ARTERIAL DILATIVE

EVAR COOK ZENITH FLEX

Introduction

Last updated: apr 5, 2023

Over the past 20 years the availability of aortic stent-grafts has allowed a major step change in the management of abdominal aortic aneurysms (AAA). Prior to this open surgical resection, first described by Charles Dubost in 1950, was the mainstay of AAA management. For elective cases open surgical repair has now largely been superseded by the deployment of a covered stent (stent-graft) through minimal surgical access in the common femoral arteries. Over the past few years there have been significant developments in stent-graft technology and an improved understanding of how best to utilise stent-grafts when treating aortic disease. Despite this, their role in the management of a patient with an AAA is still, at times, debatable.

Diameter

Rupture risk (%)

< 4

0

4 - 5

0,5 - 5

5 - 6

3 - 15

6 - 7

10 - 20

7 - 8

20 - 30

> 8

30 - 50
 

Indications

  • Patients with abdominal aortic or aortoiliac aneurysms having morphology suitable for endovascular repair
  • Adequate femoral/iliac access compatible with the required introduction systems
  • Distal fixation site > 10 mm in length and 8–20 mm in diameter (measured outer wall to outer wall)
  • Angle < 45 degrees relative to the axis of the
  • suprarenal aorta
  • Angle < 60 degrees relative to the long axis of
  • the aneurysm
  • 18–32 mm (measured outer wall to outer wall)
  • ≥ 15 mm nonaneurysmal infrarenal neck
  • Patients with abdominal aortic or aortoiliac aneurysms having morphology suitable for endovascular repair

 

Contra indications

Absolute

  • Patients with abdominal aortic or aortoiliac aneurysms having morphology not suitable for endovascular repair
  • Patients with known sensitivities or allergies to nitinol, polyester, polypropylene, gold, PTFE, nylon, or urethane
  • Patients with a systemic infection who may be at increased risk of endovascular graft infection

Relative

 

Pre procedural

  • 2000 mg Kefzol
  • Check anticoagulation
  • Check allergies
  • Imaging and EVAR measurement on wall/monitor
  • Check ordered grafts tents
  • Intravenous line

 

Materials

Essentials

  • Chlorhexidine
  • Standard angiography set
  • Lidocaine 10 ml x 2
  • Bupivacaine 10 ml x 2
  • Contrast
  • Heparinized saline and flushing syringes
  • 6F Introducer x 2
  • 0.035" Terumo Stiff guidewire (260 cm)
  • 0.035" Compatible radiopaque tip 5 F angiographic pigtail catheter
  • 0.035" Lunderquist guidewire (260 cm) x 2
  • 20 ml syringe for integrated balloon inflation
  • Exchange catheters and shaped catheters for contralateral gate cannulation
  • Graftstent including all measured and ordered parts
  • Non-compliant balloons (for leg/limb overlap) Compliant aortic balloon
  • Manta 14F (up to 14F)
  • Manta 18F (15-20F)

Non-Essentials

 

Positioning the patient

  • Head first
  • Supine

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The procedure in steps

Preparation

  • TOP
  • Antibiotic prophylaxis
  • Imaging and EVAR measurements on monitor
  • Check prostheses
  • Patient positioning: Table cranially, left arm alongside the body, check peripheral pulses
  • Sterile draping according to protocol
  • Connect pressure line to syringe pump and flush
Access
  • Infiltration with Lidocaine and Bupivacaine
  • Ultrasound-guided puncture
  • Measure and record Manta size (format: x +1)
  • Insert 7F sheaths bilaterally
  • Main Body Side
  • Insert angiography catheter over a soft guidewire (Terumo) up to the aortic arch
  • Exchange soft guidewire for stiff guidewire (Lunderquist)
  • Mark guidewire length with a sticker on the table
  • Remove angiography catheter
  • Limb Side
  • Insert angiography catheter over a soft guidewire to the level of the renal artery origin
  • Remove soft guidewire, flush with heparinized saline, and connect to pump
  • Administer 5000 IU Heparin IV
Deployment of Main Body
  • Adjust C-arm to renal artery origin with correct inclination and rotation
  • Remove 7F sheath
  • Advance main body just above the renal arteries, orienting using the contralateral limb marker
  • If main is inserted via the right side, the long V limb should point left and be centered
  • If main is inserted via the left side, the V limb should be closer to the left boundary of the prosthesis
  • Perform angiography with syringe pump (20cc, 10cc/sec, 3 images/sec)
  • Position endograft and deploy first two struts
  • Align markers (by adjusting tube position)
  • Perform new angiography
  • Deploy until the limb is released
  • Release the top
  • Turn the lower (black) knob
  • Rotate the blue lever
Placement of Contralateral Limb
  • Withdraw angiography catheter to the aortic bifurcation
  • Engage contralateral limb
  • Insert stiff guidewire (Lunderquist)
  • Advance measurement catheter over guidewire
  • Adjust imaging for AII visualization
  • Perform blowback angiography on the limb side
  • Mark the upper border of the AII on the screen
  • Fluoroscopy
  • Measure limb length (from flow divider to screen marking, then use the longest working length of the limb)
  • Remove 7F sheath
  • Deploy contralateral limb
Placement of Ipsilateral Limb
  • Deploy the final stents of the ipsilateral limb (push-and-pull technique)
  • Release the limb
  • Turn the upper (gray) knob
  • Rotate the blue lever
  • Advance calibrated catheter over stiff guidewire
  • Adjust imaging for AII visualization
  • Perform blowback angiography at iliac bifurcation via sheath
  • Fill sheath with 7.5cc/7.5cc contrast and flush with saline
  • Mark iliac bifurcation
  • Fluoroscopy
  • Measure for limb placement (from flow divider to screen marking)
  • Deploy limb
Completion
  • Post-dilation
  • Balloon-expand the first covered stent of the main body and both limbs using stiff guidewires
  • Final angiography with syringe pump (20cc, 10cc/sec, 3 images/sec)
  • Aspirate sheaths using two empty 20cc syringes
  • Long fluoroscopic series to assess for endoleak
Closure
  • Achieve hemostasis with Manta closure devices bilaterally
  • SOP

My Image
 

Complications

Endoleaks

  • Occurrence: 8–45%
  • 40–67% managed conservatively
  • Aneurysm growth <5% is present in 1% of ruptures
  • Presence of two lumbar arteries at L3 or L4** or an IMA correlates with a higher risk of endoleak, with IMA posing a greater risk than lumbar arteries
  • IMA diameter >2 mm → 46–67% chance of endoleak
1 2

Sac regression

Sac regression is correlated to improved survival and a reduced rate of secondary interventions and EVAR-related complications. The prognostic significance of sac regression should be considered in surveillance strategies. Intensified surveillance should be applied in patients who fail to achieve sac regression following EVAR.

TLA Technique:

Embolization of the sac versus sac and branches shows no difference in outcomes.
3

Laser-Assisted Transgraft Embolization

Successful embolization was achieved with aneurysmal sac regression demonstrated on 1-year follow-up CT angiography.

Martini Pre-EVAR Embolization Criteria:

  • IMA ≥ 2.5 mm
  • IMA open AND one or more lumbar arteries ≥ 2 mm at origin
  • IMA open and an AAA of aorta AND AIC

  1. O'Connor, P. J., & Lookstein, R. A. (2015, September). Predictive factors for the development of type 2 endoleak following endovascular aneurysm repair. Seminars in interventional radiology. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540615/

  2. Aoki, A., Maruta, K., Hosaka, N., Omoto, T., Masuda, T., & Gokan, T. (2017, December 25). Evaluation and coil embolization of the aortic side branches for prevention of type II endoleak after endovascular repair of abdominal aortic aneurysm. Annals of vascular diseases. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835439/

  3. Yu, H., Al-Roubaie, M., Desai, H., Isaacson, A., & Burke, C. (2017). Comparison of type II endoleak embolizations: Embolization of Endoleak Nidus only versus embolization of endoleak nidus and branch vessels. Journal of Vascular and Interventional Radiology, 28(2). https://doi.org/10.1016/j.jvir.2016.12.1019

 

Post-op

  • 4 hours bedrest
  • 2000 mg Kefzol 8 and 16 h after the procedure

 

Follow-up

Pre-Discharge and Follow-Up Plan

  • Pre-discharge CTA (CT angiography)
  • 6-week follow-up with the operating surgeon, including a CTA, to be discussed in the vascular meeting
  • Annual follow-up CTA
Management of Endoleaks and Complications
  • Type 1 or 3 endoleak on first postoperative CTA → Refer to vascular meeting and plan reintervention
  • Type 2 endoleak without aneurysm growth → Conservative management
  • Type 2 endoleak with aneurysm growth (≥5 mm in 1 year) → Refer to vascular meeting and plan reintervention
  • Target vessel occlusion or stenosis → Refer to vascular meeting
Medication Check and Secondary Prevention
  • Verify if the patient is on antiplatelet therapy or anticoagulation and a statin
  • If not prescribed, initiate:
  • Clopidogrel 75 mg once daily
  • Atorvastatin 40 mg once daily

 

Report

TOP. AB profylaxe. Huiddesinfectie en steriel afdekken. Locale anesthesie met levobupivacaine 0,5% en lidocaine 1%. Beiderzijds echogeleide punctie AFC, meten voor Manta device, plaatsen 7Fr sheaths. 5000E Heparine.

Main Aan de zijde van de main body: angiografiecatheter over slappe voerdraad (Terumo) tot in aortaboog. Slappe voerdraad wisselen voor stijve voerdraad (Lunderqvist), lengte markeren met sticker op de tafel. Aan contralaterale zijde angiografiecatheter over slappe voerdraad tot niveau origo nierarteriën. Slappe voerdraad uit, flushen heparine-zout, aansluiten op de pomp. 7F sheeth verwijderen en mainbody (ZIMB-22-84) invoeren tot net boven de nierarterieen, Orientatie mbv. positie marker contralaterale pootje. Met spuitpomp angiografie. Endoprothese positioneren, en twee struts ontplooien, markers op een lijn brengen door buispositie aan te passen, en nieuwe angio. Ontplooien tot vrijkomen pootje. Release top door de onderste (zwarte) knop los te draaien, en daarna de blauwe hendel te roteren).

Plaatsen contralaterale prothesepoot. Terugtrekken angiografiecatheter tot op bifurcatie. Aanhaken pootje met controle door pigtail te roteren in de mainbody. Plaatsen stijve voerdraad (Lunderquist). Meetkatheter en Instellen voor afbeelding AII. Blowback angiografie en aftekenen bovengrens AII op scherm. Meten pootje (ZISL-9-59). Verwijderen 7F sheath enplaatsen pootje.

Plaatsen ipsilaterale prothesepoot. Ontplooien laatste stents ipsilaterale pootje. Release door de bovenste (grijze) knop te draaien en weer de blauwe hendel te roteren. Gecalibreerde catheter over stijve voerdraad. Instellen voor afbeelden AII. Blowback angiografie iliacale bifurcatie via sheath.Aftekenen iliacale bifurcatie. Meten voor de poot. Plaatsing poot ªZISL-9-59º.

Afronden. Over stijve voerdraden naballoneren eerste beklede stent body en beide pootjes geheel. Angiografie met spuitpomp (20cc, 10cc/sec, 3 beelden/sec) en aspiratie sheaths met twee lege 20 cc spuiten, lange serie ivm endoleak.Open nierarterieen en iliaca interna beiderzijds. Geen endoleak zichtbaar.

Afsluiten Hemostase met Manta device bdz. SOP

DISCLAIMER

The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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