EVAR

Question 1

What are indications for Aortouniiliac?

Answer 1

<15mm terminal aorta
severe unilateral iliac occlusive disease
secondary treatment of migration of a short-body endograft

Question 2

What are alternatives to CTA in patients with renal failure?

Answer 2

non-contrast can’t identify intra-luminal thrombus, patency of side branches,
pigtail reduces by 50-75%
IVUS
carbon dioxide as contrast agent
gadolinium is associated now with RI

Question 3

Where and how should neck measurements be made?

Answer 3

below lowest renal and 15mm caudad
minor axis of axial cuts or reformatted images

Question 4

How much do you oversize an endograft?

Answer 4

10-20% which translates into 3-4mm

Question 5

What are the diameters for EVAR grafts and what size aortas can be accommodated?

Answer 5

20-36mm
19-32mm

Question 6

What are the diameters for TEVAR grafts and what size aortas can be accommodated?

Answer 6

26-41mm
23-37mm

Question 7

What are risks to oversizing?

Answer 7

>20-30%
Pleating of the graft which causes Type I endoleak
Neck dilation
stent migration

Question 8

What is a conical neck and how to you size it?

Answer 8

2-3mm change over 15mm of aortic length
minimum 10% oversizing in larger neck and t be achieved EVAR is ill-advised

Question 9

How should the iliacs be oversized? what are risks to oversizing too much?

Answer 9

10-20%
usually 1-3mm larger then vessel
thrombosis of the limbs

Question 10

What is an ideal neck for EVAR?
What factors influence the seal zone?

Answer 10

minimum of 15mm
angulation <45-60 degrees
Talent–minimum of 10mm

parallel neck
conical or reverse conical
thrombus
irregular shaped neck
double bubble (localized bulge in the neck)

Question 11

What are CI to percutaneous approach?

Answer 11

obesity
severely scarred groin
high femoral bifurcation
need for frequent introducer sheath chages
signif prox iliac occlusive disease
small iliofem arteries
anteriror femoral calcific disease.

Question 12

What Fr sizes are perc access available?
what is success rate for perc closure for 20, 18, 16, 12 Fr?

Answer 12

up to 24 Fr
78%, 92%, 94%, 99%

Question 13

How do you manage iliac occlusive disease?

Answer 13

aorta-uni
angioplasty
BMS after
ilio conduit
break and pave

Question 14

What are the locations and order of wire catheter placement for EVAR?

Answer 14

ipsi–floppy J to prox thoracic aorta, catheter, stiff wire
contra–pigtail
ipsi–main body

Question 15

At what location can the renals be found on Fluoro?

Answer 15

L1-L2

Question 16

Which grafts can be move craniad or caudad?

Answer 16

both direction, Zenith
caudad, Aneuryx, Talent

Question 17

What things should you look for on the completion angiogram?

Answer 17

patency of visceral vessels
proximal within 22mm of lowest renal
assess for endoleaks
look for iliac disease

Question 18

What is the classification of Type I endoleaks?

Answer 18

Ia proximal seal
Ib distal seal
Ic iliac occluder

Question 19

What is the classification of Type II endoleaks?

Answer 19

IIa filling via one branch vessel
IIb filling via two or more branch vessel

Question 20

What is classification of Type III endoleaks?

Answer 20

IIIa junctional separation of modular components
IIIb fractures of holes in the graft

Question 21

What is classification of Type IV and V endoleaks?

Answer 21

IV graft porosity 
V endotension (continued expansion of sac without demonstrable leak on imaging)

Question 22

What endoleaks are essential to identify immediately?

Answer 22

Type I and III

Question 23

How to manage Type 1a?

Answer 23

If distance from lowest renal 5mm, then place aortic cuff
If persists Palmaz stent placement (has greater radial force)

Question 24

How to deploy Palmaz stent?

Answer 24

hand-mounted on balloon in slightly asymmetric fashion (more balloon out the top end so this part of the ballon deploys first)
advance sheath past deployement zone
to prevent watermelon seeding must deploy with distal part in sheath
deploy at 10mm length in 5cm, 28mm lenght in 3.8cm

Question 25

How to manage Type 1b endoleak?

Answer 25

repeated angioplasty or diatal extension

Question 26

How to manage Type III endoleak?

Answer 26

angioplasty
if overlap not sufficient then bridging stent

Question 27

Options for partly or fully covered Renal artery?

Answer 27

Place wire or balloon are across flow divider and apply caudad pressure.
Balloon expandable stent
extra-anatomic bypass
conversion to open

Question 28

What size common iliac is appropriate to land graft?

Answer 28

up to 2 cm
>2cm require extension into external iliac (occlude internal)