.jpg)
Endoleak
• What to do? – Extension +/- embolization of IIA – Branched Iliac Graft Or Sandwich
Technique.
![Page 20: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/20.jpg)
Extension +/- embolization of IIA
![Page 21: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/21.jpg)
Branched Iliac Graft Or Sandwich Technique
![Page 22: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/22.jpg)
Limb Occlusion • Endograft limb thrombosis occurs in 4% • Predictors of limb thrombosis
– significant angulation (>60%) – Calcification (>50%) – Excessive limb oversizing (>15%)
• Precautions – Use within IFU – Completion angiography without any wires inside
• Management – Thrombectomy + stenting – Fem-Fem bypass G.K. Mantas, C.N. Antonopoulos, G.S. Sfyroeras, K.G. Moulakakis, J.D. Kakisis, S.N. Mylonas, C.D. Liapis. Factors
Predisposing to Endograft Limb Occlusion after Endovascular Aortic Repair. Eur J Vasc Endovasc Surg (2015) 49, 39-44
![Page 23: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/23.jpg)
Unsuitability for EVAR
– Proximal landing zone issues 64%
– Distal landing zone issues
– Access issues
Schanzer A, et al.. Circulation. 2011
![Page 24: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/24.jpg)
Avoid Potential Iliac Rupture
![Page 25: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/25.jpg)
Difficult Insertion
• Device main body delivery system range 18-20 Fr (~6-7 mm)
Hydrophilic coating on delivery system facilitates delivery
Use largest iliac vessel as main body access site in most instances Serial Dilation
PTA
Conduits
![Page 26: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/26.jpg)
Serial Dilation • Gradually increase vessel size by passing serial dilators
through the artery
• Dilators come in a set with 2 Fr increments Up to 26 Fr
![Page 27: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/27.jpg)
PTA
7 mm PTA Balloon
PTA of Access Iliac Artery Stenosis
![Page 28: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/28.jpg)
Conduits • Iliac conduits: 10 mm Dacron graft
10 mm Dacron graft
![Page 29: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/29.jpg)
Endovascular • Bare metal stent sutured to front edge of prosthetic graft
and loaded into delivery sheath
• Endoluminal conduit deployed so that bare metal stent lies across the internal iliac artery origin and prosthetic graft extends through diseased external artery
• Non-compliant balloon used for angioplasty within prosthetic graft
• After procedure, end of prosthetic graft sewn to external iliac or endoluminal anastomosed with common femoral artery
![Page 30: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/30.jpg)
Take Home Message Insufficient high-level evidence for or against performing standard EVAR in patients with hostile neck anatomy exists.
Prophylactic endoanchoring is better when in doubt
Low profile +/- Predilating BUT not stenting
Refer to open repair if fit
![Page 31: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/31.jpg)
THANK YOU
Prof. Mohamed Hosni
![Page 32: Anatomical challenges in EVAR · Eur J Vasc Endovasc Surg (2015) 49, 39-44 . Unsuitability for EVAR – Proximal landing zone issues 64% – Distal landing zone issues –Access issues](https://reader035.fdocuments.in/reader035/viewer/2022070113/605f282a0469a1434626bf0a/html5/thumbnails/32.jpg)
THANK YOU
Prof. Mohamed Hosni