Endovascular Surgery of Endovascular Surgery of Abdominal Aorta Planning Indication Sizing Classification Complication

1. Endovascular Surgery
of
Abdominal Aorta
Dr. KHALID AL-RAJHI
Consultant of Vascular & Endovascular Surgery
Lead of Vascular Surgery - Ministry of Health - Jazan Province
TOT Vascular Surgery Fellowship Program - Aseer Central Hospital, SCFHS

2. Abdominal Aorta
Anatomy
• begins at T12 and ends at L4,
where it divides into the right
and left common iliac
arteries.

3. Abdominal Aorta
- Anatomy
The abdominal aorta has:
• Three single anterior visceral branches (coeliac,
superior mesenteric artery, inferior mesenteric
artery)
• Three paired lateral
renal, gonadal)
• Five paired lateral abdominal wall branches
(inferior phrenic and four lumbar)
• Three terminal branches (two common iliac
arteries and the median sacral artery)

4. Endovascular
Surgery
• Endovascular repair is a minimal invasive
surgery, preferred treatment for many
patients with vascular disorders,
 General Health condition not fit for open
surgery
(major comorbidities, estimated time of
surgery, complications). Benefit / Risk
Value
 Suitable Anatomy
 SVS / ESVS / Nice Guidelines
younger patients with long life expectancy and
low-perioperative risk may benefit more from
open repair.
Circulation Research.
2019;124:647–661

5. Endovascular
Surgery of
Abdominal Aorta
The most common Aortic pathologies:
Abdominal Aortic Aneurysm AAA
Aortic Dissection
IntraMural Hematoma IMH
Penetrating Aortic Ulcer PAU
Aortic Stenosis / Occlusion
Iatrogenic / Traumatic Injuries

6. Resuscitative Endovascular Balloon
Occlusion of the Aorta, REBOA
for patients with non-compressible torso hemorrhage, to keep a minimum level
of circulatory status as a bridge to definitive therapy.
Classification of aortic zone.
• Aortic zone I extends from the origin of the left subclavian artery to the celiac
artery.
• Aortic zone II extends from the celiac artery to the lowest renal artery.
• Aortic zone III exists from the lowest renal artery to the aortic bifurcation.
N Engl J Med 2019; 380(8):763-70

7. REBOA

8. Summary of current clinical trials as listed on clinicaltrials.gov.

9. AAA

10. Abdominal
Aortic
Aneurysm
ultrasound-based abdominal aortic aneurysm (AAA) screening
- 40% reduction in aneurysm-related mortality
- an over 50% reduction in aneurysm rupture.
Cochrane Database Syst Rev. 2007; 3:1–22.

11. Abdominal Aortic Aneurysm
Brewster et al
J Vasc Surg. 2003; 37:1106–1117.

12. Abdominal Aortic Aneurysms - Anatomical Classification
• Abdominal aortic aneurysms (AAAs) are
commonly described based on the relation to
the renal arteries.
• Suprarenal AAA: The aneurysm involves the
origins of one or more visceral arteries but
does not extend into the chest.
• Pararenal AAA: The renal arteries arise from
the aneurysmal aorta but the aorta at the
level of the superior mesenteric artery is not
aneurysmal.
• Juxtarenal AAA: The aneurysm originates
just beyond the origins of the renal arteries.
There is no segment of nonaneurysmal aorta
distal to the renal arteries, but the aorta at the
level of the renal arteries is not aneurysmal.
• Infrarenal AAA: The aneurysm originates
distal to the renal arteries. There is a
segment of nonaneurysmal aorta that
extends distal to the origins of the renal
arteries.
Johnston KW et al JVS 1991; 13: 452-8

13. Types of
Endovascular
Repair - EVAR
• A. Standard EVAR,
• B. four-vessel fenestrated EVAR for
thoracoabdominal aneurysm,
• C. four-vessel multibranch stent graft EVAR for
thoracoabdominal aneurysm,
• D. Iliac side branch stent graft for aortoiliac
aneurysm,
• E. two-vessel chimney EVAR for thoracoabdominal
aneurysm,
• F. Nellix EVAS device,
• G. Hybrid thoracoabdominal debranching EVAR for
thoracoabdominal or suprarenal aneurysm
Dr Raf Ratinam

14. Abdominal Aortic Aneurysm
Endovascular approach
indications
• Unfit for open surgical repair OSR
• Age more than 80 years, Life
expectancy
• coronaropathy( previous MI or angina)
with functional test positive, coronary
lesions not indicated or unoperable.
• Cardiac insufficiency
• Left ventricle ejection fraction < 40 %
• Chronic respiratory insufficiency
• Creatinine > 200 Umol/L
• Hostile Abdomen (prior aortic or
abdominal surgery)

15. EVAR Planning
• Not all patients are candidate for EVAR
- Patient characteristics, anatomical and morphological characteristic study of the
aorta and its branches are mandatory
• Preprocedural imaging is paramount
(CTA 3D workstation, MRA, Angiography, IVUS)
Terarecon ( aquarius), Horo’s, Osirix ….
- detailed imaging of the aorta
- from descending thoracic to common femorals
- better to know the runoff as well

16. 3D
workstation

18. EVAR Planning
Develop a systemaic approach
 Visceral and Renal arteries
Proximal Neck Anatomy
Proximal Seal Zone
Distal Neck Anatomy
Distal Seal Zone
CIA / EIA
Access Arteries
CFA / EIA

19. EVAR Planning
Visceral and Renal arteries
• Assess patency of Celiac, SMA and IMA
• Renal Arteries
Position : - In relation to neck
- Which is lowest ?
Patency
Number

20. EVAR Planning
Proximal neck and sealing zone
• Measure at the lowest renal with length 10-15mm
below the lowest renal artery
• Measure diameter perpendicular to central vessel axis
• Axial measurements can overestimate due to
angulation and tortuosity
• Change in neck size of >10-15% over its length (neck
contour) associated with higher proximal endoleak rate

21. EVAR Planning
Device Sizing
• Oversize neck by 10-20%
• Look at vendor sizing chart
• Current devices range from 20-36 mm and can
diameters from 16-33 mm
• Remember:
- Undersized graft may have no seal
- Oversized graft may have pleats/folds

22. EVAR Planning
Quality of proximal neck
• Calcification
• Mural Thrombus
• Angulation
- Greater than 90 degrees is a risk factor for an endoleak
• Extensive calcification increases probability of stent migration
Angulation
Often seen with larger aneurysms
- Mild <40°
- Moderate 40-60°
- Severe >60°

23. Craniocaudal Angulation
Most infrarenal necks have
cranial angulation
LAO/RAO Angulation
Determine LAO/RAO
based on lowest renal
EVAR Planning

24. EVAR Planning
Iliac Arteries
• Common/External Iliac are the location of
distal seal
• Are they aneurysmal?
• If CIA aneurysmal, internal iliac artery (IIA)
embolization / branched iliac devices
- rare for EIA to be aneurysmal
- consider coiling of IIA when extending to
EIA
• Distal seal zone:
- length 10-15mm
- Oversize 10-20%

25. Iliac arteries
• Diameter > 6 mm
• Non calcified
• Non tortuous
• New devices are lower profile and hydrophilic
EVAR Planning

26. Abdominal Aorta Endoprosthesis
GORE

27. Abdominal Aorta Endoprosthesis

28. EVAR Sizing Sheet

29. Graft Parts
Tube
Aorto-uni-Iliac
Aorto-Bi-iliac

30. Access Selection
• Anatomic factors
• Vascular access
- Femoral cutdown
- Percutaneous

31. Planning + Sizing = Sealing

32. Ballet Type EVAR

33. • A software named PRAEVAorta (Nurea),
using artificial intelligence (AI), has the
potential to enable a fast, reproducible, and
fully automated analysis of abdominal aortic
aneurysm (AAA) sac pre- and post-
endovascular aneurysm repair (EVAR).
• can detect postoperative complications such as
endoleaks, endotension, stent graft migration, and
iliac limb occlusion.

34. Complex Abdominal Aortic Aneurysms
• In patients with complex anatomies unsuitable for
standard infrarenal endovascular bifurcate repair, a
number of techniques have emerged to extend the
suitability of endovascular treatment.
• These include fenestrated (FEVAR), branched
(BrEVAR) and chimney (ChEVAR) grafts for
thoracoabdominal repair.
• Novel aneurysm neck sealing mechanisms
(Anaconda, Ovation), supplementary embolisation of
the residual aneurysm sac at the time of surgery,
endovascular aneurysm sealing (EVAS) and,
controversially, multilayer flow-modulating stents.

35. FEVAR BEVAR

36. F-EVAR

37. B-EVAR

39. Kärkkäinen et al
journal of Vascular Surgery 2019
• Classification of endoleaks of fenestrated-branched endovascular
aortic repair (F-BEVAR).
• Types IC, IIIB, and IIIC are defined as target vessel endoleaks.

40. Endovascular
management of
rAAA
• Three-year results of the UK IMPROVE trial, randomizing patients to an
endovascular-first or open strategy in nominated aortic centers, shows
improved survival and quality of life, equivalent re-intervention rates
and reduced cost.

41. Complications
• patient’s general condition related complications
- CVD, respiratory, renal
• Vascular saite + access related complications
• Contrast related complications
- allergy and nephropathy
• Device related complications

43. Endoleak with sac
expansion = RUPTURE

44. Aorto-Iliac
Lesions
Trans-Atlantic Inter-Society
Consensus

45. Aorto-iliac lesion TASC D – Eiffel Tower

46. Aortoiliac Kissing Technique

48. Aorto-iliac occlusion

49. Aorto-iliac occlusion TASC D - CERAB