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EVAR Flashcards

1
Q

What French can 1 and 2 percloses accommodate?

A

8; 21

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2
Q

What are benefits of EVAR over Open?

A

Periop mortality improved w EVAR (EVAR 1, DREAM, OVER): <2% vs 5% Survival benefit lost after 2-3 years (EVAR 1, OVER) 6 year survival similar ~70% (OVER)

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3
Q

What are 5 disadvantages of EVAR vs Open?

A

More expensive (EUROSTAR) More reinterventions (OVER): 30% vs 20% at 6 yrs More reinterventions per year (EUROSTAR): 5% per yr Continued sac expansion/rupture rate (EUROSTAR): 40% at 5 yr, 1% per yr despite EVAR 50% lost to follow up at 5 yr

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4
Q

Which trial compares EVAR vs medical management?

A

EVAR 2

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5
Q

What was the final conclusion of EVAR 2?

A

No difference in aneurysm related or all cause mortality between EVAR and Med managment in pats who were medically unfit for open repair

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6
Q

What is the risk of death for pts who undergo treatment for ruptured AAA

A

~ 35% at 30d (IMPROVE)

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7
Q

What are 4 advantages of EVAR vs Open for ruptured AAA?

A

IMPROVE Improved 3 year survival (48% vs 56%) Shorter hospital stay Lower cost Better QALY Similar reinterventions rate

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8
Q

Which graft brand has the highest rate of limb occlusion?

A

Zenith Cook - EUROSTAR

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9
Q

Which graft has the highest rates of migration?

A

AneuRx and Talent

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10
Q

Name 5 ways of treating a type 1a endoleak

A
  • Proximal extension - Embolization w glue/coils - Palmaz - EndoStapling - Hemashielf patch aortic wrap
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11
Q

How frequent are type 2 endoleaks?

A

10-20% of EVARs

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12
Q

Name 5 ways of managing type 2 endoleak

A
  • Watch and wait, 80% spontaneously resolve - Embolize with coil or glue via SMA/marginal Drummond, or slipping wire in between stent and iliac limb - Translumbar direct sac puncture - Retroperitoneal endoscopic ligation - Explant or direct ligation of back bleed vessels
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13
Q

Name 4 anatomic risk factors for EVAR migration

A
  • Angulated neck - Short neck - Neck thrombus - Large diameter neck
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14
Q

What is the minimum neck length for a seal?

A

10-15 mm

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15
Q

What neck angulation is acceptable for EVAR?

A

< 60 degrees

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16
Q

Which stent is approved for neck angulation up to 90 deg?

A

Aorfix (Lombard)

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17
Q

What is the risk of EVAR limb occlusion?

A

3-7 %

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18
Q

What are 3 risk factors for EVAR limb occlusion?

A

Aortoiliac disease Small distal aorta < 14mm Tortuous iliac EVARs that land in external iliacs

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19
Q

How frequently do EVARs become infected?

A

Rarely <1%

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20
Q

How frequent is buttock claudication after EVAR?

A

Frequent. ~50%, higher when internals are embolized

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21
Q

What is the risk of erectile dysfunction following EVAR?

A

17% overall, up to 25% with bilateral internal iliac embolizations

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22
Q

Which imaging studies do you do to follow EVAR patients?

A

SVS guidelines: CTA at 1 month and 1 year If endoleak detected at 1 month, repeat in 6 months After 1 year, annual duplex.

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23
Q

What is the largest iliac seal zone diameter?

A

25 mm (28 is largest iliac limb diameter, Medtronic)

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24
Q

Which costs more - EVAR or Open?

A

Operative - EVAR Overall with length of stay - Open OVER trial - EVAR costs $37k vs Open 43k, benefit not significant after 2 years

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25
Q

What is the mortality rate of rAAA in hospital?

A

40%

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26
Q

What is the role of aortic thrombus in rupture

A

Weakens the wall - blocks wall from nutrients/hypoxia, MMP increased activity and increase vascular smooth muscle cell production of collagenase

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27
Q

Name 6 differentials for rAAA?

A
  1. Diverticulitis
  2. Renal colic
  3. Perforated ulcer
  4. MI
  5. GI bleed
  6. Pancreatitis
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28
Q

Is there time for a CT scan for a rAAA?

A

Yes. IMPROVE > 90% had CT scans. Avg 16 h to die.

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29
Q

Name 5 reasons why you should avoid crystalloid boluses for rAAA

A
  1. Reduce tamponade and increase bleeding
  2. Coagulopathy
  3. Hypothermia
  4. Acidosis
  5. Hemodilution
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30
Q

Should you use general anesthesia or local for ruptured EVAR?

A

Local - IMPROVE showed better 30 day survival

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31
Q

When should you suspect an aortocaval fistula during rAAA?

A

Persistent venous bleeding into the aneurysm after proximal and distal control

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32
Q

How do you repair an aortocaval fistula?

A

Sponge sticks for control, ligate from within the opened aortic sac

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33
Q

Define abdominal compartment syndrome

A

Elevation of abdominal pressure by 20 mm Hg with end organ dysfunction (resp, cardiac, renal or splanchnic)

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34
Q

What bladder pressures are indication for laparotomy?

A

Above 25 mm Hg

35
Q

What are 4 signs/symptoms of abdominal compartment syndrome

A
  1. Resp - increased PEEP, decreased tidal volume, elevated PCO2
  2. Oliguria
  3. Tense abdomen
  4. Decreased cardiac output
36
Q

What percentage of people experience a cardiac arrest with rAAA repair?

37
Q

What is the 2 hit hypothesis?

A

Hemorraghic shock + aortic clamping required for MOF. Either one on its own won’t cause such profound MOF

38
Q

Name 3 RCTs comparing EVAR and open rAAA repair

A
  1. ECAR
  2. AJAX
  3. IMPROVE
39
Q

What were the key 3 year outcomes of IMPROVE?

A

EVAR better - mortality, shorter LOS, cheaper, discharged home, local had survival benefit

40
Q

Which stent graft is this?

A

Endologix AFX

41
Q

Which stent graft is this?

A

Medtronic Endurant

42
Q

Which stent graft is this?

A

Gore Excluder

43
Q

Which stent graft is this?

A

Lombard Aorfix

44
Q

Which stent graft is this?

A

Trivascular Ovation

45
Q

Which stent graft is this?

A

Cook Zenith

46
Q

Which graft should you use for an AAA with a short or angulated neck?

A

Lombard Aorfix only one approved

47
Q

What are 3 relative indications for Aortouni EVAR?

A

1 - Very small < 15mm bifurcation

2-Severe unilateral iliac occlusive disease

3 - Treatment of migration of short body endograft

48
Q

If you have to plan an EVAR based off of non contrast CT, what 3 things are you missing?

A

1 - laminated thrombus in aortic neck

2 - patency of important branches e.g. internal iliacs

3 - potential occlusive disease in access vessels.

49
Q

Which devices require you to measure intima to intima?

A

Gore. All others are adventitia to adventitia

50
Q

Which EVAR stent grafts are cobalt chromium based?

A

Endologix AFX

51
Q

Which EVAR stent grafts are stainless steel based?

52
Q

Which EVAR stent grafts are nitinol based?

A

Medtronic, Gore, Ovation, Aorfix

53
Q

Which EVAR stent grafts have suprarenal fixation?

A

Cook Zenith, Medtronic Endurant, Trivascular Ovation

54
Q

Which EVAR stent grafts have infrarenal fixation?

A

Gore excluder, Endologix can be infra or suprarenal, Lombard Aorfix

55
Q

Which EVAR stent grafts have the lowest profile?

A

Gore excluder - 16F main body, 12F limb

Ovation - 14F main, 12F limb

AFX 19F main/9F limb

(In comparison - Cook = 21F main 14F limb, Medtronic 18F main 14F limb)

56
Q

Which EVAR stent graft is repositionable?

A

Gore Excluder

57
Q

Which graft should you use if aneurysm has a 10mm neck?

A

Medtronic Endurant

58
Q

How much should EVAR aortic neck be oversized?

A

10-20% (3-4mm)

59
Q

What is the range of neck diameters that EVARs can accommodate?

60
Q

What diameter measurement do you use for conical necks?

A

Split the difference. 10% over larger diameter, 30% smaller diameter. If there is more than 3-4mm conical change in the first 15mm, EVAR not advisable

61
Q

Do centreline measurements under or over estimate length needed?

A

Overestimate in cases with extreme tortuosity or if balleting the limb

62
Q

What are advantages of percutaneous EVAR?

A

3 RCTs, metanalysis

1 - Shorter procedure time

2-Lower postop pain

3-Shorter hospital stay

4- Less wound complications including infection and lymphocele

63
Q

What are disadvantages of percutaneous EVAR?

A

Higher cost of procedure. Occasional conversion to open.

64
Q

Name 6 relative contraindications to percutaneous EVAR

A

1 - Heavy anterior calcified plaque

2 - Severely scarred groin

3 - High femoral bifurcation

4-Need for multiple introducer sheath changes

5-Small iliofemoral

6-Significant proximal iliac disease

65
Q

Name 5 ways of addressing small iliacs when putting up an EVAR

A

1 - coons dilators

2 - focal stenoses - angioplasty

3 - “internal endoconduit” = put up a covered stent and aggressively balloon

4 - balloon expandable sheath

5-iliac conduit

66
Q

What rate/amount do you need for the initial aortogram using a power injector

A

“10 for 20” - 10 mL total contrast, 20 ml/s rate

67
Q

What are your options if you cannot cannulate the contralateral gate?

A

1-antegrade from brachial and snare

2-up and over snare

3-convert to aortouni

68
Q

What is the absolute minimum iliac seal zone?

69
Q

What percentage of AAA repairs in US are done by EVAR?

70
Q

What are the zones of the thoracic aorta?

A

0 - between innominate and L CCA

1 - between L CCA and L SCA

2 - L SCA

3 - beyond L SCA

4 - beyond arch

71
Q

Which zones thoracic aorta should have open repair? which should have TEVAR?

A

0, 1 - open

3, 4 - TEVAR

(2 TEVAR w carotid subclavian bypass or transposition.)

72
Q

What are the anatomic size requirements of the native aorta to permit TEVAR?

A

Native aorta - 16-42 mm

73
Q

How long do sealing zones need to be to permit TEVAR?

74
Q

What size do iliacs need to be to accomodate a TEVAR?

A

5-10 mm depending on device

75
Q

What are your options for TEVAR deployment when iliacs are too small?

A

Retroperitoneal “transplant” incision, or laparotomy to put conduit on aorta or common iliacs

76
Q

What 2 bypass options are available to do a Zone 1 TEVAR?

A

1) Right to Left carotid carotid bypass + left carotid to left subclavian bypass
2) Right subclavian to left subclavian + left subclavian to left carotid

77
Q

What are 2 approaches for a Zone 0 TEVAR?

A

1) Median sternotomy + proximal ascending aorta to left subclavian bypass + extra-anatomic bypass. benefit - do not require cardiopulmonary bypass
2) chimney technique - maintain flow to innominate artery by deploying from right brachial at same time as TEVAR deployed.

78
Q

What are the 2 major limitations of using a chimney technique for zone 0 TEVAR

A

1 - gutters

2 - can collapse the innominate branch - the sole branch providing perfusion to the brain - fatal

79
Q

What are 3 limitations of laser fenestration in the aortic arch to facilitate zone 0 TEVAR?

A

1 - holes may not line up

2 - potential trauma to aortic arch

3 - this modification to graft may cause type 2 endoleak

80
Q

Which 4 aortic arch zone 2 TEVARs with branches are available?

A

1) Gore c-tag: precannulated side branch for left subclavian
2) Medtronic Valiant - flexible LSCA external cuff - not precannulated
3) Relay plus double branch arch - two parallel tunnels to cannulate and revasc innominate and left CCA, still require carotid to subclavian bypass
4) Cook Zenith 2 side branches for innominate and L CCA with 4 trigger wires

81
Q

What are the Cook IFU for fenestrated device?

A

1-non aneurysmal infrarenal neck of 4mm

2-prox neck diameter of 19-31mm

3 - angulation < 45 degrees

4 - 3 cm distal landing zone

5 - adequate access

82
Q

What is a p-branch device?

A

Fenestrations with outpouchings to allow for pivot points and a bit more flexibility than fenestrations.

83
Q

What is a t-branch device?

A

Tapered stent graft sockets for the visceral vessels

84
Q

What is the primary drawbac of T-branch devices?

A

Delivery system requires 20F sheath

PGY 5 (25 decks)

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