Technique and Tips for Complicated AAA Cases with Stent Graft
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1 Technique and Tips for Complicated AAA Cases with Stent Graft Seung-Woon Rha, MD, PhD FACC, FAHA, FESC, FSCAI, FAPSIC Cardiovascular Center, Korea University Guro Hospital Mar 15, 2018 LINC AP 2018
2 Endoleak; M/C Complications Presence of flow at the aneurysmal sac after stent-graft treatment White GH, May J, Waugh RC, Chaufour X, Yu W. Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg 1998;5:
3 (Type I) Proximal or distal attachment (Type III) Structural defect or component junction (Type II) Retrograde branch flow (Type IV) Trans-graft leakage or porosity
4 Prevention of Type I Endoleak 1. Proper Case Selection % oversizing of the endograft. 3. Generous overlapping of segments. 4. Graft covers the aorta and common iliac arteries from the renal arteries down to the iliac artery bifurcation.
5 Hostile Neck; High-risk of Type 1 Endoleak following EVAR 1. Endovascular abdominal aortic aneurysm repair (EVAR) has been known to reduce morbidity, mortality and recovery time compared to open surgery. 2. However, the durability has not been definitely established yet, particularly in difficult anatomical situation which can be a source for persistent or recurrent endoleak following the EVAR procedure.
6 Hostile Neck When preoperative CT-scan showed at least 1 anatomical criterion among following factors; Neck angle > 60 degree Neck length <15mm Neck diameter >28mm Calcification 50% Circumference thrombus 50% ( 2mm thickness) Gimenez-Gaibar A et al. Annals of Vasc Surg 2017 (In Press)
7 NOT ALL NECKS ARE THE SAME Hostile Neck Straight Tapered Reversed tapered Angulated * Bulge Short + Source: Ionel Droc, Dieter Raithel and Blanca Calinescu (2012). Abdominal Aortic Aneurysms - Actual Therapeutic Strategies, Aneurysm, Dr. Yasuo Murai (Ed.), ISBN: , InTech, DOI: /48596 * Modified from source + additional anatomical criteria, not part of source
8 HOSTILE PROXIMAL NECKS FURTHER CHALLENGE EVAR Another similar meta-analysis by Stather et al. of 16 major s tudies confirms higher risks in hostile necks Total sample size: N=11,959 patients Further substantiation that EVAR still faces significant challenges in hostile proximal n eck anatomy Stather et al. JEVT. 2013;20:
9 HOSTILE ANATOMY=GREATER RISK FOR EVAR Meta-analysis / 11,959 patients AneuRx, Talent, Excluder, Zenith, Endurant In hostile anatomy Significantly higher inter-operative adjuncts needed Greater early and late Type Ia leaks Meta-analysis / 1,559patients AneuRx, Talent, Endurant Excluder, Zenith In hostile neck anatomy within 1 year: 4 fold increase Type 1 leaks 9 fold increase AAA related mortality Prospective analysis / 196 patients Greater than one hostile neck parameter significantly increases mortality, adverse events, intra-op endoleaks and adjunctive procedures Multiple elements of SWACY = increased risks Confidential, for Internal Use Only. Not for distribution to physicians.
10 How to overcome and prevent Type 1 endoleak in hostile neck? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
11 How to overcome and prevent endoleak? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
12 Figure 1. Representative preprocedural CT images illustrating a 85 mm infrarenal abdominal aortic aneurysm with a 20 mm long proximal aneurysm neck that measured 17 mm in diameter
13 Figure 2. Aortogram showing type IA endoleak (arrow).
14 Figure 3. Aortogram after Palmaz stenting. No sign of a type I endoleak was detected in the completion angiogram. Also, both renal arteries were patent.
15 How to overcome and prevent endoleak? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
16 Endurant legacy of innovation ENDURANT July, 2008 ENDURANTII January, 2012 ENDURANTIIs October, 2014
17 Heli-FX System: Applier + Guide + 10 EndoAnchors 3 mm Cross Bar 1.0 mm 3.5 mm
18 Displacement force in Newtons FIXATION OF ENDOANCHORS Create the stability of a surgical anastomosis in EVAR and TEVAR Surgical Anastomosis EndoAnchoring Talent Endurant Excluder Zenith Mean Hand Sewn No EndoAnchors With EndoAnchors Melas et al. JVS 2012;55(6): Case images from John Aruny MD, Bart Edward Muhs, MD, PhD.
19 Images courtesy of National Institute Aptus Heli-FX Product Offerings Aptus Heli-FX Thoracic EndoAnchor System 18F OD 90cm working length Aptus Heli-FX EndoAnchor System 16F OD 62cm working length
20 Figure 4. An AAA case with hostile neck treated by Gore Excluder
21 How to overcome and prevent endoleak? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
22 Figure 5. An AAA case with hostile neck
23 Figure 6. Immediate type 1A endoleak
24 Figure 7. Additional cuff implantation followed by adjuvant ballooning
25 AAA with Severe Angulation Case
26 Baseline Aortogram
27 Main body deploy
28 Rewiring and Wire Exchange
29 Immediate After MB deploy
30 Proximal Cuff Implantation
31 Limb Extension Deploy
32 Adjuvant Ballooning
33 Final Angiography
34 How to overcome and prevent endoleak? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
35 Chimney Technique 1. One of good solution for overcoming hostile neck is to use the EVAR with Chimney Technique (Ch-EVAR). 2. Kim JY et al reported a good case using Ch-EVAR (7). They performed chimney stenting to both renal arteries and EVAR was safely performed. 3. Zhang T et al reported the efficacy of 31 Ch-EVAR cases out of 51 AAA patients with hostile neck (8). They concluded that the results were safe and effective for 13 months. 4. The use of chimney grafts has been advocated recently, but longer term follow-up is lacking yet. 5. We need more experience and data for the long-term clinical outcomes. 6. Major limitations; Viabhan stentgraft is not available in Korea
36 Figure 8. An AAA case treated by Chimney technique (Endurant and Viahban)
37 How to overcome and prevent endoleak? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
38 Figure 9. Examples of fenestrated stent graft to overcome the hostile neck.
39 Summary; How to overcome and prevent Type 1 endoleak in hostile neck? 1. Adjunctive balloon expandable stents 2. Efficacy of Promising stentgraft 3. Additional cuff using stentgraft 4. Chimney Technique 5. Fenestrated endograft (f-evar)
40 Thank You for Your Attention! Korea University Guro Hospital, Seoul, Korea
41 Technique and Tips for Complicated AAA Cases with Stent Graft Seung-Woon Rha, MD, PhD FACC, FAHA, FESC, FSCAI, FAPSIC Cardiovascular Center, Korea University Guro Hospital Mar 15, 2018 LINC AP 2018
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