Overcoming Challenging Aortic Anatomy: from Hostile Necks to Tortuous Iliac arteries
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1 Overcoming Challenging Aortic Anatomy: from Hostile Necks to Tortuous Iliac arteries Robert Fisher Royal Liverpool University Hospital, UK Liverpool Vascular and Endovascular Service
2 Introduction Late results demand progress Reduce late complications Understand predictors Develop Strategies
3 When does EVAR Fail? Schanzer et al; Circulation % sac enlargement at 5 yrs 31% outside liberal IFU 58% outside strict IFU Independent factors Neck >28mm Angulation>60%
4 Adverse Outcome In EVAR with Hostile N Neck Anatomy >28cm diameter; <15/10mm length; angle>60; calcification; thrombus; conical. Stather EJVES 12 Tech success Early type I endoleak Peri-op mortality Late type I endoleak Late re-interv HNA % 2.5% 0.5% 9.5%* 22.8%* FNA % 0.8% 1.1% 4.5%* 11%* AbuRahma JVS 11 HNA % 22%* 3% 11% 15% FNA 95 99% 9%* 0% 10% 10% HNA: Hostile neck anatomy FNA: favorable neck anatomy * p<0.05
5 Unrealistic Expectation compromises fixation and seal Neck* Thrombus** Diameter Angulation Wall quality Iliac disease and tortuosity* *Wyss TR. J Vasc Surg Oct;54(4): **Patel SD et al. EJVES 2014 Apr;47(4):374-9
6 Overcoming Angulation Flexible Re-positionable Anaconder Aorfix* GORE Excluder with C3 delivery** *Sbarzaglia P. J Cardiovasc Surg (Torino) Feb;55(1): **Smeds AL et al. Ann Vasc Surg Jan;27(1):8-15. **Bachoo P et al. J Cadiovasc Surg Oct;54(5):573-80
7 The Neck s Not That Bad? Standardised technique Subjectivity Coronal vs Saggital 3D Workstation Influence of supra-renal angulation
8 Liverpool C3 Experience: GREAT Registry 37 Pts; angle 47.5 o : 7 repositions (19%); angle 62 o Grafts redeployed >60 Angle category
9 Strategy Choose ipsilateral side C shape not S Orientate Excluder Flexible plane accommodates the angulation
10 Deployment technique Start High Angulation hinders advancement once part deployed Challenge renal artery Trial deployment conform to angles? Change cranial tilt
11 Optimising neck placement through Re-deployment
12 Optimising neck placement through Re-deployment Moderate coronal/saggital angulation Effective repositioning Hypotenuse Effect
13 Use Adjuncts Retrospective analysis 44 pts with hostile neck Gore excluder +/- C3 (24/20) Need for Aortic cuff 36% 13% C3 65% standard delivery (p=0.005) No type I endoleaks 2/12 Smeds et al. Ann Vasc Surg 2013;27:8-15
14 Tortuous Iliac Arteries Recognition Calcification Access Rotation Accurate limb deployment Conformable limb
15 Limb shortening in tortuous iliacs Whittaker et a JVS 2005;41: Path alteration in Gore limbs 11% deployed >10mm shorter than centre lumen line. Iliac tortuosity Rotation (73%)
16 Iliac limb conformability 3 main devices compared Limb complications significantly higher in tortuous iliacs EVAR significantly reduced iliac tortuosity index GORE limbs reduced tortuosity index less Coulston J et al. J Vasc Surg Sep;60(3): The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications.
17 Tortuous Iliac Arteries Elephant Trunk Pre-op measurments Intra-op measurement Conformability Generous length Accommodate tortuosity Length/extension options
18 Accommodating Iliac Tortuosity Consertina Effect Incremental impaction
19 Tortuous Iliac Arteries Rotation common Correction unpredictable Helicopter shaft
20 Tortuous Iliac Arteries Rotation common Correction unpredictable Helicopter shaft Deflate valve Anticipate re-introduce Accept X legs cannulation benefit
21 Summary Outcomes influenced by Hostile neck anatomy Neck angulation Iliac tortuosity Accurate deployment aided by repositionable graft Limb conformability can accommodate tortuous iliac arteries
22 Overcoming Challenging Aortic Anatomy: from Hostile Necks to Tortuous Iliac arteries Robert Fisher Royal Liverpool University Hospital, UK Liverpool Vascular and Endovascular Service
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