EVAR TEVAR & complications

1. AORTIC INTERVENTIONS
DR.ANUSHUYA
JUNIOR RESIDENT
GOVT. STANLEY MEDICAL COLLEGE

2. AORTOGRAPHY
AORTIC INTERVENTIONS

3. AORTOGRAPHY
INDICATIONS
• Aortic regurgitation
• Aortic valve stenosis
• Aortic aneurysm
• Aortic dissection
• Before EVAR
• Sinus of valsalva anuerysm
• Coarctation of aorta
• Congenital anomalies, for
example, aorto-pulmonary
septal defect, anomalous
origin of supra-aortic vessels.
CATHETERS USED
• Pigtail 4F to 7F
CONTRAINDICATIONS
• Pregnancy
• Allergy to contrast
• Cardiac arrythmia
• Impaired RFT
• coagulopathy

4. AORTOGRAPHY
PROCEDURE
• Catheter placed 1 to 2 cms above the aortic valve.
• Depending upon the width 50 ml of contrast injected at 20ml/s.
• Catheter can straighten and move towards aortic valve at higher
flow rates
• Catheter can recoil and move distally at slower fow rates
• Therefore catheters are held safely in operators hands.
PROJECTIONS
 RAO 30 -40 deg is best to evaluate AR –extent of diastolic contrast
medium regurgitation into the left ventricle assessed.
 LAO 40-60 deg projection aortic arch, ascending and descending
aorta evaluated. Also, coronary ostia, vein grafts and origins of
supra aortic vessels as well as the aortic isthumus well evaluated.

5. AORTOGRAPHY

6. BALLOON ANGIOPLASTY AND
STENTING
AORTIC INTERVENTIONS

8. BALLOON ANGIOPLASTY AND STENTING
• Angioplasty of aortic stenosis can be performed with a single low-
profile low-pressure large-diameter balloon (10-16 mm) from one
arterial access, or two smaller balloons (8- to 10-mm diameter)
with “kissing” technique from bilateral access.
• Kissing technique is commonly used for aortic lesions that also
involve the common iliac artery origins. The long-term results of
angioplasty of focal aortic stenoses are excellent, but these are rare
lesions.
• Stent placement is indicated for eccentric lesions, recanalization of
complete occlusions, or lesions that are believed to be a source of
atheroemboli.
• Stent-grafts may be used to exclude symptomatic ulcerated plaque,
but otherwise currently have little role for aortic occlusive disease.

9. BALLOON ANGIOPLASTY AND STENTING

10. “Kissing” common iliac artery stents.
A, Digital image showing
crossing stents (white arrows) used to treat bilateral common iliac artery origin
stenoses.
B, Angiogram showing that the proximal ends of the stents
(blacK arrows )extend into the distal aorta.

11. Coarctation of aorta –
Balloon angioplasty
INDICATIONS:
• Preferred for children, adults
• Native coarctation or after surgery
• Not infants <6 mos
• Initial success in 80-90%
– Gradient ≤ 20 mm Hg

12. Balloon angioplasty - complications
• Incidence residual pressure >20 mm Hg
20% (up to 35%)
• Incidence recoarctation up to 25%
• Dissection and rupture1-3%
• Incidence aneurysm in f/u up to 5 yrs 2-8%
• Femoral artery complications up to 15%

14. Coarctation of aorta - STENTING
• Initially for those with residual gradient
after BA
• ↑ lumen diameter
• ↓ residual gradient
• Dilate stent with growth of aorta
• Not for pts <25 kg

15. BA and STENTING
in coarctation of aorta

16. ENDOVASCULAR AORTIC REPAIR
EVAR/TEVAR
AORTIC INTERVENTIONS

17. EVAR Advantages

18. Aortic aneurysm
• Aortic aneurysm is abnormal dilatation of the
aorta greater than 50% of the normal proximal
segment, or dilatation greater than 3 cm
• Thoracic or abdominal

19. Abdominal aortic aneurysm AAA

20. LOCATION OF AAA
• Suprarenal AAA involves the renal arteries and
extends superiorly so that the superior
mesenteric artery and celiac arteries arise from
the aneurysmal aorta.
• Juxtarenal AAA extends to the renal arteries, with
a normal-sized aorta superiorly .
• Infrarenal AAA arises at least 10 mm below the
renal arteries .
• Endovascular repair is best suited for infrarenal
AAAs because the renal arteries and superior
mesenteric arteries are not involved

21. Thoracic aortic aneurysm TAA
• COMMON SITE: Ascending aorta(70%)
• SYMPTOMS: Hoarseness, stridor, dypnoea, dysphagia or pain due
to local mass effects. Rupture presents with chest pain and shock.
• RISK OF RUPTURE:
4-4.9CM – 0.3%
5-5.9CM – 1.7%
>= 6CM – 3.6%
Endovascular repair should be considered
• when an asymptomatic descending aortic TAA reaches 5.5 cm.
• A higher threshold (6 cm) is suggested for open repair given its
greater risks.

22. ACUTE AORTIC SYNDROME
AORTIC
DISSECTION
PENETRATING
AORTIC
ULCER
INTRAMURAL
HAEMATOMA
ASCENDING AORTA AND ARCH
DESCENDING
THORACIC AORTA
ATHEROMATOUS
AORTIC
SEGMENTS,USUALLY
DESCENDING AORTA
SIMILAR MANAGEMENT

23. AORTIC DISSECTION
LOCATION
STANFORD A STANFORD B

24. AORTIC DISSECTION
STANFORD A DISEASE
• Pathology affecting the aortic
root and ascending aorta
(Stanford A disease)
• Unsuitable for endovascular
repair
• Due to involvement of the
aortic valve (which may also
need repair) and close
association of critical branch
vessels (the coronary arteries
and great vessels).
STANFORD B DISEASE
• Disease affecting the aorta
distal to the left subclavian
artery (Stanford B disease)
• Amenable to endovascular
repair, assuming there is
enough disease-free aorta
proximally to achieve a seal
(usually 15–20 mm).

25. AORTIC DISSECTION
TREATMENT
STANFORD B
UNCOMPLICATED-
MEDICAL
MANAGEMENT
COMPLICATED-
ENDOVASCULAR
REPAIR
STANFORD A SURGERY
COMPLICATED TYPE B –BRANCH VESSEL OCCLUSION AND END ORGAN ISCHEMIA

26. COMPLICATED TYPE B DISSECTION
– persisting or recurrent pain,
– uncontrolled hypertension despite full medication,
– early aortic expansion,
– penetrating aortic ulcer
– IMH
– Malperfusion
– signs of rupture (haematothorax, increasing periaortic
and mediastinal haematoma)

27. AORTIC DISSECTION
DYNAMIC DISSECTION
• Dissection flap has
prolapsed across their aortic
true lumen ostium
• True lumen has been
compressed by false lumen
• Perfusion could come either
from true or false lumen.
STATIC DISSECTION
• Dissection has extended
into a branch vessel
• Additional branch vessel
stenting should be done
• If a reentry tear is present,
distal perfusion is
maintained.

28. AORTIC DISSECTION
DYNAMIC DISSECTION STATIC DISSECTION

29. Static + Dynamic

30. INTRAMURAL HAEMATOMA AND
PENETRATING ULCER
• Complicated type B PAU (with or without
associated IMH) should be treated similarly to
aortic dissection, with the PAU being considered
the ‘entry tear’.
• Complicated type B IMH without an identifiable
intimal defect represents a therapeutic challenge
as there is no ‘target’ for limited stent-graft
coverage even though the IMH itself may be
extensive. It may be necessary to cover the entire
involved aorta.

31. ENDOVASCULAR STENT GRAFT REPAIR
AIMS
Restoration of branch
vessel flow is achieved
by closure of the entry
tear (i.e. coverage with
a stent-graft)
Depressurising
the false lumen
Allowing true
lumen
re-expansion

32. ENDOVASCULAR STENT GRAFT REPAIR
PRINCIPLES
①Successful placement of the device over the
primary entry tear to obliterate blood flow into
the false lumen and to redirect the flow into the
true lumen.
②Self-expanding metallic stent framework with a
high outward radial force that allows
attachment to the artery wall and graft fabric
that creates a new conduit for blood flow and
prohibits blood from entering the aneurysm sac.

33. EVAR ENDOVASCULAR STENT GRAFT DEVICE
DELIVERY SYSTEM STENT GRAFT
Stent-grafts are supplied preloaded on a deployment system.
They are usually constrained within a sheath,which, at deployment,
is gradually withdrawn, allowing the stent to expand under its own radial
force.

34. EVAR STENT GRAFT
• Fabric tube : usually woven polyester or expanded
polytetrafluoroethylene
• Metal struts : circular or crown-shaped (‘ring
stents’), usually made of nitinol or Elgiloy,
• Attached to the tube by either suturing or gluing.
• Limb extensions and aortic cuffs extend the device
distally and proximally, respectively

35. EVAR STENT GRAFT
• Most AAA stent-graft systems
comprise a main body with a
long limb on one side and a short
limb (or ‘gate’) on the other.
• Short limb is catheterised from
the opposite side.
• A second limb is then inserted
over a wire into the short limb of
the main body, sealing inside the
main body at a flow divider.

37. ENDURANT stent graft
“M-shaped” proximal stent
• Enhance wall apposition
• Prevent infolding
• Provide a 5-mm sealing zone
• Kink resistant limb

38. PRE-REQUISITES
• Good quality high-resolution imaging is required to choose the correct
stent-graft for a particular aneurysm.
• This is usually achieved with thin-section contrast enhanced arterial phase
computed tomography (CT) to include the whole of the diseased section
of the aorta and the access vessels (see below) in a volumetric acquisition.
• 3D reconstruction CT scan
• Angiography with a calibrated catheter necessary for EVAR eligibility.
Remains gold standard to select appropriate device diameter and length.
• Magnetic resonance (MR) angiography is sometimes utilised.

39. PRE-OP ASSESSMENT OF AORTA
• NECK LENGTH is measured from the lowest renal
artery to the top of the aortic aneurysm and its
measurement is important in determining
suprarenal or infrarenal fixation.The shorter the
neck, the more complicated the procedure.
• LANDING ZONE refers to the site at which the
prosthesis is placed. If the landing zone is smaller,
suprarenal fixation, may potentially be used.
Generally, a 1.5-cm landing zone of normal
anatomy is required for infrarenal fixation

40. PRE-OP ASSESSMENT OF AORTA

41. Neck
Proximal anchoring zone
Iliac arteries
Distal “seal” zone
2 important zones

42. 2 important zones
Neck
Proximal anchoring zone
Diameter < 32 mm
Length > 15 mm
Angle < 75
No thrombus
No calcification

43. 2 important zones
Iliac arteries
Distal “seal” zone
Diameter > 7 mm
‘Seal’ zone > 15 mm
Angle < 90
Not too tortuosity
Not too calcified

44. Nice-long neck

45. Nice straight iliac arteries

46. Good “ideal” anatomy

47. Neck
Diameter
Length
Angle
Thrombus
Calcification
Iliac arteries
Diameter
tortuosity
Angle
Calcification
Mostly we look at

48. >90° 80°
Neck Angulation

49. Neck Angulation
< 60 degrees angulation
Angulated and long neck “might” be OK
Angulated and short neck “is bad”

50. Angulated but long neck

51. Angulated but long neck

52. Short and angulated Neck

53. Cone-shaped Neck

54. Iliac artery tortuosity

55. Iliac Artery Stenosis
10 mm
4 mm
8 mm
6 mm

56. Small Distal Aorta
14-mm lumen at distal aortic neck which is heavily calcified

57. 40 mm
20 mm
Bilateral Common Iliac ArteryAneurysms

58. UNSUITABLE LANDING ZONE

59. EVAR Evaluation - contraindications
• Thrombus in proximal landing zone
• Conical proximal neck
• Greater than 120 degree angulations of the
proximal neck
• Critical inferior mesenteric artery
• Significant iliac occlusion
• Tortuosity of iliac vessels

60. TEVAR Pre-requisites
• Proximal neck of atleast 15 to 25 mm from the
origin of the left subclavian artery
• Distal neck of atleast 15 to 25 mm proximal to
origin of the celiac artery
• Adequate vascular access
• Absence of severe tortuosity, calcification or
atherosclerotic plaque in the aortic or pelvic
vasculature.

61. EVAR STEP BY STEP PROCEDURE
1) Access groins and dissect down to Femoral Artery
2) Access the Femoral artery with a Pinnacle introducer
needle
3) Pass soft Glidewire under fluoroscopy through the
Femoral to the Iliac and into the Aorta
4) Identify the renal arteries under fluoro
5) Pass the percutaneous sheath introducer over the
Glidewire
6) Remove the Glidewire and replace with an Amplatz
stiff guide wire. Now there is a passage for the graft
7) If vessel diameter is small, a balloon dilator may be
used

62. EVAR STEP BY STEP PROCEDURE
8) Once access is established on one side a Pigtail
angiographic catheter is passed through the opposite
femoral artery
9) A power injector angiogram may be used during the
procedure to ensure flow to the renals and to establish
placement of the graft
10) Using the stiff guidewire, introduce the main body graft.
11) Once in place, deploy graft and remove the Amplatz stiff
guidewire
12) Use Amplatz stiff guidewire on opposite side to introduce
the Iliac graft
13) Deploy graft

63. EVAR STEP BY STEP PROCEDURE
14)Cook Coda balloon catheters may be used to press
the graft against the wall of the vessel and to
prevent leaks
15)Endoleaks must be identified and treated before
closure.
16)Remove guidewires and close vessel
17)Close groin incisions and apply dressing

64. EVAR PROCEDURE

65. EVAR PROCEDURE

66. EVAR PROCEDURE

67. EVAR PROCEDURE

68. EVAR PROCEDURE

70. THORACIC ENDOVASCULAR AORTIC REPAIR
(TEVAR)
• A radiopaque marker (usually a 5F 30-cm-long
sheath) may be inserted via the left brachial
artery to single out the ostium of the left
subclavian artery.
• This marker at the ostium of the left subclavian
artery (LSA) may be very useful for optimal stent
placement in case of an isthmic lesion.
• Coil embolization of the origin of the subclavian
artery can be done from here if residual back flow
is observed in the false lumen after stent graft
deployment

71. TEVAR
Angiography and (B) CT clearly
show the entry tear (arrow),
just beyond left subclavian artery
(LSA) origin with
contrast filling of false lumen.
(C,D) After S-graft deployment
at the level of the tear,
complete exclusion of the false lumen
is achieved
and normal flow is reestablished
into the true lumen.
LSA origin was intentionally covered
to gain a better proximal sealing.

72. COMPLICATIONS
ENDOVASCULAR AORTIC REPAIR

73. SURGICAL COMPLICATIONS
• LOCAL
-groin hematoma
-infection
-lymphocele
• ACCESS ARTERY INJURY
-thrombosis
-dissection
-pseudoaneurysm

74. DEPLOYMENT/IMPLANT RELATED
DEPLOYMENT RELATED
• Failed deployment
• Bleeding
• Hematoma
• Lymphocele
• Infection
• Embolization
• Perforation
• Arterial rupture
• Dissection
IMPLANT RELATED
• Endoleaks (20-30%)
• Limb occlusion
• Stent graft kink
• Stent migration
• Sac enlargement
• Proximal neck dilatation
• Infection
• claudication

75. 1
• Each cardiac cycle produces a force estimated
to be approximately 10 N (equivalent to 1 kg)
tending to push the graft distally in the aorta.
2
• DEVICE MIGRATION
3
• KINKING AND OCCLUSION

76. Stent kinking

77. ENDOLEAKS
Continuing flow of blood into the diseased segment of aorta
outside the lumen of the stentgraft

78. TYPE I ENDOLEAKS
Poor sealing between the device and the
aortic wall, at both the proximal and distal
seals (the neck and distal landing zone)
CAUSE:
Error in sizing of the graft
Adverse neck morphology
Device migration
COMPLICATION:
Ongoing sac pressurisation,expansion and
rupture.
NEEDS TREATMENT:
Insertion of proximal or distal extension
cuffs, balloon moulding or restenting of the
seal zones, open surgical buttressing,
device explantation and repair or attempts
at transcatheter embolisation of the
endoleak.

79. TYPE II ENDOLEAKS
• Small side branches of the aorta
(e.g. the intercostal, lumbar or
inferior mesenteric arteries) are not
usually occluded during endovascular repair.
This allows the possibility of retrograde flow of blood into
the diseased segment of aorta via these side branches—a
type 2 endoleak.
CEASE SPONTANEOUSLY
• Treated only if there is on going expansion of the sac
• Usually side branches are not embolized except left
subclavian artery and internal iliac artery

80. TYPE III ENDOLEAKS
CAUSE:
Graft defects and fabric
tears
COMPLICATIONS:
repressurisation of the
diseased segment of aorta
and (for aneurysmal disease)
sac expansion and rupture.
TREATMENT :
relining defects with a
secondary device or operative
repair.

81. TYPE IV & V ENDOLEAKS
TYPE IV
• transient graft
‘porosity’—equivalent to
the ‘sweating’ sometimes
seen with knitted open
surgical grafts.
• NO TREATMENT
TYPE V
• ongoing aneurysm sac
expansion in the absence
of any other
demonstrable endoleak.
• CAUSE:
Dissolving atheroma
Low grade infection

82. SYSTEMIC CARDIAC PULMONARY
• Renal insufficiency
• Contrast induced nephropathy
• Deep vein thrombosis
• Pulmonary embolism
• Coagulopathy
• Bowel ischemia
• Spinal cord ischemia
• Cardiac ischemia
• Stroke and paraplegia(5 -20% vs < 1%)

83. STAGED ENDOVASCULAR APPROACH

84. Strategies to minimise risk of spinal cord injuries

85. Review questions
1. Which type of stanford disease is best
amenable for endovascular repair?
Stanford B
2. Requisite length and diameter of proximal
anchoring zone for EVAR?
Diameter <32mm and length >15mm
3. Requisite neck angle for EVAR?
<75 degrees

86. Review questions
4. Fabric tubes and metal struts
are made up of?
Polytetrafluroethylene (PTFE)
and nitinol/elgiloy
5. Recently approved stent graft
which is kink resistant?
Endurant
6. What is the Rx for the below
complication of EVAR?
Cease spontaneously

87. Review questions
7. What is the m.c complication following EVAR?
ENDOLEAK
8. EVAR is the preferred intervention in children.
True/false.
False/ Relative contraindication

89. Review questions
9. What is the type /importance ?
Static dissection / Additional
branch vessel stenting should be
done
10. Staged endovascular approach-
importance?
Minimise spinal cord ischemic
complications

90. REFERENCES
• Abrams’ angiography : interventional radiology /
editors, Jean-François H. Geschwind,
• Michael D. Dake.—Third edition.Vascular and
interventional radiology: the requisites / John A.
Kaufman, Prof Michael J. Lee.—Second edition.
• Gustavo S. Oderich (eds.) - Endovascular Aortic
Repair_ Current Techniques with Fenestrated,
Branched and Parallel Stent-Grafts (2017,
Springer International Publishing)

91. THANK YOU
AORTIC INTERVENTIONS