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27. Karnabatidis D, Katsanos K, Kagadis GC, etal. Distal embolism during percutaneous revascularization of infra-aortic arterial occlusive disease: an underestimated phenomenon. J
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28. Belli AM, Cumberland DC, Knox AM, etal. The complication rate of percutaneous peripheral
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29. Matsi PJ, Manninen HI.Complications of lower limb percutaneous transluminal angioplasty:
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30. Krishnan P, Tarricone A, Purushothaman KR, Purushothaman M, Vasquez M, Kovacic J, Baber
U, Kapur V, Gujja K, Kini A, Sharma S.An algorithm for the use of embolic protection during
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32. Armstrong EJ, Waldo SW.Prevention of distal embolization during peripheral vascular interventions: ltering the evidence. J Am Coll Cardiol Intv. 2017;10(4):411–2.
M. H. Wholey
Chapter 18
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Management ofAortic Aneurysms
MelJ.Sharafuddin andJeanetteH.Man
Introduction
Abdominal aortic aneurysms (AAA) are a common disorder with an estimated incidence of 4–7% in western countries [1–5]. It is the 13th leading cause of death in
the United States, with 15,000 deaths yearly. Ruptured AAA carry an operative
mortality of 40–70% and overall mortality of 80–90% [6–11]. Risk factors include
smoking, hypertension, hyperlipidemia, and family history of aneurysms. Screening
is recommended to adults >65years who have smoked or have a family history of
aneurysms.
AAA are dened as an enlargement of the aorta 1.5 times the normal diameter,
which has led to conventional diameter requirement >3cm. The risk of rupture
increases dramatically with increasing aortic size. Therefore, elective repair is indicated when the aortic diameter is >5.5cm in men and >5.0cm in women or when
the growth rate is faster than average, >0.3cm/year.
Traditionally, open repair was the gold standard of repair. Endovascular repair of
aortic aneurysm (EVAR) has since revolutionized the treatment of AAA and has
become the new standard. EVAR is associated with decreased morbidity, operative
times, hospital stay, and perioperative mortality [12]. The idea of using vascular
endoprosthesis to exclude aneurysms originated in the late 1960s with animal
experimentation. The rst landmark deployment of an aortic stent to exclude a
human AAA was reported by Parodi etal. in 1991 [13]. Straight grafts consisting of
polyester tubes were used and reinforced with Palmaz stents. Today, this design has
M. J. Sharafuddin (*) · J. H. Man
Division of Vascular Surgery, Department of General Surgery, University of Iowa Hospitals
and Clinics, Iowa City, IA, USA
e-mail: mel-sharafuddin@uiowa.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
N. W. Shammas (ed.), Peripheral Arterial Interventions, Contemporary
Cardiology, https://doi.org/10.1007/978-3-031-09741-6_18
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evolved into modular grafts. Furthermore, with the constant evolution of endovascular technology, variations of EVAR are also being used to treat increasingly complicated aneurysms. Patients who are poor candidates for open repair have the
option of treatment with fenestrated EVAR (FEVAR), chimney EVAR (ch-EVAR),
and physician-modied endografts (PMEG) [14–16].
There have been several randomized trials demonstrating the early advantage of
EVAR compared to open repair. The EVAR 1 trial demonstrated that EVAR offered
a 30-day mortality benet over open repair [12]. The DREAM and OVER trials
demonstrated that although this early benet was not sustained long term, EVAR
patients still had a similar survival rate compared to the open group at 6 and 9years,
respectively, despite having long-term problems related to graft durability such as
endoleaks that may require reintervention [17, 18]. Meanwhile, the IMPROVE trial
showed that patients with ruptured AAA were more likely to discharge to home
when compared to those who underwent open repair [19].
M. J. Sharafuddin and J. H. Man
Indications forEVAR
The ideal candidate for EVAR must have the anatomy amendable for stent grafts.
This includes having adequately sized access vessels, good proximal and distal xation zones (with special attention to the aortic neck and iliac arteries), good aortic
wall quality without excessive calcication, and non-severe angulation. Different
devices will have different anatomical criteria based on their instructions for use.
However, in general, the ideal candidates for EVAR will have a neck length >15mm,
neck diameter <32mm, neck angulation <60°, iliac artery diameter <22 mm, and
iliac artery length >20mm. Below are graphs comparing some of the criteria of different devices currently available (Table 18.1). With the constant technological
developments, there are also several newer devices that continue to push boundaries. Gore Excluder Iliac Branch Endoprosthesis is the rst off-the-shelf aortic
branch solution approved in the United States that allows for preservation of blood
ow to the external and internal iliac arteries. Furthermore, currently in trial is Gore
Excluder Conformable AAA Endoprosthesis with Active Control System that can
be used for AAA with a shorter neck length of 10mm, high neck angulation up to
90°, and smaller diameter neck of 16mm. Meanwhile, other indications for EVAR
include ineligibility to open repair due to reduced cardiac reserve, reduced pulmonary capacity, hostile abdomen, or multiple comorbidities. EVAR may also be used
a bridge to open repair in patient who are too sick to undergo emergent open repair,
such as those with aorto-enteric stulas.
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Small prole of
delivery system
Overcame issues of
Suprarenal stent
with barbs
Suprarenal xation
Neck indication
(angle and diameter) Active xation Advantages
≥10mm, ≤45° if
neck <10mm. 16–30
Suprarenal neck
earlier- generation
stent grafts
steps in deployment
Good for angulated
short necks
with barbs
Infrarenal barbs User friendly, less
<45°, infrarenal neck
<60°. 19–32mm
ePTFE sealing cuff
19–32mm
Allows for small,
large, or scalloped
fenestrations
aortic bifurcation
Dual proximal
Suprarenal xation
with barbs
<45°, infrarenal neck
<60°. 18–32mm
Suprarenal and
311
xation and lock
stent
infrarenal xation
barb
<45°, infrarenal neck
<75°. 16–30mm
Distal iliac
Table 18.1 Comparison of currently available stent grafts for endovascular repair of AAA
Graft
material
Stent
material
diameter
range
Prole OD
(limb)
Prole OD
(main body)
14–15Fr 13–15Fr 8–20mm Nitinol PTFE ≤60° if neck
Device
TriVascular
18–20Fr 14–15Fr 8–25mm Nitinol Multi-
ovation prime
Medtronic
lament
polyester
endurant II
Gore excluder C3 16–18Fr 12–15Fr 8–25mm Nitinol ePTFE ≤60°. Infrarenal neck
Polyester Suprarenal neck
steel
15–18Fr 12–15Fr 8–25mm Nitinol ePTFE ≤90°. 16–32mm Nitinol anchors,
Gore excluder
conformable with
active control
cook zenith ex 18–22Fr 14–16Fr 7.5–20mm Stainless
ePTFE ≤60°. 18–32mm Suprarenal xation Preservation of
chromium
Endologix AFX 17–19Fr 11Fr 10–23mm Cobalt
Treo 18–19Fr 13–14Fr 8–20mm Nitinol Polyester Suprarenal neck
OD outer diameter
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M. J. Sharafuddin and J. H. Man
Preoperative Assessment andPlanning
Imaging plays in an important role in sizing aneurysms to allow for the appropriate
choice of stent grafts. A CTA abdomen/pelvis should be obtained at 2.5-mm intervals. MRA abdomen/pelvis with time of ight can be obtained instead in patients
with renal disease. After obtaining the proper imaging, one can use 3D reconstruction programs and centerline calculations to obtain accurate measurements. The key
areas of focus include dimensional details of angles, areas of wall irregularity, existence of any thrombus, the shape and diameter of the ow lumen, the level of tortuosity, the severity of calcication, and the relationship with the lowest renal artery.
Once these measurements are performed, most endovascular device companies recommend oversizing by 10–15% to allow for good seal. However, beware of excessive oversizing which can cause excessive radial expansile force and graft migration
(Fig.18.1).
Fig. 18.1 Clinical example. Here is an example of an EVAR we performed. It was complicated by
a right iliac artery aneurysm and distal tortuosity that required us to perform a right internal iliac
artery embolization to allow for extension of the stent graft limb into the right external iliac artery.
(a) Preoperative scan. Preoperative measurements for the stent graft were performed using a CTA
with ne cuts. Centerline measurements were then made through the aorta, right iliac artery, and
left iliac artery. (b) Intraoperative. Access was gained with a 12-Fr sheath in the right common
femoral artery and 18-Fr sheath in the left common femoral artery. An Active Control Conformable
Excluder Device was chosen for the repair. A 28-mm×14.5-mm×16-cm device was deployed in
the recommended manner. The contralateral gate was cannulated and then extended into the
expected position of the right iliac bifurcation using a 16-mm× 12-mm×7-cm iliac extension.
Angiography revealed extreme deformity of the straightened tortuous iliac segment with the common iliac aneurysm as well as the hypogastric artery readily lling. It became obvious that achieving seal in the distal right common iliac artery right above the bifurcation would not be
accomplishable with the excluder limb. We therefore proceeded with embolization of the internal
iliac artery and extension of the right iliac limb into the distal external iliac artery. A 14-mm
Amplatzer plug was used to occlude the ostium of the internal iliac artery and then extended using
a 13-mm×100-mm Viabahn stent graft. The interfaces were dilated with a 14-mm balloon angiography which revealed persistent endoleak which we felt might represent a junctional endoleak.
Because of that and because of the now improved accessibility across that segment, we decided to
reline the entire limb using a 14.5-mm×16-cm excluder limb. The ipsilateral limb of the device
was then deployed, and we extended further to the level of the bifurcation using a 16-mm×13.5cm excluder limb. The proximal seal zone and the overlap segments were all dilated with either a
CODA balloon or 14- or 12-mm angioplasty balloons. Angiography revealed excellent position of
the endograft with exclusion of the aneurysm and maintained patency of both renal arteries and the
left hypogastric artery. Occlusion of the plugged right internal iliac artery was conrmed. There
was no evidence of type I or III endoleak. (c) Postoperative scan (1year after). On 1-year follow up, the patient remained asymptomatic. CTA scan showed interval mild regression of his sac diameter. There was a small type II endoleak emanating from the inferior mesenteric artery that we will
continue to monitor
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M. J. Sharafuddin and J. H. Man
b
Fig. 18.1 (continued)
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315
c
Fig. 18.1 (continued)
Operative Technique
Several different types of anesthesia can be used when performing EVAR.If the
patient can tolerate lying at, monitored anesthesia cares and local anesthetic are
sufcient and quite common. However, if the patient has more worrisome risk factors, general anesthesia can also be used. An epidural is another option in frail and
sick patient who cannot undergo general anesthesia.
The following steps for an EVAR are for modular devices. The patient is prepared from the xiphoid to the bilateral knees, in case there is a need for emergent
conversion to open repair. First, obtain percutaneous access in the bilateral common
femoral arteries with ultrasound guidance, and use preclose technique. Next, introduce the wire into the descending abdominal aorta. Upsize the sheaths based on the
stent graft being used and if a sheath is required for the device. Heparinize the
patient to keep ACT >200–250. Perform an aortogram using a ush catheter.
Angulate the C-arm and mark where the lowest renal artery is. Introduce the main
body, position just the lowest renal artery, and deploy. An additional piece may or
may not be needed depending on the length to the ipsilateral common iliac artery.
Afterward, cannulate the contralateral gate. Introduce the contralateral iliac delivery
system, and deploy with care to not cover the internal iliac artery. Once the stent
grafts are in place, use a molding balloon to ensure good expansion of the stent
grafts. Lastly, perform a completion angiogram to assess for stent graft apposition,
exclusion of the aneurysm, and the presence of any endoleaks.
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M. J. Sharafuddin and J. H. Man
Postoperative Surveillance andComplications
Postoperative surveillance is performed at 30days, 6months, 1year, and then annually afterward. EVAR complications can be grouped into access complications,
graft-related complications, and organ system failure [20–22]. Access-related complications can include hematoma, pseudoaneurysm, infection, lymphocele, dissection, and distal limb emboli. Graft-related complication includes endoleaks, limb
kinking or thrombosis, graft migration, and graft infection. Endoleaks are a common complication and can be further subdivided into ve types. A type I endoleak
occurs when there is an inadequate seal at either the proximal or the distal seal zone.
A type II endoleak occurs when there is back bleeding from a collateral artery, such
as a lumbar artery. A type III endoleak occurs when there is a leak between the stent
grafts. A type IV endoleak occurs when the material of the stent graft has high
porosity. A type V endoleak occurs when there is endotension of unknown origin.
Of all the endoleaks, type I and III should be repaired upon diagnosis to prevent
continued transmission of systemic pressure into a conned sac. Last but certainly
not least, there are several organ systems that can fail postoperatively. Renal failure
is not uncommon secondary to contrast nephropathy from the large amounts of
contrast used during the procedure. Renal failure may also result from atheroemboli, acute renal artery obstruction, and cephalad graft migration. Meanwhile, mesenteric ischemia is a known and feared consequence when the inferior mesenteric
artery is covered and there is otherwise poor blood supply to the bowels. Pelvic
ischemia may result when there is coverage of both internal iliac arteries.
Furthermore, spinal cord ischemia is another potential consequence when an extensive length of descending aorta is covered.
Conclusion
In conclusion, EVAR has revolutionized the treatment of AAA by allowing for
decreased mortality and morbidity. Proper imaging and sizing of stent graft are
crucial for its success. The durability of EVAR is dependent on long-term surveillance and being mindful of potential postoperative complications.
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