ARTERIAL DILATIVE
EVAR JOTEC E TEGRA
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 For elective cases open surgical repair has now largely been superseded by the deployment of a covered stent (stent-graft) through minimal surgical access in the common femoral arteries.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.
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
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
The procedure in steps
Preparation
- Time-Out Procedure (TOP)
- Antibiotic prophylaxis
- Access
- Skin disinfection and sterile draping
- Local anesthesia: Levobupivacaine 0.5% + Lidocaine 1%
- Ultrasound-guided puncture of the CFA bilaterally
- Measurement for Manta closure device
- Sheath placement:
- 7Fr sheath on the IBE side
- 10F sheath on the contralateral side
- Administer 5000U Heparin
IBE Placement
- Guidewire insertion
- Use 300 cm soft Terumo 0.035 wire
- Insert 260 cm Lunderquist wire from the IBE side into the aorta
- Mark the wire length on the table
- Insertion of IBE device
- Remove sheath on the IBE side
- Orient IBE (black stripe corresponds to the limb)
- Insert IBE "bare" (ensure both wires are in place)
- Clamp crossover wire
- Advance the IBE device until the marker is 1 cm above the AII
- Use C-arm in AII projection
- Verify orientation with E-marker
- Ensure wires are not twisted
- Deployment of IBE
- Perform angiography via the 10F sheath
- Deploy IBE up to and including the limb + 2 clicks
- Withdraw the indwelling catheter to the black marker
- Advance the 10F sheath over the bend into the limb
- Engage AII with a 260 cm stiff Terumo wire
- If needed, use a measurement catheter to determine AII length
- Remove crossover wire
- Place covered AII stent (if using two, deploy the distal one first)
- Withdraw 10F sheath back to AIC
- Advance wire from AII to aorta
- Deploy external IBE component
- Release distal fixation (using white knob/wire)
- Set delivery device to neutral (N)
- Retrieve nosecone
- Park (P) the device
- Exchange device for a 16/20F Medtronic sheath
Aortic Device Placement
- Insertion and Orientation
- Align the main graft (black stripe medially)
- Insert the main graft "bare"
- Orient using E-marker
- Angiography and Deployment
- Insert pigtail catheter via the IBE side
- Perform angiography to mark the lowest renal artery
- Deploy the main body:
- Switch to Drive (D) mode
- Deploy up to the limb
- Perform angiographic confirmation
- Release the top cap (remove white ring and press orange button while securing the system)
- Bridge Limb Placement
- Withdraw pigtail catheter
- Engage the limb
- Measure AII length: From distal limb marker to IBE E-marker (overlap is not included in the given length)
- Deploy bridge limb
- Retrieve nosecone
- Final Deployment
- Ipsilateral limb release
- Retrieve main nosecone
- Exchange main delivery device for 16/20F sheath
- Expand AII limb
- Extend main graft if necessary
Closure
- Achieve hemostasis bilaterally using Manta closure devices
- SOP
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
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
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
- 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
- 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
Time out procedure. Antibiotica profylaxe. Huiddesinfectie en steriel afdekken. Locale anesthesie met Levobupivacaïne 0,5% en Lidocaïne 1%. Beiderzijds echogeleide punctie AFC, meten voor Manta device, plaatsen 8Fr sheath links, 10Fr sheath rechts. 5000EH Heparine.
Via Terumo/pigtail plaatsen stijve voerdraad links, Terumo rechts, deze wordt genared en links uitgeleid. Inbrengen IBD (72IB1414L65L44) via links, angio via lange 10Fr sheath links en aftekenen AII. Ontplooien IBD, opvoeren 10 Fr sheath tot AII origo, catheteriseren AII, inbrengen Terumo stiff en interna pootje (91BX5710). Ontplooien en balloneren na verwijderen through-and-through wire. Ontplooien externa poot en verwijderen delivery device waarna inbrengen 16 Fr sheath links.
Via rechts opvoeren Terumo/pigtail/stijve voerdraad en inbrengen main body (93MB2913L10-08). Via links opvoeren pigtail. Angiogram en aftekenen nierarteriën. Ontplooien main body tot contralaterale poot. Ontplooien topcap na controle-angio. Aanhaken, controle positie in stentgraft door pigtail te roteren ter hoogte van de infrarenale hals. Inbrengen stijve voerdraad, meten met pigtail. Inbrengen bridge via links (93CL1516L05).
Verder ontplooien mainbody en verwijderen delivery device. Inbrengen 16 Fr sheath. Angiogram en aftekenen AII rechts. Meten met pigtail. Ontplooien ipsilaterale poot (93CL1522L05). Naballonneren. Ontplooien externa poot. Balloneren. Angio: fraaie positie en doorgankelijkheid prothese, nierarteriën en AII beiderzijds doorgankelijk, geen endoleak. Verwijderen catheters en voerdraden. Hemostase met 2x Manta device. Sign out procedure.
