Accessi Iliaci Ostili
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1 Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery Accessi Iliaci Ostili nel trattamento della patologia aortica E. Gallitto
2 Iliac Navigations Alma Mater Studiorum Università di Bologna
3 Femoral Access Alma Mater Studiorum Università di Bologna
4 Alma Mater Studiorum Università di Bologna
5 Identifying & grading factors that modify the outcome of endovascular aortic aneurysm repair Chaikof EL et al. JVS 2002;35: Iliac Artery Absent = 0 Mild = 1 Moderate = 2 Severe = 3 Calcification none < 25% vessel lenght 25-50% vessel lenght > 50% vessel length Diameter >10 mm 8-10 mm 7-8 mm < 7 mm Occlusive disease no Stenosis > 7 mm diameter or > 3 cm long Focal stenosis < 7 mm diameter and < 3 mm lenght Stenosis < 7 mm diameter and > 3 mm length Angulation and tortuosity - iliac tortuosity index - iliac angle τ < τ τ τ > 1.6 < 90 Iliac artery sealing zone - length > 30 mm mm mm < 10 mm - diameter < 12.5 mm mm mm > 17 mm Hostile Anatomy Alma Mater Studiorum Università di Bologna
6 Hostile Iliac Anatomy Reason for EVAR ineligibility in 16.4% of AAA Arko FR et al. J Endovasc Ther 2004; 11: Alma Mater Studiorum Università di Bologna
7 Hostile Iliac Anatomy Cause of 43% of primary & perioperative conversion Millon A et al. Eur J Vasc Endovasc Surg 2009; 38: Alma Mater Studiorum Università di Bologna
8 Hostile Iliac Anatomy Reason for EVAR ineligibility in 16.4% of AAA Arko FR et al. J Endovasc Ther 2004; 11: Cause of 42.9% of primary & perioperative conversion Millon A et al. Eur J Vasc Endovasc Surg 2009; 38: Related with late EVAR re-interventions Johnson PG et al. J Vasc Surg 2013; 58: Alma Mater Studiorum Università di Bologna
9 Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
10 Management of Challenging Access Preoperative Evaluation CTA with Volume Rendering, CLL-MPR-MIP reconstructions Alma Mater Studiorum Università di Bologna
11 VR Presence of the lesions Alma Mater Studiorum Università di Bologna
12 Quality of the lesions MIP Alma Mater Studiorum Università di Bologna
13 Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
14 Management of Challenging Access Low Profile Endografts Increase the EVAR feasibility Device MB size (Fr) Iliac limb size (Fr) Cordis - Incraft Trivascular - Ovation Cook Zenith Alpha Gore Excluder C Alma Mater Studiorum Università di Bologna
15 Zenith Alpha Abdominal: Italian Registry
16 Zenith Alpha Abdominal: Italian Registry No differences in terms of Technical Success Pre-discharge complications Survival Limb Patency 30-day
17 TEVAR Delivery System Profile Comparison (Fr size OD) Graft Diameter (mm) Zenith Alpha (Fr) Medtronic Valiant (Fr) Gore C-TAG (Fr) Bolton Relay (Fr)
18 TEVAR Delivery System Profile Comparison (Fr size OD) Graft Diameter (mm) Zenith Alpha (Fr) Medtronic Valiant (Fr) Gore C-TAG (Fr) Bolton Relay (Fr) mm 16 Fr (19 Fr OD) mm 18 Fr (21 Fr OD) mm 20 Fr (23 Fr OD)
19 Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
20 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 1 a. common/external iliac artery stenosis b. common/external iliac artery stenosis PTA failure Scenario # 2 external iliac artery occlusion Alma Mater Studiorum Università di Bologna
21 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 1 a. common/external iliac artery stenosis - Balloon Angioplasty - Evaluation of navigability by Dilatators - Iliac Stenting at the end of procedure Alma Mater Studiorum Università di Bologna
22 Alma Mater Studiorum Università di Bologna
23 Left External Iliac Artery Pre-dilatation EIA stenosis PTA Alma Mater Studiorum Università di Bologna Dilator
24 Left External Iliac Artery PTA-stenting Self - expandable bare metal stent Alma Mater Studiorum Università di Bologna
25 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 1 b. common/external iliac artery stenosis PTA failure - In Situ Sheath dilatation von Segesser LK et al EJCTS Paving & Cracking Hinchliffe R et al JET 2007 Alma Mater Studiorum Università di Bologna
26 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 1 b. common/external iliac artery stenosis PTA failure - In Situ Sheath dilatation von Segesser LK et al EJCTS Paving & Cracking Hinchliffe R et al JET 2007 Alma Mater Studiorum Università di Bologna
27 Alma Mater Studiorum Università di Bologna Hinchliffe, JET 2007
28 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Endoconduits Endpoints Technical Success ability to deliver the aortic stent graft through the EC without rupture, dissection, or thrombosis of the iliac or femoral arteries, with the absence of haemodynamically significant blood loss related to the EC EC patency during follow and mortality
29 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS cases 14 (74%) TASC D lesion
30 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS cases 14 (74%) TASC D lesion
31 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Aortic Endograft Endoconduit graft Adjunctive procedure
32 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Technical Success 100% EC patency at EVAR completion 100% 30-day Mortality 10.5%* *2 cases: 1 of these had been treated for rupture
33 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Median follow-up period 17months Primary assisted patency of the EC 89% Claudication - Lower limb amputations -
34 Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Conclusion Endoconduit allows EVAR of varying complexity without the need for open surgical ilio-femoral conduits in patients with concomitant advanced iliac occlusive disease. Intra-operative haemodynamic instability was always avoided and mid-term patency was high
35 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 2 external iliac artery occlusion Alma Mater Studiorum Università di Bologna
36 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 2 external iliac artery occlusion - Revascularization of internal iliac artery - Recanalization of external iliac artery - Aorto-uniliac endograft Alma Mater Studiorum Università di Bologna
37 EVAR Right MB ZALB Right ZSLE ZT Hypogastric Artery Alma Mater Studiorum Università di Bologna
38 EVAR Right MB ZALB Right ZSLE ZT Left Viabahn 13 x 100 Hypogastric Artery Alma Mater Studiorum Università di Bologna
39
40 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 2 external iliac artery occlusion - Revascularization of internal iliac artery - Recanalization of external iliac artery - Aorto-uniliac endograft Alma Mater Studiorum Università di Bologna
41 Alma Mater Studiorum Università di Bologna JVS 2012;56:
42 Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 2 external iliac artery occlusion - Revascularization of internal iliac artery - Recanalization of external iliac artery - Aorto-uniliac endograft Alma Mater Studiorum Università di Bologna
43 Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
44 # 3 Surgical Conduit Rutherford Vascular Surgery University of Bologna
45 # 3 Rutherford Vascular Surgery University of Bologna
46 # 3 Rutherford Vascular Surgery University of Bologna
47 # 3 Ø10mm Vascular Surgery University of Bologna
48 Management of Challenging Access Surgical Iliac Conduit Inclusion criteria - small external iliac artery - external iliac artery with severe and no-focal stenosis Alma Mater Studiorum Università di Bologna
49 Ann Vasc Surg 2015; 29: No Conduit Conduit
50 Management of Challenging Access CX 2017, Gallitto et al Conclusions - Iliac characteristics should be carefully evaluated for EVAR indication and planning - Low-profile endograft increased the eligibility to EVAR in pts with challenging access - Endo/Open adjunctive iliac maneuvers associated with a flexible approach to challenging access increase the TS and decrease the risk of perioperative complications of EVAR Vascular Surgery, University of Bologna - DIMES Policlinico S.Orsola-Malpighi, Bologna, Italy
51 Fenestrated Branched Endograft Sheath Size O.D Fr 8.5 mm Alma Mater Studiorum Università di Bologna
52 Type II TAAA Vascular Surgery University of Bologna
53 Fenestrated Branched Endograft Vascular Surgery University of Bologna
54 Fenestrated Branched Endograft Vascular Surgery University of Bologna
55 Fenestrated Branched Endograft Vascular Surgery University of Bologna
56 Ø 7 mm Vascular Surgery University of Bologna
57 Ø 7mm Vascular Surgery University of Bologna
58 Ø 7mm Vascular Surgery University of Bologna
59 Ø 7mm Covered Stent Vascular Surgery University of Bologna
60 Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery Impact of iliac arteries anatomy on the outcome of FB - EVAR E. Gallitto, M. Gargiulo, G. Faggioli, R. Pini, A.Freyrie, C. Mascoli, S.Ancetti, A. Stella JVS 2017
61 - Aim Impact of iliac anatomy on FB-EVAR outcome 1/5 Vascular Surgery University of Bologna
62 - Aim Impact of iliac anatomy on FB-EVAR outcome - Methods High-risk patients, underwent FB-EVAR j/p-aaa TAAA Hostile vs Friendly Iliac Anatomy (HA vs FA) 1/5 Vascular Surgery University of Bologna
63 - Aim Impact of iliac anatomy on FB-EVAR outcome - Methods High-risk patients, underwent FB-EVAR j/p-aaa TAAA Hostile vs Friendly Iliac Anatomy (HA vs FA) - HA *Severe angles ( 90 ) *Extensive calcification ( 50%) *Stenosis / obstruction *External artery ø < 7mm Previous aortic-iliac/femoral graft * SVS reporting standards, JVS /5 Vascular Surgery University of Bologna
64 - Aim Impact of iliac anatomy on FB-EVAR outcome - Methods Early Intra-operative adjunctive maneuvers (IAM) High-risk patients, underwent FB-EVAR Intra-operative technical problems (ITP) j/p-aaa TAAA Hostile vs Friendly Iliac Anatomy 30-day Mortality (HA vs FA) - HA Technical Success (TS) Mid-term Endpoints Iliac PTA-stenting, Surgical iliac conduit, Intra-aortic graft rotations, several attempts of TVV cannulations Iliac rupture, Significant endograft twisting, TVV loss, TVV injuries Absence of type I-III endoleaks, TVV loss, conversion to OR, 24-h mortality Survival *Severe Freedom angles From Re-interventions ( 90 ) (FFR) *Extensive Target calcification Visceral Vessels ( 50%) (TVV) patency *Stenosis / obstruction *External artery ø < 7mm Previous aortic-iliac/femoral graft * SVS reporting standards, JVS /5 Vascular Surgery University of Bologna
65 - Results n % Patients j/p-aaa TAAA /5 Vascular Surgery University of Bologna
66 - Results n % Patients j/p-aaa TAAA n % External Iliac Ø < 7mm Severe Calcification Stenosis-occlusion Severe angles Previous graft Hostile Anatomy /5 Vascular Surgery University of Bologna
67 - Results n % Patients j/p-aaa HA 59(%) 63FA (%) p Age (yrs) 73±6 73±6.61 Male Hypertension Smoke Dyslipidemia TAAA n % Diabetes COPD CAD BMI > POAD CRF Dialysis ASA External Iliac Ø < 7mm Severe Calcification Stenosis-occlusion Severe angles Previous graft Hostile Anatomy /5 Vascular Surgery University of Bologna
68 - Results ITP n % n % Patients j/p-aaa TAAA n % External Iliac Ø < 7mm Severe Calcification Stenosis-occlusion Severe angles Previous graft Hostile Anatomy Iliac rupture 1 1 Endograft Twisting Difficult TVV cannulation TVV loss / injuries 14 3 IAM Iliac PTA / stent Surgical Conduit Tot /5 Vascular Surgery University of Bologna
69 - Results n % Patients j/p-aaa TAAA ITP n % Iliac rupture 1 1 Endograft Twisting Difficult TVV cannulation TVV loss / injuries 14 3 IAM Iliac PTA / stent n % External Iliac Ø < 7mm Severe Calcification Stenosis-occlusion Severe angles Previous graft Hostile Anatomy Surgical Conduit Tot HA FA p (%) (%) Test X 2 Technical Success IAM day Mortality /5 Vascular Surgery University of Bologna
70 - Results ITC n % n % Patients j/p-aaa TAAA Endograft Twisting Ø External Iliac < 7mm External iliac calcification Difficult 4.1 TVV cannulation Common + External n Iliac calcification % TVV loss 8.3/ injuries External Steno-obstructive Iliac Ø < 7mm disease Tot Severe Calcification Severe angle HA FA p Previous graft (%).08 (%) Stenosis-occlusion Test X 2 TAAA Severe angles Technical 2.3Success Hostile iliac Anatomy Previous graft IAM day Mortality Hostile Anatomy Iliac rupture 1 1 Intra-operative Adjunctive Maneuvers Iliac PTA / stent Surgical Conduit IAM Multivariate Analysis OR 95% CI p 2/5 Vascular Surgery University of Bologna
71 - Results F-up 27±14months Survival 92% 60% FA HA P=.01 months 3/5 Vascular Surgery University of Bologna
72 - Results F-up 27±14months Survival 92% 60% FA HA P=.01 Multivariate Analysis HA significant predictor of Mortality (OR:3.6, CI ; p=.04) months 3/5 Vascular Surgery University of Bologna
73 - Results F-up 27±14months 90% HA 93% HA FA 81% FA 89% p=.53 p=.53 FFR TVV patency months months 4/5 Vascular Surgery University of Bologna
74 Impact of iliac arteries anatomy on the outcome of FB - EVAR - Conclusion Hostile Iliac Arteries Not affect Technical Success and 30-d Mortality Procedures associated with IAM Late mortality is increased Iliac characteristics should be carefully evaluated for accurate indication to FB-EVAR 5/5 Vascular Surgery University of Bologna
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P Paraplegia abdominal aortic aneurysm repair, 52 paraparesis, 52 pathophysiology, 51 rates and endografts, 51 two-stage approach, 129
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