醫(yī)生培訓(xùn)原文6.evar course-additional considerations

1、AccessComplications EndoleaksReimbursementAccess ChallengesSmall arteriesCalcified Stenotic Acute angulationEIA usually the culpritProphylaxis is the KEYNote: Endurant II Main Body (Bifurcated Configuration) 18 and 20FAccess StrategyIliac anatomy should be evaluated on preoperative CT scanIliac anat

2、omic challengesUse largest iliac vessel as main body access site in most instancesAccess StrategyStrategy to address iliac disease should be formulated preoperativelyPerform angiogram to assess the situation and locate the area of difficultyAdvance device over super-stiff guidewires (Lunderquist, Am

3、platz) to straighten vesselAlways advance stiff guidewires through a catheterHand pressure on abdominal wall by assistant to reduce iliac tortuosityIliac Artery LoopsLarge lumen, minimal Ca+ - Vessel straightens out with stiff wireAccess Troubleshooting: Balloon, Serial DilationConduitsGradually inc

4、reases vessel size by passing serial dilators through the arteryPerform percutaneous transluminal angioplasty to predilate the access arteryConduitCIA10mm dacron graftLigate if not needed to bypass EIATunnel under inguinal ligament and use in future for accessClamp arteriesProstheticTakes timeAccess

5、: WARNING!Preparatory steps do not compensate for undersized iliac vessels / oversized deviceOver-dilatation of iliac arteries can lead tovessel endarterectomy (iliac-on-a-stick) or vessels ruptureUse particular caution in small, elderly female patients, external iliac stenosesMay not be evident unt

6、il removal of introduction sheathYou sure want to avoid this!TechniqueIf arterial dissection occurs during graft deployment, complete deployment, then consider endoluminal intervention.NEVER lose wire accessespecially as endograft being removedDiagnosisFeel for pulse AngiogramHemodynamicsDo not hesi

7、tate to open conversion in an unstable patientTechniqueBe prepared with compliant occlusion balloon and have appropriate devices available: stents, covered stentsLarge balloon up ipsilateral side to get controlCutdown and perform repair operation Endo optionUpsize contra sheathBalloon up contralater

8、al sideInflate contra balloon; deflate ipsi balloonPlace covered stentDo not hesitate to open conversion in an unstable patientEndoleaksEndoleaks are a concern because they have the potential to pressurize the aneurysm sac, which may expand the aneurysm and cause rupture.Not all endoleaks have clini

9、cal significance (i.e. sac pressurization)Not all endoleaks require interventionAny leak left untreated must be carefully monitoredPrimary procedural endoleaksEtiologies:Inaccurate deployment of correctly sized deviceLow placement of proximal implantation siteHigh placement of distal implantation si

10、teIncorrectly sized device in suitable aneurysm for EVARUndersized graft leads to perigraft leakOversized graft leads to graft infoldingUnsuitable candidate for EVARType IAttachment siteProximal and distalType IICollateral vesselBackbleeding from covered vessels IMA, lumbar, accessory renalType IIIF

11、ailure of graft, fabric tearModular disconnection at junctionType IVTransgraft “blush” due to porosity of graftType VEndotensionEndoleaksType Ia (Proximal) EndoleaksEtiology plete opposition of stent graft with aortic neckFactors: thrombus, calcium, angulation, short neck, non-parallel walls, incorr

12、ect device sizingTreatmentCorrect for parallax to ensure correct proximal placementBallooning with Reliant compliant balloon (prolonged inflation)Placement of proximal aortic cuff with adequate distance below lowest renal arterySupra-renal stenting with uncovered balloon inflatable stentMini-laparot

13、omy with open suture fixation of neckConversion to open procedureSmall Type I Endoleaks MAY be observed after corrective measures have been performedClose CT follow-up must be performedType Ib (Distal) EndoleaksEtiologyIncorrect oversizing of iliac limbs“Short” deployment within larger proximal ilia

14、c vessel due to excessive tortuosity of iliacs or crossed (ballerina) iliac limbsTreatmentBalloon angioplasty of distal attachment siteIn cases of short seal zone length, use iliac extension to lengthen landing zoneIn cases of undersized distal attachment zone, place a (flared) iliac extension to ac

15、hieve adequate fixation and seal. Coil IIA if necessaryType II EndoleaksPersistent, collateral blood flow into the aneurysmal sac from one or more of these sources:The lumbar arteriesThe inferior mesenteric arteryThe internal iliac arteryOften do not require treatment A subset will demonstrate sac e

16、nlargement, an indication of elevated pressure, and increased risk of ruptureTreatment of these Type II Endoleaks is mendedType III EndoleaksModular component separation or defect in the graft material mon with correct overlap zone between componentsMay occur with removal of stiff wires in extremely

17、 tortuous iliac anatomyRequires re-establishment of wire access and additional extension limbsType IV EndoleaksOccurs when blood leaks through intact but porous graft material.If a Type IV Endoleak is suspected, apposition of the stent graft components at the proximal and distal implant sites should

18、 be confirmed by angiography or IVUS to rule out Type I Endoleaks.Lateral and oblique angiograms may also be considered. The angiograms should be carefully assessed to determine if the leak is late blush due to anticoagulation and to rule out Type I and Type III leaks.Treatment is not usually necess

19、ary since this type of endoleak may resolve spontaneouslyType IV EndoleaksTroubleshooting a blush:If the power injector pressure is set too high, it can cause a blush. Lower the pressure of the power injector and reshoot the angiogramIf ACT is too high, let ACT come down and reshoot the angiogramTyp

20、e V EndoleaksEndotension is classified as a Type V Endoleak Characterized by elevated pressure within the aneurysm without evidence of blood flow in the sac Watchful waiting is mendedPotential for open conversion if continued expansion or re-expansion of the sac is observed Potential EVAR Complicati

21、onsEarlyAccess IssuesRemoval IssuesDeployment ComplicationsProximal neckType IRenal coverageRadiationContrast LoadLateEndoleakMigrationSac Growth/RuptureStent FractureNeck degenerationLimb occlusionKinking / CollapseDevice fatigueRepeat CT scans Complication ManagementCareful preoperative sizing and

22、 planning is criticalAlways bring more than you need:WiresSnaresAdditional limbs/cuffsAdjuvant stents (renal, iliac, aortic)Covered stents including AUIOccludersCoilsDiagnostic catheters Synthetic Grafts for conduit of Fem-Fem BypassReference: Complications and bailout situations during AAA endovasc

23、ular repair. Overbeck K, et al. Tech Vasc Inter Rad 2005, 8: 22-29Bring more than you need: Ancillary Product ListSupplementary EquipmentSentrant Sheath16Fr introducer sheath (30-35 cm)21-24Fr introducer sheath (25 cm)Cell saver and/or autotransfuserSnare (15 mm to 25 mm)Reliant Stent Graft Balloon

24、CatheterPTA balloons (8-16 mm by 2-4 cm)IVUS Unit with cathetersCoils for occlusionInflation device with pressure gaugeSterile markerDilatorsOperating Light / Head LampStandard Equipment0.035-in. Amplatz Super-Stiff (260 cm or comparable)0.035-in. guidewire (260 cm) Terumo Glidewire (straight and an

25、gled)0.035-in. guidewire Meier Wire, Lunderquist, Mallinkrodt Wholey Plus5Fr angiographic catheters (Berenstein, Headhunter(H1), Cobra(C2), multi-sidehole, Shepherds Crook, Sidewinder, flush catheter Vanschie 5)5Fr pigtail marker catheter8Fr and 12Fr sheathPuncture needles (18 G or 19 G Seldinger or

26、 single wall)Heparinized saline solutionSterile lubricant K-Y jelly, silicone, paraffin or mineral oilBifucated Stent Graft Deployed Too LowLow deployment in the neck of the aneurysm / insufficient fixation length ( 10 mm) May result in Type I Endoleak Predisposition to post-deployment migrationInac

27、curate device deployment may be due to operator error or poor device selectionPrecase planning is critical to ensure accurate deploymentUpper margin of the main body should be positioned just below the lowest renal artery to ensure proper sealingMaximize renal artery visualization with magnification

28、 views and correct for parallaxMovement of delivery catheter during deploymentStent graft position changes as it conforms to the angulated vessel anatomy. If the stent graft is deployed too low aortic extensions may be used. See IFU for sizing guidelines. Aortic ExtensionIf additional proximal stent

29、 graft length is needed, aortic extension configurations are available* OD (Fr) Proximal x Distal Diameter (mm x mm) Covered Length (mm)Vessel inner diameter (mm) 20 36x36 49, 7029-32 32x32 26-28 18 28x28 23-25 25x25 21-22 23x23 19-20 Proximal DiameterDistal DiameterGraft Covered LengthBare proximal

30、 suprarenal stentwith anchor pins designe MarkerRadiopaque MarkersProper sizing of the device is the responsibility of the physician* For Endurant II 2-piece cases- a 49 mm aortic extension cannot fit fully within a 124 mm bifur Deployment: Jailed Contralateral GatePoor Pre-Case Planning, if recogni

31、zed early, allows tucking up the main bodyLow deployment of the bifurcated device may result in gate cannulation difficultiesMore common with swift deployment strategiesEarly recognition: reposition the graft to higher locationLate recognition: Open contralateral gate with contralateral aortic ballo

32、onAttempt up-and-over access with curved catheter/snareDeployment: Jailed contralateral gateInsufficient Distal Fixation / Seal:Insufficient distal fixation or seal of the ipsilateral or contralateral limb may occur when there is: Extreme angulation or tortuosity of the aortaIncorrect selection of s

33、tent graft length (too short!)Ensure a minimum of 15 mm of fixation is achieved by placing an appropriate extension. It is mended to extend stent graft coverage all the way down to the hypogastric artery to maximize fixation.If short or aneurysmal CIA does not allow 15mm of fixation, then extend the

34、 graft into the EIA Embolize the IIA to avoid subsequent Type II Endoleak, if the patient can tolerate the procedure.Risks associated with IIA embolization include buttock claudication, erectile dysfunction, spinal cord ischemia, and colonic ischemia. Iliac ExtensionIf additional distal stent graft

35、length is needed, iliac extension configurations are availableOD (Fr) Proximal x Distal Diameter (mm x mm) Covered Length (mm)Vessel inner diameter (mm) 18 28x28 8223-25 16 24x24 19-22 20 x20 15-18 14 16x16 12-14 13x13 10-1110 x108-9Proximal DiameterDistal DiameterGraft Covered LengthOpen Web Config

36、urationRadiopaque MarkersOverlap MarkerProper sizing of the device is the responsibility of the physicianInternal Iliac Artery / Hypogastric Artery 5% aneurysmalUnilateral occlusion40% hip and buttock claudicationOrigin often best seen on 30% RAO (left hypo) and LAO (right hypo) projectionsRetrograd

37、e injection from sheath showing IIA and its branchesDistal Deployment Too LongInternal iliac (hypogastric) coverageMay be well-tolerated if contralateral IIA is patent and without significant stenosesIntervention required if:Contralateral IIA occlusion: can cause severe pelvic ischemia or colonic/buttock necrosisAneurismal iliac causes significant distal Type I EndoleakIf contralateral IIA is occluded:Attempt to