This document summarizes some of the challenges and complexities involved in endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and hybrid procedures. It describes various patient and anatomical factors that can make AAA intervention difficult, such as short and angulated neck anatomy, iliac artery tortuosity and stenosis, accessory renal arteries, and aneurysms involving the common iliac arteries. It also discusses the risks of pelvic ischemia when occluding internal iliac arteries and highlights mortality and morbidity rates reported in studies of hybrid AAA procedures.

1. Difficult Landing Zone
for AAA Intervention
Harapan Kita Experience 2013-2014
Dicky A.Wartono, MD FIHA FICA
Cardiac & Vascular Surgeon
National Cardiac & Vascular Centre Harapan Kita
Jakarta 2015

2. Conflict of interest: none declared.

3. PROBLEMS
• Intervention it self 15-20.000 USD
• Re Intervention 10 – 15.000 USD
• Surgical Intervention 10 – 15.000 USD
• Primary Surgery 5 – 10.000 USD
• Hybrid OR 5.000.000 USD

4. Murphy’s law

5. Female 77yo
Pulsating Abdominal Mass
Uncontroled Hipertension
HHD, ASHD, CAD
CHF IV

10. – 20 to 30% required a secondary intervention during the next 6
months
– related to the development of endoleaks
– conversion to open repair is necessary in 2 to 10% of patients
– Late ruptures after endovascular repair were reported
which reintervention/convertion were postpone.
The incidence was highest in the trial that began the earliest
– occur in patients who have not undergone postoperative
monitoring or those for whom a decision has been made not to
reintervene.
• patients recommended long-term surveillance by means of CT at 1
month and 12 months after the intervention

12. 80 yo male
Asymptomatic A-I Aneurysm
CHF IV, AF, HHD, ASHD
Hosptl for ALO

14. D-0, the patient complained of mild left lower-leg numbness,
No complaints of pain and demonstrated intact motor and sensory function of all extremities.
Normal palpable pedal pulses were present and were unchanged from the patient’s preoperative
D-1, developed a sudden decrease in urine output
Focal left buttock pain and left lower-leg weakness and numbness with intact proximal strength
and sensation.
Normal peripheral pulses remained present, making an acute distal ischemic insult unlikely
D-2, developed increasing tenseness of the left buttock
Motor weakness of the leg in the distribution of the sciatic nerve
Surgical Consult
diagnosis of gluteal compartment syndrome was made,

15. Yano, 2001
Karch, 2000
Criado, 2000
Mehta, 2001
IIA occlusion
cases
103
22
39
154
Pelvic ischemia complications
total
cases
22 (21%)
10 (42%)
6 (15%)
71 (46%)
buttock
claudication
95%
70%
83%
79%
colonic
ischemia
5%
30%
0%
6%
others
17%
15%

16. 2.25% pelvic ischemic complications appears to equal that described for open
repair, approxi- mately 1% to 2%

17. treatment of embolizing arterial lesions with stent grafts.
In our study westaged coil embolization and EVAR by
1 or 2 days. There isno consensus regarding the appropri-
ate staging interval between embolization of asingle hypo-
gastric artery and EVAR. Indeed, some authors have pro-
posed that simply covering the hypogastric artery during
EVAR does not increase the risk for endoleak or ischemia
and avertsthe need for apreoperative embolization proce-
dure.2 6
Nevertheless, most authors agree that when bilat-
eral hypogastric artery embolization is planned, EVAR
should be delayed by 2 to 4 weeks.1 3 , 1 8 , 2 3
Interruption of bilateral internal iliac arteries has also
been reported to be free from colon ischemia. Englke et
al2 7
reviewed 16 patientswith bilateral embolization before
EVAR, and found buttock claudication and sexual dysfunc-
tion to bethe only adverseevents. Othersare morewary of
interrupting important pelviccollateral vesselsin thesetting
of EVAR.1 4 , 1 8 , 2 2 , 2 8 - 3 0
Leyden et al1 8
report 1 of 21 pa-
tients(4.3%) with colonic ischemia after hypogastric artery
embolization. Likewise, Karp et al3 1
reviewed 24 patients
with either coiled or unintentional covering of a hypogas-
tric artery during EVAR, and found 3 patients (12%) in
Internal iliac artery interruption and ischemic complications after
endovascular abdominal aortic aneurysm repair. Note: 16.3%of all
patients treated with coil embolization had an ischemic event,
compared with 8.0%of patientswho underwent internal iliac artery
embolization (P .091).
JOURNAL OF VASCULAR SURGERY
Volume 40, Number 4 Maldonado et al 707
The overall ischemic complications
after interruption of hypogastric
arteries before EVAR was 16.3%,
compared with 8% in intact
hypogastric arteries
The incidence of buttock
claudication ranges from 11% to 50%
after coil embolization of one or
both internal iliac arteries

18. WHAT CAN WE DO ???

20. Antegrade and
Retrograde Periscoping
Technique for visceral
revascularization"
s for Sandwich grafts"

21. Comparison of fenestrated endovascular aneurysm repair
and chimney graft techniques for pararenal aortic
aneurysm
Hiroshi Banno, MD, PhD, Frédéric Cochennec, MD, Jean Marzelle, MD, Jean-
Pierre Becquemin, MD, FRCS
Department of Vascular Surgery, Henri Mondor Hospital, University Paris XII,
Créteil, France
Received: September 3, 2013; Accepted: January 18, 2014; Published Online:
February 20, 2014
Conclusions
In this limited retrospective series, short-term and midterm
results of f-EVAR and c-EVAR were not statistically different.
c-EVAR could be an attractive option for patients not
suitable for f-EVAR.

22. Critical Analysis of the Mid-term Results after Chimney
EVAR: Cause for Concern
Salvatore T. Scali, Robert J. Feezor, Catherine K. Chang, Alyson Waterman-Pugh,
Scott A. Berceli, Thomas S. Huber, Adam W. Beck
University of Florida- Gainesville, Gainesville, FL
CONCLUSIONS: These results demonstrate that chEVAR can
be completed with a high degree of initial success. Significant
rates of both perioperative complications and major adverse
events during follow-up, including loss of chimney patency
and endoleak, are not uncommon thus underscoring the
critical need for close surveillance. Elective use of chEVAR
should be performed with caution and comparison to open
and/or fenestrated EVAR is needed to determine the long-
term efficacy of this technique.

23. Critical Analysis of the Mid-term Results after Chimney
EVAR: Cause for Concern
Salvatore T. Scali, Robert J. Feezor, Catherine K. Chang, Alyson Waterman-Pugh,
Scott A. Berceli, Thomas S. Huber, Adam W. Beck
University of Florida- Gainesville, Gainesville, FL
CONCLUSIONS: These results demonstrate that chEVAR can
be completed with a high degree of initial success. Significant
rates of both perioperative complications and major adverse
events during follow-up, including loss of chimney patency
and endoleak, are not uncommon thus underscoring the
critical need for close surveillance. Elective use of chEVAR
should be performed with caution and comparison to open
and/or fenestrated EVAR is needed to determine the long-
term efficacy of this technique.

25. discharge. Primary end-points included chimney stent patency and freedom from MAE.
Secondary end-points included complications and long-term survival.
RESULTS: From 2008-2012, 41 patients [age ± standard deviation (SD); 72.7±8.3; male
65.9%(N=27)] were treated with a total of 76 chimney stents (renal, N=51; superior
mesenteric artery, N=16 celiac artery, N=9) for a variety of pathologic indications,
including: juxtarenal aneurysm, 41.5% (N=17, 1 rupture); suprarenal aneurysm, 17.1%
(N=7), thoracoabdominal aneurysm, 17.1% (N=7), aortic anastomotic pseudoaneurysm,
14.6% (N=6; 3 ruptures), type 1a endoleak after EVAR, 7.3% (N=3), and atheromatous
disease, 2.4% (N=1). Two patients had a single target vessel abandoned due to
cannulation failure and 1 patient had a type 1a endoleak at case completion (technical
success = 92.7%). Intraoperative complications occurred in 7 (17.1%) cases: graft
maldeployment with unplanned mesenteric chimney (N=2) and access vessel injury
requiring repair (N=5). Major postoperative complications developed in 19.5% (N=8).
30-day and in-hospital mortality were 4.9% (N=2) and 7.3% (N=3), respectively.
At median follow-up of 18.2 (range 1.4-41.5) months, 22% (N=9) of patients developed
endoleak at some point during follow-up [type 1a, 7.3% (N=3); type 2, 9.6% (N=4);
indeterminate, 7.3% (N=3)]. One patient (2.4%) underwent surgical conversion who was
initially treated for dissection-related suprarenal aneurysm. The estimated probability of
freedom from reintervention (±standard error mean) was 96±4%
at both 1 and 3 years. Primary patency of all chimney stents was 88±5% and 85±5% at 1
and 3 years, respectively (Figure 1). Corresponding freedom from MAE was 83±7% and
57±10% at 1 and 3 years (Figure 2). The 1 and 5-year actuarial estimated survival for all
patients was 85±6% and 65±8%, respectively.
.

27. •! 72 patients in 2 centres"
•! 46 balloon-ex (V-12 and Endurant) and 81
self-ex (Viabahn and Excluder)"
•! Only 1 vessel occlusion and 1 persistent Type
I endoleak"
•! No deterioration in renal function"
•! Success persisted out to 2 years"
JVS Dec 2011!

28. Future Applications"
Off the Sh
Fenestrate
Graft
Endologi
VENTAN

32. Intent of Hybrid Approaches:
Expand the Landing Zone for Endoluminal Grafting
by Rerouting Arterial Branches
Hybrid Procedures-
• No randomized trials
• Small case volumes
• Application of a variety
of techniques (no
uniformity)
• No commercial products
• Requires customization
Surgical
Endovascular

33. Hybrid procedures have several advantages over
conventional open repair, including avoiding :
- thoracotomy,
- single-lung ventilation,
- aortic cross-clamping, and
- minimizing end-organ ischemia
several centers with large complex aortic volume,
systematic reviews, and a national registry have shown
that hybrid procedures carry high mortality rates

34. NACAAD registry 2011
208 patients complex abdominal aneurysms at 14 centers in North America.
a mean age 71 years
Mortality 14% for all patients, 16% for TAAAs, and 9% for pararenal aneurysms.
Independent predictors of early mortality included
three-vessel reconstruction,
coronary artery disease,
congestive heart failure,
high SVS scores,
chronic kidney disease stage >
morbidity occurred
Morbidity
pulmonary (22%), renal (19%),
gastrointestinal (14%)
Spinal cord injury (10%), and
ischemic coli- tis (6%).

36. OUR ROUTINE
• FOR A PERFECT FIT
– Multidisiplinary Team
– Patient for Good & Bad Cases
– Device, “know our device”
– Planning
– Surveillace
• IMAGING IS CRITICAL
– Selection, Patients & Device
– Additional Proc

37. Good “ideal” anatomy

38. Nice-long neck

39. Nice straight iliac arteries

40. Proximal Neck
Diameter
Length
Angle
Thrombus
Calcification
Distal Landing Zone
Diameter
Length
Angle
Thrombus
Calcification

41. Neck
Proximal anchoring zone
Diameter < 32 mm
Length > 15 mm
Angle < 75°
No thrombus
No calcification

42. Iliac arteries
Distal “seal” zone
Diameter > 7 mm
‘Seal’ zone > 15 mm
Angle < 90°
Not too tortuosity
Not too calcified

43. Neck
Too wide (> 25 mm – AneuRx, >32 mm - Talent)
Too short (< 15 mm)
Too angulated (>60°)
Too diseased
Cone-shaped Iliacs
Too tortuous
Too small (< 7 mm)
Too calcified
There are always challenges

44. >90° 80°
Neck Angulation

45. 65°
Neck Angulation
65° angulation neck Implant angio shows endoleak

46. Angulated but long neck

47. LR_4HKL2046 80°
Angulated but long neck

48. LR_4HKL2046
Angulated but long neck

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

50. Short and angulated Neck
Angulated neck, 75Angulated neck, 75ºº
20 mm20 mm
16 mm16 mmNeck Length 10 mmNeck Length 10 mm

51. Short and angulated Neck

52. Cone-shaped Neck

53. Cone-shaped Neck

54. Cone-shaped Neck
Device migration

56. Neck Filling Defect

57. Neck Filling Defect (>50%)

58. Iliac artery tortuosity

59. Iliac artery tortuosity

60. Iliac Artery Stenosis
10 mm10 mm
4 mm4 mm
8 mm8 mm
6 mm6 mm

61. Iliac Artery Stenosis

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

63. Accessory Renal Artery
Accessory renal arteryAccessory renal artery

64. Low right accessory renal artery
Accessory Renal Artery

65. Enlarged CIA: 30% of cases
22 mm
18 mm

66. R L
Bilateral Common Iliac Artery Aneurysms

67. 40 mm40 mm20 mm20 mm
Bilateral Common Iliac Artery Aneurysms

68. Right CIARight CIA
AneurysmAneurysm
Coil occlusionCoil occlusion
right internal iliacright internal iliac
EndograftEndograft
extendedextended
IIA occlusion and limb extension

69. Yano, 2001
Karch, 2000
Criado, 2000
Mehta, 2001
IIA occlusion
cases
103
22
39
154
Pelvic ischemia complications
total
cases
22 (21%)
10 (42%)
6 (15%)
71 (46%)
buttock
claudication
95%
70%
83%
79%
colonic
ischemia
5%
30%
0%
6%
others
17%
15%

71. Bell-bottom

72. Bell-bottom

73. Thank you