EVAR Flashcards
What are indications for Aortouniiliac?
<15mm terminal aorta
severe unilateral iliac occlusive disease
secondary treatment of migration of a short-body endograft
What are alternatives to CTA in patients with renal failure?
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
Where and how should neck measurements be made?
below lowest renal and 15mm caudad
minor axis of axial cuts or reformatted images
How much do you oversize an endograft?
10-20% which translates into 3-4mm
What are the diameters for EVAR grafts and what size aortas can be accommodated?
20-36mm
19-32mm
What are the diameters for TEVAR grafts and what size aortas can be accommodated?
26-41mm
23-37mm
What are risks to oversizing?
>20-30%
Pleating of the graft which causes Type I endoleak
Neck dilation
stent migration
What is a conical neck and how to you size it?
2-3mm change over 15mm of aortic length
minimum 10% oversizing in larger neck and t be achieved EVAR is ill-advised
How should the iliacs be oversized? what are risks to oversizing too much?
10-20%
usually 1-3mm larger then vessel
thrombosis of the limbs
What is an ideal neck for EVAR?
What factors influence the seal zone?
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)
What are CI to percutaneous approach?
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.
What Fr sizes are perc access available?
what is success rate for perc closure for 20, 18, 16, 12 Fr?
up to 24 Fr
78%, 92%, 94%, 99%
How do you manage iliac occlusive disease?
aorta-uni
angioplasty
BMS after
ilio conduit
break and pave
What are the locations and order of wire catheter placement for EVAR?
ipsi–floppy J to prox thoracic aorta, catheter, stiff wire
contra–pigtail
ipsi–main body
At what location can the renals be found on Fluoro?
L1-L2
Which grafts can be move craniad or caudad?
both direction, Zenith
caudad, Aneuryx, Talent
What things should you look for on the completion angiogram?
patency of visceral vessels
proximal within 22mm of lowest renal
assess for endoleaks
look for iliac disease
What is the classification of Type I endoleaks?
Ia proximal seal
Ib distal seal
Ic iliac occluder
What is the classification of Type II endoleaks?
IIa filling via one branch vessel
IIb filling via two or more branch vessel
What is classification of Type III endoleaks?
IIIa junctional separation of modular components
IIIb fractures of holes in the graft
What is classification of Type IV and V endoleaks?
IV graft porosity V endotension (continued expansion of sac without demonstrable leak on imaging)
What endoleaks are essential to identify immediately?
Type I and III
How to manage Type 1a?
If distance from lowest renal 5mm, then place aortic cuff
If persists Palmaz stent placement (has greater radial force)
How to deploy Palmaz stent?
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
How to manage Type 1b endoleak?
repeated angioplasty or diatal extension
How to manage Type III endoleak?
angioplasty
if overlap not sufficient then bridging stent
Options for partly or fully covered Renal artery?
Place wire or balloon are across flow divider and apply caudad pressure.
Balloon expandable stent
extra-anatomic bypass
conversion to open
What size common iliac is appropriate to land graft?
up to 2 cm
>2cm require extension into external iliac (occlude internal)
