On November 10, a meeting about the role of IVUS on vascular surgery (Chairman Prof. Andrea Stella) took place in Bologna. The meeting was an excellent opportunity to discuss about the role of the IVUS in every field of vascular surgery: type B dissections, AAA's, PAOD, popliteal aneurysms and chronic venous obstructions.

1. Dr. Michelangelo Ferri – Dr. Andrea Viazzo
S.C. Chirurgia Vascolare - Ospedale Mauriziano Umberto I
Torino
IVUS for Abdominal Aortic
Aneurysm
I part
Bologna, 10 novembre 2016

2. IVUS in EVAR procedure
2
 Digital imaging catheter (Visions PV
.035) ensures accuracy of critical size
measurements of larger vessels up to
60 mm
 .038” and .035” guide wire compatible
 90cm Over The Wire catheter design
(for outstanding trackability and
pushability)

3. Why IVUS in EVAR?
Rationale
•Minimise renal load with contrast media
•Minimise X-ray exposure time
•During procedure
– Accurate measurement of the diameter and
the lenght of the neck
– Optimizing deployment
– Accurate evaluation iliac accesses

4. …this may change with routine use of intravascular ultrasound (IVUS)providing real time read out of
luminal vascular dimensions, in combination with identification of vessel branches, and simultaneous
possibility of vessel wall analyses.
…the amount of radiopaque contrast medium injected per patient was zero in 47/80 patients (59%) of the
entire series
IVUS is a reliable tool for target site identification, landing zone measurement, neck quality analysis,
perprocedural quality assessment, and trouble shooting during endovascular aortic aneurysm repair. In most
cases, perprocedural angiography is not necessary for endovascular aneurysm repair.

5. • Using IVUS technology allows one to identify the renal vein as our landmark, and subsequently
identification of the diameter and length of the neck…
• Presence of thrombus at the neck of the aneurysm may be a relative contraindication for deployment
of an endograft, and this can easily be detected with the help of an IVUS.
• Intravascular ultrasound is also helpful for determination of apposition of the stent graft to the aortic
wall
• A significant advantage of IVUS in comparison with the angiogram is that it may be used instead of
the angiogram to save contrast on a patient that has renal insufficiency

6. Conclusion:
 IVUS can reduce radiation and contrast exposure from both
preoperative CT scans and intraoperative angiography.
 IVUS allows for precise device sizing and identification of critical
vessel origins.
 As more users become familiar with interpretation of the IVUS
imaging, many procedures can be performed with limited or no use
of iodinated contrast agents.
 IVUS is invaluable in identifying true lumen access and defining
entry sites in dissection pathology. It allows for precise placement
of endovascular devices and limits the extent of aortic coverage.
Minimising contrast medium and X-ray exposure
Semin Vasc Surg. 2009 Sep;22(3):172-80

7. Eur J Vasc Endovasc Surg. 2010 Nov;40(5):559-63
Minimising contrast medium and X-ray exposure
112 patients divided in 2 groups:
• non IVUS (n=79)
• IVUS (n=33)
Subsets of IVUS
(17 pazients with renal dysfunction or suspected allergy to intravascular
arterial contrast agents):
IACA  67 ± 34 ml
Patients non-IVUS group:
IACA 123 ± 50 ml
Conclusion:
IVUS is a powerful auxiliary method in EVAR for reducing the volume of contrast agent
and reducing radiation exposure to patients and operators. The authors recommend the
routine use of IVUS during EVAR procedures, but they stress that IACAs are usually a
necessary component of this technique.

8. Abdominal Aorta
 When imaging at the level of the renal vein,
rotate the image so that the renal vein is at 12
o’clock
 To rotate: when LIVE, click ADJUST IMAGE
and use the REVOLVE key
 This is because the renal vein naturally runs
anterior to the aorta

9. EVAR procedure recommendations (1)
 Obtain bilateral access to the femoral arteries
 Insert 5F sheath
 Insert glide wire and marker pigtail catheter on the side designated to deliver the main
body of the graft
 Perform angiogram
 At this point you will use the markers on the pigtail to get a length measurement for the
main body of the graft (lowest renal artery to hypogastric)
 Remove pigtail catheter and insert 9F or 11F sheaths to both sides

10.  Insert IVUS catheter
 On the side where the main body of the graft will be inserted
 Advance IVUS catheter to locate the hypogastric take off
 Mark the take off on the monitor
 Continue to advance the catheter to locate the renal vein and renal arteries
 Mark the level of the lowest renal on the monitor
 Advance catheter to the level of the celiac and record a pullback
 Go back through the pullback and make your measurements
EVAR procedure recommendations (2)

11. 11
Identification of anatomic references
With .035” or .038” guide wire is possible
identify:
 Celiac trunk
 Left renal vein
 Renal Arteries
 Aneurysm
 Aortic bifurcation and iliac vessels
 Hypogastric arteries
Renal vein
Renal artery

12. Examples of length measurements with IVUS
12
Celiac
SMA
Aneurysm
LFT. Renal Artery
Renal Vein
Hypogastrics
Common illiacs
Length
Length
Length Measurements
IVUS to ensure 25mm distal support.
Length measurements:
1. Infrarenal to base of proximal neck
2. Infrarenal to bifurcation of aorta (illiacs)
3. Base of neck to bifurcation of aorta
(illiacs)
4. Illiacs to Hypogastrics

13. Infrarenal neck measurement…

14. Distal neck measurement…

15. Common Iliac measurement…

16. External Iliac measurement…

17. IVUS for EVAR
Aortic angiography IVUS: proximal neck

18. IVUS for EVAR: Abdominal aortic measurement

19. Access RCIA Calcifico Access RCIA Occluso
IVUS for EVAR: access

20. IVUS: Gate compression on IVUS
LCIA Gate Compression on Angio
IVUS: Accesso LCIA Post-PTA
IVUS for EVAR: access

21. IVUS measurementof right
common iliac artery length
Aneurysmdiameterin right
iliacartery
1° caso 3° caso2° caso
EVAR BRANCHED

22. Rtiliac vessel preandpostopening endoprosthesis
Hypogastric
1° caso 3° caso2° caso

23. Infrarenalneck
diameter
1° caso 3° caso2° caso
Renalartery

24. IVUSandangiogrampostEVAR
1° caso 3° caso2° caso
IVUS is utilized to choose
a graft appropriately
and to confirm the correct
deployment under renal
arteries

25. EVAR: Endo-Vascular Aneurysm Repair
Infrarenalneck
diameter
Renalvein
1° caso 3° caso2° caso
Leftrenalartery
Rightrenal
artery
Guidewire
Calcific plaque

26. 1° caso 3° caso2° caso
Renalvein
Measurement ofneckdiameter

27. 1° caso 3° caso2° caso
IVUS catheter:EVARguidedby
intravascularultrasound
Rightrenalartery

28. 1° caso 3° caso 4° caso2° caso

29. 1° caso 3° caso2° caso
Angiogram postEVAR

30. EVAR (no m.d.c.)
1° caso 3° caso2° caso
Renal
vein
Wire artifact
Neck diameter

31. 1° caso 3° caso2° caso
IVUS:
image of
iliac vessel
Wire artifact
Presence of calcific plaque

32. 1° caso 3° caso2° caso

33. 1° caso 3° caso2° caso
Preop. 6 months