DIFFICULT ACCESS REMAINS A CONTRAINDICATION FOR EVAR APOSTOLOS K. TASSIOPOULOS, MD, FACS PROFESSOR AND CHIEF DIVISION OF VASCULAR SURGERY

DIFFICULT ACCESS REMAINS A CONTRAINDICATION FOR EVAR APOSTOLOS K. TASSIOPOULOS, MD, FACS PROFESSOR AND CHIEF DIVISION OF VASCULAR SURGERY

Disclosures Speaker Bureau: - Medtronic - Cook Medical - Bolton

INTRODUCTION EVAR has become the preferred treatment for AAAs because it is associated with reduced perioperative morbidity and mortality and no difference in long-term outcomes Adequate vascular access is a key determinant of successful outcomes in EVAR and TEVAR procedures Access artery injury presenting as Rupture Dissection Pseudoaneurysm Thrombosis remains a significant cause of perioperative morbidity complicating up to 3% of all endovascular procedures Maleux G., et al. Semin Intervent Radiol 2009;26:3-9

ACCESS ARTERY INJURY EARLY EXPERIENCE In the early years, access site complications after EVAR were more common, often with devastating results Iliac artery on a stick

THE PROBLEM Access Site Complications EUROSTAR REGISTRY - 1871 patients underwent EVAR - 13% had access site problems due to small iliac vessel diameter, excessive iliac tortuosity or stenoses - 49 (2.6%) of patients required conversion mainly due to access problems - An estimated 10% of all patients have complex access and would not be able to accommodate the usual device diameter Cuypers PW et al. Eur J Vasc Endovasc Surg 2000;20:183-9

THE PROBLEM Iliac artery Rupture Single Center Results (1997-2008) - 369 EVARs and 67 TEVARs performed - Iliac artery rupture complicated - 11 EVAR procedures (2.8%) - 6 TEVAR procedure (8.9%) - One EVAR patient required conversion to OSR - Rest of ruptures treated with endograft extension to cover the site of injury Fernandez JZ et al.j Vasc Surg 2009;50:1293-300

Iliac artery Rupture Single Center Results (1997-2008) THE PROBLEM - Patients who sustained an iliac artery rupture had - Longer hospital stay (7.6 vs. 5.1 days) - Higher procedure-related mortality (11.8% vs 4.0%) Fernandez JZ et al.j Vasc Surg 2009;50:1293-300

RISK DETERMINANTS RISK FACTORS FOR ACCESS ARTERY INJURY Access vessel diameter External iliac diameter < 7mm Size and flexibility of device Complications more common with larger size devices Degree of calcification Circumferential calcium Excessive access vessel tortuosity Significant occlusive disease Approximately 25% of all AAA patients have iliac artery occlusive disease

RISK FACTORS FOR ACCESS ARTERY INJURY PATIENT SUB-GROUPS AT INCREASEED RISK Ethnicity Patients of Asian descend have shorter, smaller diameter and more tortuous external iliac arteries This contributes to a higher rate of access site complications (OR 7.3, 95%CI: 1.5 35.8, p=0.015) Masuda ES, et al. J Vasc Surg 2004;40:24-9)

RISK FACTORS FOR ACCESS ARTERY INJURY PATIENT SUB-GROUPS AT INCREASEED RISK Female patients Smaller diameter iliac arteries Women EVAR candidates have adverse iliac anatomy twice as often as men (62.3% vs. 33.6%) More likely to require iliac conduits for device delivery compared to men (28.6% vs 1.2%) Velasquez OC et al. J Vasc Surg 2001;33: S77-84

RECENT ADVANCES TECHNIQUE Smaller size, more flexible devices Stiffer wires and improved techniques for iliac tortuosity Aorto-uni-iliac devices Alternative access techniques Iliac direct access and conduits Paving and cracking Endoluminal conduit Carotid artery access

ANATOMIC BARRIERS TO EVAR Moise MA, et al. Vasc Endovasc Surg 40;197-203, 2006

RECENT ADVANCES TECHNIQUE Smaller size, more flexible devices Stiffer wires and improved techniques for iliac tortuosity Aorto-uni-iliac devices Iliac direct access and conduits Alternative access sites Paving and cracking Endoluminal conduit Carotid artery access ASSOCIATED RISK Complication risk improved but still present Complication risk improved but still present Limb ischemia from occlusion of the fem-fem bypass graft Prolonged OR time, increased blood loss Sacrifice of the ipsilateral internal iliac artery, increased risk of ipsilateral limb occlusion, stroke

THE MISSING PIECE What is the impact of adverse access site anatomy and of the techniques used to overcome it on mid- and long-term outcomes?

ILIAC ARTERY TORTUOSITY ILIAC TORTUOSITY AFFECTS LIMB PATENCY 504 patients underwent EVAR with the Cook Zenith graft Limb patency 97% at 12 months 96% at three years Excessive Iliac tortuosity quantified by three different indices on preoperative CT scan was associated with a higher rate of limb occlusions Taudori M. et al. Eur J Vasc Endovasc Surg 2014;Epub May 27

COMPLICATIONS OF ENDOGRAFT EXTENSION TO THE EXTERNAL ILIAC Retrospective analysis of prospectively collected data 567 patients with both endograft limbs deployed in the CIA were compared to 94 patients with at least one limb into the external iliac artery Limb occlusion rate: 3% in CIA group vs. 15% in the EIA group (p<0.0001) Amputations: 0 in CIA occlusions vs. 3 in EIA occlusions (p=0.003) Conway AM, et al. J Endovasc Ther 2012;19:79-85

LIMB OCCLUSION Iliac artery rupture treated with endograft extension Ipsilateral limb: Primary patency 88% (mean follow up of 40 months) Primary assisted patency: 94% Fernandez JZ et al.j Vasc Surg 2009;50:1293-300

ILIAC LIMB OCCLUSION RISK FACTORS Female gender Extension of endograft to the external iliac artery Smaller diameter iliac vessels Arterial dissection Compromised runoff More than 50% of all iliac limb occlusions present as acute limb ischemia Taudori M. et al. Eur J Vasc Endovasc Surg 2014;Epub May 27

COMPLICATIONS OF ILIAC CONDUIT USE 2.6-fold higher blood loss 82% longer procedure time 1.5-day increased hospital stay 1.8-fold increased perioperative complication rate Lee WA, et al. J Vasc Surg 2003;38:459-65

MY VIEW Technical and technological advances in recent years have increased patient eligibility for EVAR and safety of EVAR procedures Access vessel anatomic limitations although less commonly still represent contraindications to EVAR and TEVAR procedures Careful preoperative planning is essential in minimizing access site complications during and after endovascular procedures Patient surgical risk profile is also important in deciding between EVAR and OSR

MY VIEW The real question should not be Can it be done? but rather Should it be done?

ACCESS CHALLENGES DISTAL AORTIC CALCIFIED RING BILATERAL EIA OCCLUSION

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