Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery Accessi Iliaci Ostili nel trattamento della patologia aortica E. Gallitto
Iliac Navigations Alma Mater Studiorum Università di Bologna
Femoral Access Alma Mater Studiorum Università di Bologna
Alma Mater Studiorum Università di Bologna
Identifying & grading factors that modify the outcome of endovascular aortic aneurysm repair Chaikof EL et al. JVS 2002;35:1061-6 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 < 1.25 160-180 τ 1.25-1.5 121-159 τ 1.5 1.6 90-120 τ > 1.6 < 90 Iliac artery sealing zone - length > 30 mm 20-30 mm 10-20 mm < 10 mm - diameter < 12.5 mm 12.5-14.5 mm 14.5-17 mm > 17 mm Hostile Anatomy Alma Mater Studiorum Università di Bologna
Hostile Iliac Anatomy Reason for EVAR ineligibility in 16.4% of AAA Arko FR et al. J Endovasc Ther 2004; 11: 33-40 Alma Mater Studiorum Università di Bologna
Hostile Iliac Anatomy Cause of 43% of primary & perioperative conversion Millon A et al. Eur J Vasc Endovasc Surg 2009; 38: 429-434 Alma Mater Studiorum Università di Bologna
Hostile Iliac Anatomy Reason for EVAR ineligibility in 16.4% of AAA Arko FR et al. J Endovasc Ther 2004; 11: 33-40 Cause of 42.9% of primary & perioperative conversion Millon A et al. Eur J Vasc Endovasc Surg 2009; 38: 429-434 Related with late EVAR re-interventions Johnson PG et al. J Vasc Surg 2013; 58: 582-8 Alma Mater Studiorum Università di Bologna
Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
Management of Challenging Access Preoperative Evaluation CTA with Volume Rendering, CLL-MPR-MIP reconstructions Alma Mater Studiorum Università di Bologna
VR Presence of the lesions Alma Mater Studiorum Università di Bologna
Quality of the lesions MIP Alma Mater Studiorum Università di Bologna
Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
Management of Challenging Access Low Profile Endografts Increase the EVAR feasibility Device MB size (Fr) Iliac limb size (Fr) Cordis - Incraft 14 12 Trivascular - Ovation 14-15 12-15 Cook Zenith Alpha 16-17 12-14 Gore Excluder C3 16-18 12-16 Alma Mater Studiorum Università di Bologna
Zenith Alpha Abdominal: Italian Registry
Zenith Alpha Abdominal: Italian Registry No differences in terms of Technical Success Pre-discharge complications Survival Limb Patency Re-interventions @ 30-day @ 30-day
TEVAR Delivery System Profile Comparison (Fr size OD) Graft Diameter (mm) Zenith Alpha (Fr) 18 19 20 19 Medtronic Valiant (Fr) Gore C-TAG (Fr) 21 21 Bolton Relay (Fr) 22 19 22 22 24 19 22 22 26 19 22 23 22 27 23 28 19 22 23 22 30 19 22 25 22 31 25 32 21 22 23 34 21 24 25 23 36 21 24 27 24 37 27 38 21 24 24 40 23 24 27 25 42 23 25 25 44 23 25 25 45 27 46 23 25 26
TEVAR Delivery System Profile Comparison (Fr size OD) Graft Diameter (mm) Zenith Alpha (Fr) 18 19 20 19 Medtronic Valiant (Fr) Gore C-TAG (Fr) 21 21 Bolton Relay (Fr) 22 19 22 22 24 19 22 22 26 19 22 23 22 27 23 18-30 mm 16 Fr (19 Fr OD) 28 19 22 23 22 30 19 22 25 22 32-38 mm 18 Fr (21 Fr OD) 31 25 32 21 22 23 40-46 mm 20 Fr (23 Fr OD) 34 21 24 25 23 36 21 24 27 24 37 27 38 21 24 24 40 23 24 27 25 42 23 25 25 44 23 25 25 45 27 46 23 25 26
Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
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
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
Alma Mater Studiorum Università di Bologna
Left External Iliac Artery Pre-dilatation EIA stenosis PTA Alma Mater Studiorum Università di Bologna Dilator
Left External Iliac Artery PTA-stenting Self - expandable bare metal stent Alma Mater Studiorum Università di Bologna
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 2002 - Paving & Cracking Hinchliffe R et al JET 2007 Alma Mater Studiorum Università di Bologna
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 2002 - Paving & Cracking Hinchliffe R et al JET 2007 Alma Mater Studiorum Università di Bologna
Alma Mater Studiorum Università di Bologna Hinchliffe, JET 2007
Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 Endoconduits 2009-2015 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
Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 19 cases 14 (74%) TASC D lesion
Endoconduits with Pave and Crack Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results G. Asciutto, EJVS 2017 19 cases 14 (74%) TASC D lesion
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
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
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 -
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
Management of Challenging Access Endovascular treatment of Iliac Hostility Scenario # 2 external iliac artery occlusion Alma Mater Studiorum Università di Bologna
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
EVAR Right MB ZALB 26 84 Right ZSLE 13 122 ZT Hypogastric Artery Alma Mater Studiorum Università di Bologna
EVAR Right MB ZALB 26 84 Right ZSLE 13 122 ZT Left Viabahn 13 x 100 Hypogastric Artery Alma Mater Studiorum Università di Bologna
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
Alma Mater Studiorum Università di Bologna JVS 2012;56:1549-54
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
Management of Challenging Access Preoperative Evaluation Endograft Choice Endovascular Treatment of Iliac Hostility Surgical Iliac Conduit Alma Mater Studiorum Università di Bologna
# 3 Surgical Conduit Rutherford Vascular Surgery University of Bologna
# 3 Rutherford Vascular Surgery University of Bologna
# 3 Rutherford Vascular Surgery University of Bologna
# 3 Ø10mm Vascular Surgery University of Bologna
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
Ann Vasc Surg 2015; 29:1548-1553 No Conduit Conduit
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
Fenestrated Branched Endograft Sheath Size O.D. 22-24 Fr 8.5 mm Alma Mater Studiorum Università di Bologna
Type II TAAA Vascular Surgery University of Bologna
Fenestrated Branched Endograft Vascular Surgery University of Bologna
Fenestrated Branched Endograft Vascular Surgery University of Bologna
Fenestrated Branched Endograft Vascular Surgery University of Bologna
Ø 7 mm Vascular Surgery University of Bologna
Ø 7mm Vascular Surgery University of Bologna
Ø 7mm Vascular Surgery University of Bologna
Ø 7mm Covered Stent Vascular Surgery University of Bologna
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
- Aim Impact of iliac anatomy on FB-EVAR outcome 1/5 Vascular Surgery University of Bologna
- Aim Impact of iliac anatomy on FB-EVAR outcome - Methods 2010 2015 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
- Aim Impact of iliac anatomy on FB-EVAR outcome - Methods 2010 2015 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 2002 1/5 Vascular Surgery University of Bologna
- Aim Impact of iliac anatomy on FB-EVAR outcome - Methods Early 2010 2015 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 2002 1/5 Vascular Surgery University of Bologna
- Results n % Patients 94 100 j/p-aaa 59 63 TAAA 35 37 2/5 Vascular Surgery University of Bologna
- Results n % Patients 94 100 j/p-aaa 59 63 TAAA 35 37 n % External Iliac Ø < 7mm 26 28 Severe Calcification 21 22 Stenosis-occlusion 27 29 Severe angles 18 19 Previous graft 31 33 Hostile Anatomy 60 64 2/5 Vascular Surgery University of Bologna
- Results n % Patients 94 100 j/p-aaa HA 59(%) 63FA (%) p Age (yrs) 73±6 73±6.61 Male 85 91.52 Hypertension 98 97 1.0 Smoke 28 38 Dyslipidemia 72 68.81 TAAA 35 37 n % Diabetes 5 18.07 COPD 57 35.06 CAD 47 24.03 BMI > 31 15 18.77 POAD 12 0.04 CRF 42 44 1.0 Dialysis 8 0.15 ASA 4 28 9.03 External Iliac Ø < 7mm 26 28 Severe Calcification 21 22 Stenosis-occlusion 27 29 Severe angles 18 19 Previous graft 31 33 Hostile Anatomy 60 64 2/5 Vascular Surgery University of Bologna
- Results ITP n % n % Patients 94 100 j/p-aaa 59 63 TAAA 35 37 n % External Iliac Ø < 7mm 26 28 Severe Calcification 21 22 Stenosis-occlusion 27 29 Severe angles 18 19 Previous graft 31 33 Hostile Anatomy 60 64 Iliac rupture 1 1 Endograft Twisting 13 14 Difficult TVV cannulation 33 35 TVV loss / injuries 14 3 IAM Iliac PTA / stent 27 29 Surgical Conduit 14 15 Tot 44 47 2/5 Vascular Surgery University of Bologna
- Results n % Patients 94 100 j/p-aaa 59 63 TAAA 35 37 ITP n % Iliac rupture 1 1 Endograft Twisting 13 14 Difficult TVV cannulation 33 35 TVV loss / injuries 14 3 IAM Iliac PTA / stent 27 29 n % External Iliac Ø < 7mm 26 28 Severe Calcification 21 22 Stenosis-occlusion 27 29 Severe angles 18 19 Previous graft 31 33 Hostile Anatomy 60 64 Surgical Conduit 14 15 Tot 44 47 HA FA p (%) (%) Test X 2 Technical Success 97 95.06 IAM 55 32.03 30-day Mortality 3 5.09 2/5 Vascular Surgery University of Bologna
- Results ITC n % n % Patients 94 100 j/p-aaa 59 63 TAAA 35 37 Endograft Twisting 13 14 Ø External Iliac < 7mm 12.5 2.2-71.4.01 External iliac calcification Difficult 4.1 TVV cannulation 0.5-33.4.18 33 35 Common + External n Iliac calcification % TVV loss 8.3/ injuries 1.4-50.0.02 External Steno-obstructive Iliac Ø < 7mm disease 26 28 Tot 08 0.1-4.4.85 44 47 Severe Calcification Severe angle 21 22 1.1 0.2-4.3.90 HA FA p Previous graft 0.3 0.6-1.9 (%).08 (%) Stenosis-occlusion 27 29 Test X 2 TAAA Severe angles 18 19 Technical 2.3Success 0.8-6.7 97.12 95.06 Hostile iliac Anatomy 2.3 0.4-12.3.32 Previous graft 31 33 IAM 55 32.03 30-day Mortality 3 5.09 Hostile Anatomy 60 64 Iliac rupture 1 1 Intra-operative Adjunctive Maneuvers Iliac PTA / stent 27 29 Surgical Conduit 14 15 IAM Multivariate Analysis OR 95% CI p 2/5 Vascular Surgery University of Bologna
- Results F-up 27±14months Survival 92% 60% FA HA P=.01 months 3/5 Vascular Surgery University of Bologna
- Results F-up 27±14months Survival 92% 60% FA HA P=.01 Multivariate Analysis HA significant predictor of Mortality (OR:3.6, CI 1.1-13.2; p=.04) months 3/5 Vascular Surgery University of Bologna
- 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
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