How to do AAA EVAR: Tips and Tricks

Transcription

1 How to do AAA EVAR: Tips and Tricks June 14, 2007 Jon S. Matsumura, MD Associate Professor of Surgery Division of Vascular Surgery Northwestern University Medical School

2 Disclosure Information Jon Matsumura, M.D. The following relationships exist related to this presentation: Research/grant support, consultant, and training director Abbott, Bard, Cook, Cordis, ev3, Gore and Medtronic. Off label use of products will be discussed in this presentation: EVR devices are off-label if anatomic criteria are not met. Self-expanding biliary stents are off-label in the arterial bed. Prostar is off-label above 10 Fr. TEVAR is off-label for rupture.

3 General Tips for Avoiding Major Problems Size balloons to native artery size, don t balloon outside of device, closely follow pressure/volume compliance. Resistance to sheath insertion and device insertion is a warning sign to be heeded. Always verify entry into contralateral limb. Use sheath injection to check location of hypogastric and inspect iliac on way out. Pin the guidewire.

4 Hypogastric Embolization: Solid coil pack, Coaxial aortic extender, or Amplatzer Femoral-femoral wire for contralateral sheath stabilization in cases of extreme tortuosity

5 Neck Dilation

6 Impulse-momentum equation

7 Resultant Force Resultant Force on Curved Stent-Graft 15 Degrees 30 Degrees 45 Degrees Pressure (mm/hg)

8 EVAR Wrong Technique!

9 Anatomic Entry Criteria Respect Proximal Neck Proximal Neck angle < 60 degrees, particularly if short length > 15 mm mm inside diameter <2 mm reverse taper no sig thrombus Preserve flow to one hypogastric artery

10 Heirarchal Ipsi Side Selection Tips Select safer access for larger sheath External iliac size, tortuosity, calcification Femoral scar, previous infrainguinal bypass Select iliac that lays main trunk more parallel in tortuous proximal neck Anticipate use of larger diameter iliac components and place larger sheath on ipsilateral side Select the side with better outflow Select the side with best puncture Select patient s right side

11 Introducing Main Trunk

12 Tips for Gate Cannulation Position gate where it will be easy to access Rotate toward contralateral wire/12 Fr sheath Not near shelf or second neck Rotate gantry angle frequently to check position of wire relative to gold ring Use a simple curve catheter for 5-10 minutes, then switch to cobra or shepherd s crook for minutes, then go up and over with snare and long sheaths Observe interaction/deflection of wire with gold ring Withdraw sheath only if necessary Definitively confirm entry into limb: at least two of the following Balloon inflation in proximal neck Curved catheter rotation in proximal neck Entanglement with ipsi wire IVUS/angiogram in proximal neck Carefully advance guide/sheath if short main trunk used

13 Gate Junction Cannulation

14 IVUS Morphology

15 Tips for Excluder Users Device does not foreshorten. Do not oversize length or iliac limbs will cover the hypogastric. Use shorter wires. Sheath angio to check hypogastric before deployment. Deploy rapidly, not slowly or staged until very experienced. All contralateral legs and iliac extenders are tapered: Proximal diameter is always same size (>16 mm) Smaller diameter iliac components will seal with previously placed larger diameter components May try to seal in CIA with mm, and option to EIA with 10mm

16 Tips for Zenith Users Deploy topstent prior to cannulating gate. Place tip of wireguide in ascending aorta. Consider prophylactic extra support in tortuous iliac vessels do an angio after stiff wires are out if in doubt. Don t overballoon the bifurcation area.

17 Access and Measuring

18 Contra Leg Deployment

19 Distal Type I Endoleak

20 Push Graft Up and Place Larger Diameter Iliac Endograft

21 Advanced Techniques Percutaneous preclose Slow deployment Micropositioning Endowedge excluder Snorkel stent--zenith Staged deployment Accordion foreshortening Kilt Conversion to aortomonoiliac Main trunk ipsi, aortic extender, convertor Endoconduit

22 Summary Measure, think, and plan yourself Have backup inventory of aortic and iliac extenders, but remember endoprocedure can be staged Techniques are different with individual devices, mastery with one is useful

23 Percutaneous Tricks

24 General Considerations for Percutaneous Repair User experience AAA endograft system Closure device Procedure room support Choose a safe strategy Patient selection--important for beginners

25 User Experience Mastery of endograft system Predictably quick--no surprises Facile with deployment sequence, modular size selection, retrograde cannulation, troubleshooting Mastery of closure system Understand how it works Recognize signs of impending trouble Know how to get out of trouble--backdown maneuver

26 Selection of Strategy Strategy I: Select the patient Preferred when starting out Femoral artery size, calcification, plaque Avoid previous femoral dissection/fibrosis About 70% of patients are predictably easy Strategy II: Attempt percutaneous in all May leave the guidewire in until hemostasis assured Check pedal pulses before undraping Convert to a cutdown PRN

27 Suitable Percutaneous Access

28 MIP: Access Arteries

29 Preclose Technique Tips Adhesive, antiseptic drape Anterior common femoral puncture confirmed by sheath arteriogram No systemic heparin if EIA is patent Soak sutures in heparinized saline Adjunctive pressure Trim sutures well below surface Newer devices under development: OTW, larger bites, longitudinal orientation

30 Video Case Demonstration

31 Endovascular Surgical Suite

32 Tidy

33 Percutaneous Summary Percutaneous endovascular aneurysm repair works and is worthwhile: Faster procedure and recovery Fewer postoperative complications Greater patient acceptance Morasch et al., J Vasc Surg :12-16 Device familiarity is essential Choose a strategy that fits your practice

34 Case Presentation: Percutaneous TEVAR With Endoconduit Elderly male with fever, RUQ pain, and chest pain Ruptured DTAA Bilateral forefoot gangrene Recent urosepsis, biliary sepsis Pacemaker (no MR) Recent contrast nephropathy, recovering with creat 2.5 mg/dl Limited imaging from OSH Speaks only Polish Intravenous antibiotics Emergently to angiosuite for arteriography, IVUS and TEVAR Off-label use!!!

35 Pretreatment: Noncontrast OSH CT

36 Pretreatment: Noncontrast OSH CT

37 Pretreatment: Noncontrast OSH CT

38 Pretreatment: Noncontrast OSH CT

39 Pretreatment: Noncontrast OSH CT

40

41 Conduits Conduits are an integral part of TEVAR 15% of TAG study and 3 failed access More frequent in CCF PS-IDE 9% in TX2 pivotal trial and 2 failed access Resistance with subsequent passage of devices from femoral route can lead to dissection/disruption Iliac rupture is a common major complication and can be fatal Endoconduit--Need 12 mm PTA for 24Fr sheath Percutaneous preclose femoral access Consider hypogastric artery patency/sacrifice An off-label option to avoid a crisis.

42 12 mm PTA--Controlled Rupture