Intravascular Ultrasound in the Treatment of Complex Aortic Pathologies Naixin Kang, M.D. Vascular Surgery Fellow April 26 th, 2018
DISCLOSURES Nothing To Disclose 2
ENDOVASCULAR AORTIC INTERVENTION Improved perioperative morbidity and mortality compare to open repair Endo vs. Open: Endo first Requires use of intra-arterial contrast agents What options do we have for patients with contraindication for use of contrast? i.e. renal insufficiency Increased risk of developing contrast-induced nephropathy 3
CARBON DIOXIDE (CO 2 ) ANGIOGRAPHY Evidence 4
CO 2 ANGIOGRAPHY CO 2 guided EVAR is safe and feasible CHALLENGES: Bowel Gas Abdominal pain Above the diaphragm? Potential neurotoxicity and cardiac arrhythmia CO 2 should NOT be used in thoracic aorta, coronary artery and cerebral circulation 5
INTRAVASCULAR ULTRASOUND (IVUS) Provides real-time data during aortic intervention Locate anatomy and location of branch vessels Define entry and reentry sites of dissection Graft sizing Assess graft apposition after deployment Known to LOWER contrast use 6
INTRAVASCULAR ULTRASOUND (IVUS) Volcano Visions PV 0.035 digital IVUS catheter (Volcano corporation, Rancho Cordova, CA, USA) 7
INTRAVASCULAR ULTRASOUND (IVUS) 8
Can IVUS be used in conjunction with duplex and TEE to ELIMINATE contrast use for treatment of thoracic and abdominal aortic pathologies? OUR EXPERIENCE 9
CASE 1
CASE 1 37yo pregnant female at 22 weeks of gestation Presented with chest pain and 5.1cm descending thoracic aneurysm distal to left subclavian Increased risk of rupture during pregnancy TOF-MRI
CASE 1 Pre-deployment Wire parked in left subclavian through left brachial access IVUS Diameter of proximal landing zone measured Distance from aneurysm to L SCA measured 20mm Spot fluoroscopy (total of 45sec, 8mGy) No contrast given Post-deployment Evaluated by IVUS and TEE for graft apposition and endoleak
CASE 1- Post-Partum CT 13
CASE 2 42yo male Liver failure due to Caroli syndrome Renal failure due to polycystic kidney disease Pending liver and kidney transplantation Incidental finding of 4.5cm infrarenal AAA on non-con CT GFR 20, not on dialysis, Cr 4.0
CASE 2 EVAR with IVUS and fluoroscopy guidance No contrast given IVUS used to identify lowest renal artery, bifurcation of CIA, vessel diameter Stent deployed infrarenal Intraoperative arterial duplex pre and post stent deployment Done by experienced vascular lab technician Small type II endoleak detected from lumbar, with flow of 8ml/sec No type Ia or Ib endoleak Total dose of radiation: 106.8mGy Discharged home POD#3 with stable renal function 15
PRE STENT DEPLOYMENT
DUPLEX PRE STENT DEPLOYMENT
DUPLEX POST STENT DEPLOYMENT -perfusion of both renal arteries
POST PROCEDURE DISTAL TO STENT
CASE CONTROL EVAR for infrarenal AAA Guided by IVUS and duplex Contrast enhanced images were performed pre and post deployment of stent Validation and confirmation only Showed that IVUS and duplex are precise
CASE 3 52yo male presented with chest pain Acute type B aortic dissection Chest pain improved after BP controlled However with worsening renal function GFR 22, Cr 3.5mg/dL from baseline of 1.4 TEVAR planned due to end-organ malperfusion
CASE 3 23
CASE 3
CASE 3 TEVAR with IVUS and fluoroscopy guidance No contrast given IVUS used to identify the entry tear, origin of left subclavian artery, evaluate graft apposition Stent deployed distal to left subclavian artery Post op: Chest pain resolved Cr improved to baseline
PRE STENT DEPLOYMENT 26
POST STENT DEPLOYMENT 27
CONCLUSION IVUS can eliminate the use of intra-arterial contrast agents altogether for endovascular aortic repair in selected anatomy and various pathologies aortic dissection, thoracic aortic aneurysm, abdominal aortic aneurysm Particularly useful in patients with decreased renal function or contraindication for contrast use
CHALLENGES Finding proper method to reliably evaluate for endoleak both intraoperatively and postoperatively Need to individualize based on each case Potential methods Vascular US by experienced technician Time of Flight MRI High resolution thin cut non-contrast CT scan
REFERENCES Pearce BJ, Jordan WD. Using IVUS During EVAR and TEVAR: Improving Patient Outcomes. Semin Vasc Surg. 2009 Sep; 22(3): 172-180 Von Segesser LK, Marty B, Ruchat P, Bogen M, Gallino A. Routine use of IVUS for Endovascular Aneurysm Repair: Angiography is Not Necessary. Eur J Vasc Endovasc Surg. 2002 Jun; 23(6): 537-42 Veer Chahwala, J Tashiro, A Baqai, J. Rey. Endovascular Repair of a Thoracic Aortic Aneurysm in Pregnancy at 22 weeks of Gestation. JVS. 2015 Nov; 62(5); 1323-25 Pandey N, Litt HI. Surveillance Imaging Following Endovascular Aneurysm Repair. Semin Intervent Radiol. 2015 Sep; 32(3): 239-48 Angelis, Sardanelli. Carbon Dioxide Angiography as an Option for Endovascular Abdominal Aortic Aneurysm Repair in Patients with Chronic Didney Disease. Int J Cardiovasc Imaging. 2017; 33:1655-1662
Thank you Questions? 31