STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY SINGLE CENTER EXPERIENCE Dr Rajendra Kumar Premchand M.D., D.M,D.I.U. Senior consultant Interventional cardiologist Director, KIMS Hospitals, Hyderabad, India
EVAR-Single Centre Experience Total cases-50 Mean age -63 45 M: 5 F Risk factors- SM-15, DM-15, HTN-15, CKD-5 Thoracic- 18, abdominal-19, thoracoabdominal- 7, Dissection-4. Chimney- 5, hybrid -3, on table fenestration-3
Approach to Aortic Aneurysm
Case -1 Type B Dissection Acute -EVAR 52 yrs male HTN+, chronic smoker C/O- sudden onset chest pain and abdominal discomfort radiating to back. O/E- feeble pulses in both L/L. ECG- Sinus tachycardia Echo- Normal LV function CT Aortogram- Type B aortic dissection starting below LSCA and extending distally into B/L CIA, left EIA with thrombus.
Case -1 EVAR Aortic dissection Type B Pre - EVAR Post - EVAR Medtronic 36 mm stent graft x 2
Case 2-Hybrid EVAR to Acute Aortic dissection Type B 52 yrs male HTN+, Chronic smoker S/O chest pain radiating to back associated with worsening dyspnea CXR- widened mediastinum Echo- Good LV function CT Angiogram- Type B aortic dissection with DTA aneurysm and mildly dilated aortic root Type B Aortic aneurysm LCCA / LSCA arising from aneurysm
Case 2-Hybrid EVAR to Acute Aortic dissection Type B STRATEGY Bypass graft to Rt Carotid & LSCA from LT Carotid artery f/b EVAR COOK 36 MM COVERED STENT
CASE 3 - Hybrid aortic arch debranching 69 yrs old male Chronic smoker (30 pack years) Non-diabetic, Non hypertensive Being worked up for Squamous cell carcinoma tongue Incidentally diagnosed to have Thoracic aortic aneurysm
CASE 3 - Hybrid aortic arch debranching S T R A T E G Y
Case -4 EVAR with on table Fenestration + stent to LSCA 82 yrs male Hypertensive, dyslipidaemic & non diabetic S/P CABG (1996) x 3 (LIMA LAD, SVG Ramus & PLB) DOE class II-III and chest pain (atypical) CXR- wide mediastinum s/o Thoracic AA CT scan- 4.2 x 5.1 Saccular aneurysm in arch/isthmus after the origin of LSCA with mural thrombus and burrowing in lung parenchyma.
Case -4 EVAR with on table Fenestration + stent to LSCA ZENITH TZ2 36 X 77 mm, LSCA- 8 X 38 mm Advanta V12
Case -5 Multilayer Flow Modulator device for Thoracoabdominal aneurysm Case history 54yr male HTN, HLP,Non-DM. Severe back pain -6 days. On evaluation USG abd showed aortic aneurysm. CT aortogram - aneurysm of distal descending thoracic and upper abdominal measuring 5.5*29 mm (fusiform ) with mural thrombus along posterior and lateral walls with celiac artery stenosis.
Case -5 Multilayer Flow Modulator device for Thoracoabdominal aneurysm Issues: Aneurysm involving major branches: Hypogastric artery celiac artery Superior mesenteric artery Renal arteries.
Case -5 Multilayer Flow Modulator device for Thoracoabdominal aneurysm Prerequisite - side branch stenosis should not be >50%. Celiac artery stenting (hippocampus renal stent) via LBA MFM (28*180) deployed slowly ~ 15 min
MFM - Principle Eliminates erratic flow vortices by redirecting the flow into laminar flow. Patency of side branches- The side branches act as a vacuum, augmenting the lamination which results in shrinkage of the aneurysm and increased side branch flow. Rapid endothelialization makes it quickly embedded within the aortic wall. The effect of peak wall stress is grossly diminished. Treat aneurysm rather than excluding it.
Case -6 EVAR to Thoracic aneurysm presenting as Hoarseness of voice 62 yrs male HTN+, DMII, Chronic smoker C/O Hoarseness of voice since 10 months Referred from ENT b/s of abnormal CXR and diagnosed to have Lt RLN palsy. CT Chest- 4.2 x 5.5 saccular thoracic aneurysm with diffuse atherosclerosis.
Case -6 EVAR to Thoracic aneurysm presenting as Hoarseness of voice Pre - EVAR Post - EVAR VALIANT 32 X 32 X 100mm
Case -7 Hypertensive emergency with leaking AAA 57 yrs old male Chronic smoker (38 pack years), hypertensive Presented with abdominal discomfort in gastroenterology department USG abdomen- 4 x 3.8 cm saccular abdominal aortic aneurysm with eccentric thrombus. CECT abdomen 5.2 x 5.8 saccular abdominal aneurysm with eccentric mural thrombus.
Case -7 Hypertensive emergency with leaking AAA
Case -8 Infrarenal AAA extending into B/L CIA 60yr, Doctor By Occupation Non- HTN, Non DM Post CABG- 15 yrs back., continues to smoke. Epigastric symptoms, back ache- On evaluation- USG ABD Infra Renal AAA CT angio- Infra renal AAA (8.6mm diameter) Diagnosis- symptomatic infra renal AAA and aneurysm of bilateral CIA
Case -8 Infrarenal AAA extending into B/L CIA Main body (cook 24*96)deployed across the aneurysm infrarenally
Case -8 Infrarenal AAA extending into B/L CIA Deployment of Rt & Lt extension limbs 12*73 24*56 24*73 Two Lt sided Extension limbs
Case -9 Traumatic Aortic Laceration 68 years, male H/O RTA Traumatic aortic laceration with leak into pleural cavity Lung contusion with hemothorax Cerebral contusion SAH STRATEGY Emergency EVAR
Case -9 Traumatic Aortic Laceration Post - EVAR After stent graft- ICD placed for hemothorax Pre - EVAR Post - EVAR Conservative management of SAH Valiant thoracic stent graft 36-36 C 150TE Recovered sensorium over 3 days
Case -10 Sub Acute Type B Aortic dissection with SMA Occlusion 45 yrs male HTN+, Chronic smoker C/O- Acute onset tearing type of abdominal pain radiating to back and chest associated with malena 3-4 episodes. O/E- Pulse 116/min, feeble in B/L L/L ; BP- (RUL) 190/114 mmhg and 70 systolic in B/L L/L ECG- Sinus tachycardia CT Angio- Dissection flap starting just below LSCA & extending upto Rt EIA and Lt CFA; SMA Total occlusion seen
Case -10 Acute Type B Aortic dissection with SMA Occlusion STRATEGY Emergency EVAR + SMA Stenting 1 year follow up- Patient asymptomatic SMA Stented with 8 x 80 mm Luminex Bard stent 32 x 200 mm COOK stent graft in DTA CT Angio DTA stent graft and SMA stent patent
Troubleshooting complications :
Complications Paraparesis- 4 Renal failure- 2 Endovascular leak-1 brachial artery complications- 2 Common iliac rupture -2 Death during procedure-1 During hospital stay-1 Death at 30 days-2.
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR Post dilation of the stent grafts with CODA balloon (10-35) Flaring of struts due to excessive dilatation Patient developed hypotension (SBP- fell from140 to 90 mm Hg)
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR Check aortogram showing rupture of Rt CIA. CODA Balloon inflation to decrease the blood loss by occluding the stent graft Balloon inflation in RT extension limb Balloon inflation in Main stem infrarenally to work on Rt CIA 10:40 PM Strategy? Surgery?covered stent?? How to prevent endoleak 10:42 PM
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR 10:45 PM Rt Int Iliac Internal iliac artery selectively engaged with Diagnostic JR & 7 Coils deployed [(8-10)*1,(3-4)*2,(5-8)*4] Deployment of another Rt sided Extension limb Final Angio- No leak & well contained aneurysm
Avulsion of Right CIA and Right EIA The sheath which was oversized to EIA diameter (6mm) led to the avulsion of the Right common iliac artery and Rt external iliac artery. POBA was done and 2 stents were deployed across the lesion till the femoral head but flow could not be restored. Hence PTFE graft was done anatomizing Right CIA and RT Common femoral artery after ligating the internal iliac artery. Pt developed retroperitoneal leak due to peri PTFE graft oozing induced by overzealous heparin usage, managed conservatively. The approximate size of peripheral access artery should be atleast 8mm to prevent avulsion of arteries.
Avulsion of Left common Iliac Artery Avulsion of LT CIA Covered with another stent
Conclusions Anatomical challeges- small arteries, calcification( No Data to support) Most of the procedures- Out of pocket expense Not uniformly remursable DCGI- challenges in approving new devices Only few Centres are doing these procedures Intervenitonal cardiologist/radiologist/vascular surgeon/ CT surgeon.
STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY Dr Rajendra Kumar Premchand M.D., D.M,D.I.U. Senior consultant & Interventional cardiologist Director, KIMS Hospitals, Hyderabad, India