Aortic interventions

EVAR TEVAR & complications

1. AORTIC INTERVENTIONS DR.ANUSHUYA JUNIOR RESIDENT GOVT. STANLEY MEDICAL COLLEGE

2. AORTOGRAPHY AORTIC INTERVENTIONS

3. AORTOGRAPHY INDICATIONS Aortic regurgitation Aortic valve stenosis Aortic aneurysm Aortic dissection Before EVAR Sinus of valsalva anuerysm Coarctation of aorta Congenital anomalies, for example, aorto -pulmonary septal defect, anomalous origin of supra-aortic vessels. CATHETERS USED Pigtail 4F to 7F CONTRAINDICATIONS Pregnancy Allergy to contrast Cardiac arrythmia Impaired RFT coagulopathy

4. AORTOGRAPHY PROCEDURE Catheter placed 1 to 2 cms above the aortic valve. Depending upon the width 50 ml of contrast injected at 20ml/s. Catheter can straighten and move towards aortic valve at higher flow rates Catheter can recoil and move distally at slower fow rates Therefore catheters are held safely in operators hands. PROJECTIONS RAO 30 -40 deg is best to evaluate AR –extent of diastolic contrast medium regurgitation into the left ventricle assessed. LAO 40-60 deg projection aortic arch, ascending and descending aorta evaluated. Also, coronary ostia , vein grafts and origins of supra aortic vessels as well as the aortic isthumus well evaluated.

5. AORTOGRAPHY

6. BALLOON ANGIoPLASty and stenting AORTIC INTERVENTIONS

7. BALLOON ANGIOPLASTY AND STENTING Angioplasty of aortic stenosis can be performed with a single low -profile low-pressure large-diameter balloon (10-16 mm) from one arterial access, or two smaller balloons (8- to 10-mm diameter) with “kissing” technique from bilateral access. Kissing technique is commonly used for aortic lesions that also involve the common iliac artery origins. The long- term results of angioplasty of focal aortic stenoses are excellent, but these are rare lesions. Stent placement is indicated for eccentric lesions, recanalization of complete occlusions, or lesions that are believed to be a source of atheroemboli . Stent -grafts may be used to exclude symptomatic ulcerated plaque, but otherwise currently have little role for aortic occlusive disease.

8. BALLOON ANGIOPLASTY AND STENTING

9. “Kissing” common iliac artery stents. A , Digital image showing crossing stents (white arrows) used to treat bilateral common iliac artery origin stenoses . B, Angiogram showing that the proximal ends of the stents ( blacK arrows )extend into the distal aorta .

10. Coarctation of aorta – Balloon angioplasty INDICATIONS: Preferred for children, adults Native coarctation or after surgery Not infants <6 mos Initial success in 80-90% Gradient ≤ 20 mm Hg

11. Balloon angioplasty - complications I ncidence residual pressure >20 mm Hg 20 % (up to 35%) Incidence recoarctation up to 25 % D issection and rupture1 -3% I ncidence aneurysm in f/u up to 5 yrs 2 -8% F emoral artery complications up to 15%

12. Coarctation of aorta - STENTING Initially for those with residual gradient after BA ↑ lumen diameter ↓ residual gradient Dilate stent with growth of aorta Not for pts <25 kg

13. BA and STENTING in coarctation of aorta

14. ENDOVASCULAR AORTIC REPAIR EVAR/TEVAR AORTIC INTERVENTIONS

15. EVAR Advantages

16. Aortic aneurysm Aortic aneurysm is abnormal dilatation of the aorta greater than 50% of the normal proximal segment, or dilatation greater than 3 cm Thoracic or abdominal

17. Abdominal aortic aneurysm AAA

18. LOCATION OF AAA S uprarenal AAA involves the renal arteries and extends superiorly so that the superior mesenteric artery and celiac arteries arise from the aneurysmal aorta. Juxtarenal AAA extends to the renal arteries, with a normal-sized aorta superiorly . Infrarenal AAA arises at least 10 mm below the renal arteries . Endovascular repair is best suited for infrarenal AAAs because the renal arteries and superior mesenteric arteries are not involved

19. Thoracic aortic aneurysm TAA COMMON SITE: Ascending aorta(70%) SYMPTOMS: Hoarseness, stridor, dypnoea, dysphagia or pain due to local mass effects. Rupture presents with chest pain and shock. RISK OF RUPTURE: 4-4.9CM – 0.3% 5-5.9CM – 1.7% >= 6CM – 3.6% Endovascular repair should be considered when an asymptomatic descending aortic TAA reaches 5.5 cm. A higher threshold (6 cm) is suggested for open repair given its greater risks.

20. ACUTE AORTIC SYNDROME ASCENDING AORTA AND ARCH DESCENDING THORACIC AORTA ATHEROMATOUS AORTIC SEGMENTS,USUALLY DESCENDING AORTA SIMILAR MANAGEMENT

21. AORTIC DISSECTION

22. AORTIC DISSECTION STANFORD A DISEASE Pathology affecting the aortic root and ascending aorta (Stanford A disease) Unsuitable for endovascular repair Due to involvement of the aortic valve (which may also need repair ) and close association of critical branch vessels ( the coronary arteries and great vessels). STANFORD B DISEASE Disease affecting the aorta distal to the left subclavian artery (Stanford B disease) Amenable to endovascular repair , assuming there is enough disease-free aorta proximally to achieve a seal (usually 15–20 mm).

23. AORTIC DISSECTION COMPLICATED TYPE B –BRANCH VESSEL OCCLUSION AND END ORGAN ISCHEMIA

24. CO MPLICATED TYPE B DISSECTION persisting or recurrent pain, uncontrolled hypertension despite full medication, early aortic expansion, penetrating aortic ulcer IMH Malperfusion signs of rupture ( haematothorax , increasing periaortic and mediastinal haematoma )

25. AORTIC DISSECTION DYNAMIC DISSECTION Dissection flap has prolapsed across their aortic true lumen ostium True lumen has been compressed by false lumen P erfusion could come either from true or false lumen. STATIC DISSECTION Dissection has extended into a branch vessel Additional branch vessel stenting should be done If a reentry tear is present, distal perfusion is maintained.

26. AORTIC DISSECTION DYNAMIC DISSECTION STATIC DISSECTION

27. Static + Dynamic

28. INTRAMURAL HAEMATOMA AND PENETRATING ULCER Complicated type B PAU (with or without associated IMH) should be treated similarly to aortic dissection, with the PAU being considered the ‘entry tear’. Complicated type B IMH without an identifiable intimal defect represents a therapeutic challenge as there is no ‘target’ for limited stent-graft coverage even though the IMH itself may be extensive. It may be necessary to cover the entire involved aorta.

29. ENDOVASCULAR STENT GRAFT REPAIR AIMS

30. ENDOVASCULAR STENT GRAFT REPAIR PRINCIPLES Successful placement of the device over the primary entry tear to obliterate blood flow into the false lumen and to redirect the flow into the true lumen . Self -expanding metallic stent framework with a high outward radial force that allows attachment to the artery wall and graft fabric that creates a new conduit for blood flow and prohibits blood from entering the aneurysm sac.

31. EVAR ENDOVASCULAR STENT GRAFT DEVICE DELIVERY SYSTEM STENT GRAFT Stent-grafts are supplied preloaded on a deployment system. They are usually constrained within a sheath,which, at deployment, is gradually withdrawn, allowing the stent to expand under its own radial force.

32. EVAR STENT GRAFT Fabric tube : usually woven polyester or expanded polytetrafluoroethylene M etal struts : circular or crown-shaped ( ‘ring stents’), usually made of nitinol or Elgiloy , Attached to the tube by either suturing or gluing . Limb extensions and aortic cuffs extend the device distally and proximally, respectively

33. EVAR STENT GRAFT Most AAA stent-graft systems comprise a main body with a long limb on one side and a short limb (or ‘gate’) on the other. S hort limb is catheterised from the opposite side. A second limb is then inserted over a wire into the short limb of the main body, sealing inside the main body at a flow divider.

34. E NDURANT stent graft “M-shaped” proximal stent Enhance wall apposition Prevent infolding Provide a 5-mm sealing zone Kink resistant limb

35. PRE-REQUISITES Good quality high-resolution imaging is required to choose the correct stent-graft for a particular aneurysm . This is usually achieved with thin-section contrast enhanced arterial phase computed tomography (CT) to include the whole of the diseased section of the aorta and the access vessels (see below) in a volumetric acquisition . 3D reconstruction CT scan Angiography with a calibrated catheter necessary for EVAR eligibility. Remains gold standard to select appropriate device diameter and length. Magnetic resonance (MR) angiography is sometimes utilised.

36. PRE-OP ASSESSMENT OF AORTA NECK LENGTH is measured from the lowest renal artery to the top of the aortic aneurysm and its measurement is important in determining suprarenal or infrarenal fixation.The shorter the neck, the more complicated the procedure. LANDING ZONE  refers to the site at which the prosthesis is placed. If the landing zone is smaller, suprarenal fixation, may potentially be used. Generally, a 1.5-cm landing zone of normal anatomy is required for infrarenal fixation

37. PRE-OP ASSESSMENT OF AORTA

38. Neck Proximal anchoring zone Iliac arteries Distal “seal” zone 2 important zones

39. 2 important zones Neck Proximal anchoring zone Diameter < 32 mm Length > 15 mm Angle < 75  No thrombus No calcification

40. 2 important zones Iliac arteries Distal “seal” zone Diameter > 7 mm ‘Seal’ zone > 15 mm Angle < 90  Not too tortuosity Not too calcified

41. Nice-long neck

42. Nice straight iliac arteries

43. Good “ideal” anatomy

44. Neck Diameter Length Angle Thrombus Calci f icat i on Iliac arteries Diameter tortuosity Angle Calcifica t ion Mostly we look at

45. >9 ° 80 ° Neck Angulation

46. Neck Angulation < 60 degrees angulation Angulated and long neck “might” be OK Angulated and short neck “is bad”

47. Angulated but long neck

48. Angulated but long neck

49. Short and angulated Neck

50. Cone-shaped Neck

51. Iliac artery tortuosity

52. Iliac Artery Stenosis 10 mm 4 mm 8 mm 6 mm

53. Small Distal Aorta 14-mm lumen at distal aortic neck which is heavily calcified

54. 40 mm 20 mm Bilateral Common Iliac Artery Aneurysms

55. UNSUITABLE LANDING ZONE

56. EVAR Evaluation - contraindications Thrombus in proximal landing zone Conical proximal neck Greater than 120 degree angulations of the proximal neck Critical inferior mesenteric artery Significant iliac occlusion Tortuosity of iliac vessels

57. TEVAR Pre-requisites Proximal neck of atleast 15 to 25 mm from the origin of the left subclavian artery Distal neck of atleast 15 to 25 mm proximal to origin of the celiac artery Adequate vascular access Absence of severe tortuosity, calcification or atherosclerotic plaque in the aortic or pelvic vasculature.

58. EVAR STEP BY STEP PROCEDURE Access groins and dissect down to Femoral Artery Access the Femoral artery with a Pinnacle introducer needle Pass soft Glidewire under fluoroscopy through the Femoral to the Iliac and into the Aorta Identify the renal arteries under fluoro Pass the percutaneous sheath introducer over the Glidewire Remove the Glidewire and replace with an Amplatz stiff guide wire. Now there is a passage for the graft If vessel diameter is small, a balloon dilator may be used

59. EVAR STEP BY STEP PROCEDURE Once access is established on one side a Pigtail angiographic catheter is passed through the opposite femoral artery A power injector angiogram may be used during the procedure to ensure flow to the renals and to establish placement of the graft Using the stiff guidewire , introduce the main body graft. Once in place, deploy graft and remove the Amplatz stiff guidewire Use Amplatz stiff guidewire on opposite side to introduce the Iliac graft Deploy graft

60. EVAR STEP BY STEP PROCEDURE Cook Coda balloon catheters may be used to press the graft against the wall of the vessel and to prevent leaks Endoleaks must be identified and treated before closure. Remove guidewires and close vessel Close groin incisions and apply dressing

61. EVAR PROCEDURE

62. EVAR PROCEDURE

63. EVAR PROCEDURE

64. EVAR PROCEDURE

65. EVAR PROCEDURE

66. THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) A radiopaque marker (usually a 5F 30-cm-long sheath) may be inserted via the left brachial artery to single out the ostium of the left subclavian artery. This marker at the ostium of the left subclavian artery (LSA) may be very useful for optimal stent placement in case of an isthmic lesion. Coil embolization of the origin of the subclavian artery can be done from here if residual back flow is observed in the false lumen after stent graft deployment

67. TEVAR Angiography and (B) CT clearly show the entry tear (arrow), just beyond left subclavian artery (LSA) origin with contrast filling of false lumen. ( C,D) After S-graft deployment at the level of the tear, complete exclusion of the false lumen is achieved and normal flow is reestablished into the true lumen . LSA origin was intentionally covered to gain a better proximal sealing.

68. COMPLICATIONS ENDOVASCULAR AORTIC REPAIR

69. SURGICAL COMPLICATIONS LOCAL -groin hematoma -infection - lymphocele ACCESS ARTERY INJURY -thrombosis -dissection - pseudoaneurysm

70. DEPLOYMENT/IMPLANT RELATED DEPLOYMENT RELATED Failed deployment Bleeding Hematoma Lymphocele Infection Embolization Perforation Arterial rupture Dissection IMPLANT RELATED Endoleaks (20-30%) Limb occlusion Stent graft kink Stent migration Sac enlargement Proximal neck dilatation Infection claudication

71. Stent kinking

72. ENDOLEAKS Continuing flow of blood into the diseased segment of aorta outside the lumen of the stentgraft

73. TYPE I ENDOLEAKS Poor sealing between the device and the aortic wall, at both the proximal and distal seals (the neck and distal landing zone) CAUSE: Error in sizing of the graft Adverse neck morphology Device migration COMPLICATION: Ongoing sac pressurisation,expansion and rupture. NEEDS TREATMENT : Insertion of proximal or distal extension cuffs, balloon moulding or restenting of the seal zones, open surgical buttressing, device explantation and repair or attempts at transcatheter embolisation of the endoleak.

74. TYPE II ENDOLEAKS Small side branches of the aorta ( e.g. the intercostal, lumbar or inferior mesenteric arteries) are not usually occluded during endovascular repair. This allows the possibility of retrograde flow of blood into the diseased segment of aorta via these side branches—a type 2 endoleak. CEASE SPONTANEOUSLY Treated only if there is on going expansion of the sac Usually side branches are not embolized except left subclavian artery and internal iliac artery

75. TYPE III ENDOLEAKS CAUSE: Graft defects and fabric tears COMPLICATIONS: repressurisation of the diseased segment of aorta and (for aneurysmal disease) sac expansion and rupture. TREATMENT : relining defects with a secondary device or operative repair.

76. TYPE IV & V ENDOLEAKS TYPE IV transient graft ‘porosity’—equivalent to the ‘sweating’ sometimes seen with knitted open surgical grafts. NO TREATMENT TYPE V ongoing aneurysm sac expansion in the absence of any other demonstrable endoleak. CAUSE: Dissolving atheroma Low grade infection

77. SYSTEMIC CARDIAC PULMONARY Renal insufficiency Contrast induced nephropathy Deep vein thrombosis Pulmonary embolism Coagulopathy Bowel ischemia Spinal cord ischemia Cardiac ischemia Stroke and paraplegia(5 -20% vs < 1%)

78. STAGED ENDOVASCULAR APPROACH

79. Strategies to minimise risk of spinal cord injuries

80. Review questions Which type of stanford disease is best amenable for endovascular repair? Stanford B Requisite length and diameter of proximal anchoring zone for EVAR? Diameter <32mm and length >15mm 3. Requisite neck angle for EVAR? <75 degrees

81. Review questions 4. Fabric tubes and metal struts are made up of? Polytetrafluroethylene (PTFE) and nitinol / elgiloy 5. Recently approved stent graft which is kink resistant? E ndurant 6. What is the Rx for the below complication of EVAR? Cease spontaneously

82. Review questions 7. What is the m.c complication following EVAR? ENDOLEAK 8. EVAR is the preferred intervention in children. True/false. False/ Relative contraindication

83. Review questions 9. What is the type /importance ? Static dissection / Additional branch vessel stenting should be done 10. Staged endovascular approach- importance? Minimise spinal cord ischemic complications

84. REFERENCES Abrams’ angiography : interventional radiology / editors, Jean-François H. Geschwind , Michael D. Dake .—Third edition. Vascular and interventional radiology: the requisites / John A. Kaufman, Prof Michael J. Lee.— Second edition. Gustavo S. Oderich (eds.) - Endovascular Aortic Repair_ Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts (2017, Springer International Publishing )

85. THANK YOU AORTIC INTERVENTIONS