Obesity, Scaring, Access in EVAR. Kiskinis D, Melas N, Ktenidis K. 1 st Department of Surgery Aristotle University of Thessaloniki, Greece
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1 Obesity, Scaring, Access in EVAR Kiskinis D, Melas N, Ktenidis K. 1 st Department of Surgery Aristotle University of Thessaloniki, Greece
2 Obesity Decreased radiolucency (visibility) Max weight load < 160 kgr (radiolucent floating table)
3 Scaring Scaring in femoral region needs more attention during dissection to prepare the femoral arteries
4 Access problems related to EVAR 1. Narrow iliacs 2. Excessive calcification 3. Unilateral iliac occlusion 4. Iliac tortuosity 5. Narrow terminal aorta 6. Combination Upon insertion and withdrawn of the sheath Dissection Thrombosis Embolization Ischemia Rupture Conversion
5 Access related EVAR Failure 1. Frank R. Arko, C.K. Zarins. How many patients with infrarenal aneurysms are candidates for endovascular repair. The Nothern California experience. JEVT, 2004, 11; J.P. Carpenter, R.M. Fairman. Impact on exclusion criteria on patient selection for EVAR. JVS, 2001 Dec, 34(6):1050-4
6 Most of them can be anticipated and solved before or during the operation By choosing the appropriate Device the most convenient technique the most suitable configuration (Bifurcated, AUI, TUBE, Conduit, OPEN)
7 1. Narrow iliacs Usually refers to EIA More often in women / PAD / radiotherapy Can be anticipated from preop. imaging Related to: Sheath diameter (OD) Proximal neck diameter (wider grafts need wider sheaths)
8 Sheath diameters (OD) large diameter: Zenith, E-vita, Talent, Endofit Intermediate diameter: Anaconda, Powerlink Small diameter: Excluder, Endurant Zenith E-vita Talent Endofit Anaconda Powerlink Excluder Endurant 28 mm graft 23 Fr 22 Fr 22 Fr 22 Fr 22.5 Fr 21 Fr 20.4 Fr 20 Fr 36 mm graft 25 Fr 24 Fr (34) 24 Fr 24 Fr 22.5 Fr (34) 22 Fr (34) 22 Fr (31) 20 Fr
9 Solutions for narrow iliacs Accurate preop. measurements (CTA, DSA) Choose the smaller appropriate sheath Choose the wider iliac for body insertion Think of Excluder (advance partially without sheath) Consider iliac conduit Consider OPEN repair
10 Underestimated narrow and calcified iliacs Upon withdrawn of the sheath Dissection and iliac thrombosis Ilio-femoral by pass
11 2. Excessive calcification Refers to EIA and CIA More often in PAD Can be anticipated from preop imaging More important when causing stenosis
12 Solutions for Excessive calcification Accurate preop. measurements (CTA, DSA) Choose the smaller appropriate sheath Choose the less calcified iliac for body insertion Pushability is more important than trackability (prefer stiff sheath over flexible) Consider paving and cracking (pre dilate) Consider iliac conduit
13 3. Unilateral iliac occlusion Refers to EIA and CIA More often in PAD Can be anticipated from clinical evaluation and preop imaging
14 Solutions for Unilateral iliac occlusion AUI + Fem Fem by pass Intraoperative angiography: Brachial approach
15 4. Iliac tortuosity Refers to EIA and CIA More often in huge AAA / Aortoiliac aneurysm Can be anticipated from preop imaging If calcification and stenosis be very cautious
16 Solutions for Iliac tortuosity Accurate preop. measurements (CTA, DSA) Extra stiff wire is mandatory Choose the smaller sheath (of appropriate graft) Choose the less tortuous iliac for body insertion Trackability is more important than Pushability (prefer flexible sheath over stiff ) Consider Through and Through wire catheter technique Consider external maneuvers Consider iliac conduit
17
18 Through and Through wire catheter technique
19 5. Narrow terminal aorta Less than 15 mm Can be anticipated from preop imaging
20 Solutions for Narrow terminal aorta Accurate preop. measurements (CTA, DSA) Consider kissing balloon if marginal diameter and Bifurcated graft is decided Consider AUI / TUBE
21 Narrow terminal aorta with CIA angulation
22 6. Combination of access difficulties
23 D: 25mm L: 30mm LR-TA: 128mm D: 17mm D: 22mm L:45mm L: 40mm
24 24 th month Post-op CTA Patent renals, IIA, No endoleak, Sack shrinkage
25 Iliac rupture iliofemoral bypass
26 Combination of access difficulties
27 Aorto-unoiliac Endografting
28 Conclusions Vast majority of access problems can be anticipated from thorough preoperative and intraoperative imaging Most of the problems can be solved with appropriate device selection Completion angiography should always check for -renal, IIA patency -iliac thrombosis -rupture
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