EVAR Planning: Keys to Success Shawn Sarin, MD Vascular and Interventional Radiology The George Washington University Medical Center

Shawn N. Sarin, MD I/we have no real or apparent conflicts of interest to report. Off-Label: Some peripheral intervention devices are off-label.

Planning Not all patients are candidates for EVAR Choose the right patients Patient characteristics and aneurysm anatomy Only 60% ideal for EVAR based on anatomy Preprocedural imaging is paramount Detailed imaging of the aorta From descending thoracic to common femorals Nice to know the runoff as well

Pre Procedure Imaging CTA 3D Workstation MRA Angiography IVUS

Develop a Systematic Approach Visceral and Renal arteries Proximal Neck Anatomy Proximal Seal Zone Distal Neck Anatomy Distal Seal Zone CIA/EIA Access Arteries CFA/EIA

Visceral and Renal Arteries Assess patency of Celiac, SMA and IMA Renal Arteries Position In relation to neck Which is lowest? Patency Number

Diameter of Proximal Neck Measure at the lowest renal and 10-15mm below the lowest renal

Measurements Axial measurements can overestimate due to angulation and tortuosity Measure diameter perpendicular to central vessel axis

Device Sizing Oversize neck by 10-20% Look at vendor sizing chart Current devices range from 20-36mm and can treat aortic neck diameters from 19-32mm Remember: Undersized graft may have no seal Oversized graft may have pleats/folds

Length of Proximal Neck Need to create a seal between the endograft and the aortic wall 10-15mm length

Contour of Proximal Neck Change in neck size of >10-15% over its length associated with higher proximal endoleak rate Straight Tapered Reverse Tapered Morphology of proximal aortic neck

Quality of Proximal Neck Calcification Mural Thrombus Angulation Greater than 90 degrees is a risk factor for an endoleak Extensive calcification increases probability of stent migration

Angulation of Proximal Neck Often seen with larger aneurysms Mild <40° Moderate 40-60° Severe >60°

Tips and Tricks Assess angulation on preprocedure imaging will help during procedure and optimize endograft placement Place endograft as close to lowest renal as possible

Craniocaudal Angulation Most infrarenal necks have 5-15° cranial angulation

LAO/RAO Angulation Determine LAO/RAO angulation based on lowest renal

LAO/RAO Angulation Determine LAO/RAO angulation based on lowest renal

Iliac Arteries Common/External Iliacs are the location of distal seal Are they aneurysmal? rare for EIA to be aneurysmal consider coiling of IIA when extending to EIA Distal seal zone: 10-15mm Oversize 10-20%

Iliac Arteries

Iliac Arteries Ideally Newer devices are lower profile and hydrophilic Larger than 6mm Non calcified Non tortuous Newer devices are lower profile and hydrophilic

Graft Selection Fixation Type Sizes Anatomy Delivery System Positive fixation (hooks, barbs) Radial force, friction Column support Sizes Anatomy Delivery System Flexibility Trackability OD of delivery system

Graft Selection

Endurant Endologix GORE COOK Proximal neck length 10 mm 15 neck diameter 19-32 18-32 mm 19-29 mm (inner to inner) infrarenal angle <60 access 6.5 mm/17 18 fr OD 6.5 mm/17 fr ID/8 fr. contralateral 12 fr/18 fr/20 fr 5mm/6.8mm/7.6mm 18, 20 and 22 fr OD min access profile (28mm graft) 20F OD 19.2F OD 20.4 F OD 23.1F OD/18F OD (LP)

Access Selection Anatomic factors Vascular access Femoral cutdown Percutaneous

Anesthesia Considerations General Anesthesia Regional: Lumbar Spinal Conscious Sediation

Take Home Points Not all patients are ideal for EVAR as of 2/24/13 Work in a team Need a quality pre procedure imaging (CTA) Helps decide if patient is an EVAR candidate Device sizing and selection Aids in intraprocedural planning Planning will become more important in the future

Thank you! ssarin@gwu.edu