ARTERIAL DILATIVE

EVAR GORE EXCLUDER

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 For elective cases open surgical repair has now largely been superseded by the deployment of a covered stent (stent-graft) through minimal surgical access in the common femoral arteries.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

 

The procedure in steps

Pre-Procedural Steps

  • Preparation
  • Time-Out Procedure (TOP)
  • Antibiotic prophylaxis
  • Imaging and EVAR measurements on monitor
  • Check prostheses
  • Patient positioning: Table moved 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)
  • Place 6F sheaths bilaterally
  • On the 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
  • On the 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 (1-2 magnifications)
  • Insert main body just above the renal arteries, using the marker position of the contralateral limb for orientation
  • Remove sheath
  • Advance prosthesis to just above renal artery level
  • Angiography with syringe pump (20cc, 10cc/sec, 3 images/sec)
  • Position and partially deploy endograft until limb is released
  • Angiography with syringe pump (20cc, 10cc/sec, 3 images/sec)
  • Reposition endograft if necessary
  • Deploy top endograft by turning the small wheel
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)
  • Remove sheath
  • Insert larger sheath
  • Deploy contralateral limb
Placement of Ipsilateral Limb
  • Deploy the final stents of the ipsilateral limb
  • Retrieve the top cap:
  • Advance device cranially while rotating counterclockwise
  • Then, screw down and remove the top cap
  • Insert large sheath
  • 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
  • Measure for limb placement
  • 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.

Via rechts inbrengen 260 cm Lunderquist via terumo/pigtail waarna inbrengen main body (ESBF-32-14-103). Via links inbrengen angiocatheter. Angiogram en aftekenen nierarteriën. Ontplooien mainbody tot en met contralaterale pootje, controle angiogram, ontplooien top-cap. Aanhaken contralaterale poot vanuit links, controle positie in de endograft door de pigtail te roteren. Inbrengen 260 cm Lunderquist via terumo/pigtail . Blow-back angiogram links en aftekenen AII. Inbrengen contralaterale poot (ETLW-16-16-156), ontplooien waarbij we landen in de AIC net boven de origo AII. Verwijderen delivery device en plaatsen 12Fr sheath.

Verder ontplooien main body tot en met de ipsilaterale poot, ophalen topcap en verwijderen delivery device. Inbrengen 16Fr sheath. Blowback angiogram en aftekenen AII rechts. Inbrengen en ontplooien ipsilaterale poot (ETLW-16-16-156) tot in de AIC net boven de origo AII.  Naballoneren.

Controle angiogram: fraaie positie endograft, geen endoleak. AII en nierarteriën bdz doorgankelijk.

Vervolgens op 4 posities fixatie van de hals met Aptus EndoAnchors.

Hemostase met Manta device bdz. SOP.

Conclusie: Uitschakeling AAA percutane EVAR.

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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