This document discusses abdominal aortic aneurysms (AAAs) and their endovascular repair (EVAR). It defines AAAs as a dilatation of the abdominal aorta over 3cm in diameter. EVAR involves inserting a folded graft through the femoral artery which expands to exclude the aneurysm sac from blood flow and pressure. The benefits of EVAR over open repair include lower peri-operative mortality and complications. Proper patient assessment including vascular anatomy and medical comorbidities is important for determining candidacy for EVAR. The procedure involves deploying graft components in the aorta and iliac arteries under imaging guidance. Post-operative surveillance with imaging is needed to monitor for complications like endoleaks.

2.  What are AAA?
 Management Options
 Endovascular Repair
 Procedure
 Complications
 Post-Operative Management

3. Anatomy Revisited
 Abdominal aorta
 Hiatus of diaphragm  bifurcation into common iliac
arteries (L4)
 Paired and unpaired visceral branches
 Common iliac a.
 Internal iliac a.
 External iliac a.
 Common femoral a (after passing below inguinal
ligament)

5. AAA Definition
 Localised dilatation of abdo aorta
 Diameter >50% of normal aortic
diameter
 Normal 2cm (1.4-3cm)
 >3cm considered aneurysmal
 Up to 40% assd with
iliac artery anuerysm

6. Indications for Repair
 Symptomatic
 Tenderness, abdo or back pain
 Embolization
 Rupture
 AAA ≥ 5.5cm
 >0.5cm expansion withing 6-months

7. Management Options
 Open AAA repair
 EVAR
 Conservative

8. What is EVAR?
 Nicholas Volodos, Kiev, 1987
 Endovascular aneurysm repair
 Folded graft components inserted through femoral
artery into aorta and then deployed
 Graft expands contacting the aorta wall
 Excludes aneurysm sac from aortic blood flow and
pressure
 Suitable for 2/3 of pts with infrarenal AAA

9. Benefits of EVAR
 Accounts for nearly half of all AAA repairs
 Significant  peri-op mortality
 No open exposure or aortic clamping
  incidence of ruptured AAA
 Can be offered to pts not suitable for open repair

10. Disadvantages
 Not suitable for all
 Cost
 £3,000 - £10,000 more expensive
 May need conversion to open repair
 Lifetime surveillance
 ?radiation risk
 Does not completely eliminate future risk of rupture

11. Assessment
 Pre-Operative Assessment
 Technical Assessment

12. Pre-Operative Assessment
 As for open repair
 POAC
 IHD is leading cause of early & late mortality
 COPD
 Renal insufficency

13. Technical Assessment
 CT angiography with 3-D reconstruction
 (Arteriography in emergencies)
 Measurements:
 Aortic neck diameter
 Aortic neck length
 Aortic neck angulation
 Infrarenal aortic length
 Common iliac a. Diameter
 Renal or artery anomalies

14. Technical Aspects
 Aortic neck diameter
 Size + 15-20%
 Sufficient radial force
 Oversize - Kinking,
thrombus formn, endoleak
 Aortic neck
 10-15mm (sufficient landing zone)
 Normal appearance
 Aortic neck angulation
 <60°

15.  Iliac Arteries
 Minimal calcification / tortuosity
 No stenosis or mural thrombus
 Sufficient diameter & length
 If external Iliac art. = landing
zone, internal iliac art. should
be embolised (prevent
backflow)

16. Pre-Operative Preparation
 Thromboprophylaxis
 Prophylatic antibiotics
 Cephalosporin or vancomycin for <24hrs
 Prevent Contrast-Induced Nephropathy

17. Procedure
1. Anaesthetise
2. Gain vascular access
3. Place guidewires & sheaths
4. Confirm anatomy
5. Main body deployment
6. Gate cannulation
7. Iliac limb deployment
8. Graft ballooning
9. Completion imaging

18. 1. Anaesthetise
 GA, regional, LA with sedation
2. Gain vascular access
 Bilateral femoral access
 Surgical cutdown or percutaneous
3. Place guidewires & sheaths
4. Confirm anatomy
 Aortography

19. 5. Main body deployment
 Proximal radiopaque markers
 Below renal artery
6. Gate cannulation
 Guidewire through contralateral femoral vessel
 Into graft gate
7. Iliac limb deployment (bilateral)
8. Graft ballooning
 Angioplasty of attachment sites and endograft
junctions
9. Completion imaging
 Renal artery patency & exclude endoleak

20. Post-Operative Care
 Ward care
 Eat & drink
 Analgesia
 IV fluids (prevent contrast nephropathy)
 D1 – mobile
 LOWER LIMB PULSE MONITORING

21. Surveillance
 Contrast CTA
 Duplex US
 1 month
 12 month
 Annual thereafter

22. Complications
 Renal damage
 IV contrast, emboli
 DVT/PE
 5.3% develop DVT despite thromboprophylaxis
 MI
 Lower limb ischaemia/emboli
 Endoleak

23. Complications
 Overall complication rate ~ 10%
 Device-related
 Open conversion (<2%)
 30-day all cause mortality:
 1.6% vs 4.8% (all)
 4.7% vs 19.2% (ASA IV)
 3-4 year mortality equal

24. EndoleakType Aetiology
I Incompetent seal at proximal (Ia) or distal (Ib) attachment
sites
- Ongoing risk of rupture, correct promptly
II Flow into and out of aneurysm sac via patent branch vessels
(lumbar, IMA)
- 10-25%
III Separation of graft components (IIIa) or fabric tear (IIIb)
- Ongoing risk of rupture, correct promptly
IV Egress of blood through fabric pores
V Continued aneurysm sac expansion without demonstrable
leak

26. Thank You