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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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Mostly dependent on catheter time and the experience of
the operator, the following is an incomplete list of tips
and tricks to assist with cannulation:
i. The use of a steerable hydrophile angled wire (e.g.
angled Glidewire) with an appropriately angled
catheter (e.g. Kumpe [Cook], Berenstein
[Angiodynamic], or Sos 1/2 [Cook]).
ii. Frequent adjustment of the imaging gantry, both
oblique and cephalad/caudal, to attempt to “open”
the gate on fluoroscopic views.
iii. Placement of a stiff buddy wire through the
contralateral sheath into the thoracic aorta to help
guide the catheter and wire toward the contralateral
gate.
iv. Advancement of a smaller French sheath into the
aneurysm sac in conjunction with an angled
catheter, which can be partially retracted into the
sheath to allow for greater catheter‐tip “steerability”
(the “turret technique” [18]).
Gate cannulation is usually confirmed with the
combination of contrast angiography and the ability to
spin a pigtail catheter freely in the proximal neck of the
graft.
If retrograde cannulation is not possible, antegrade
cannulation can be attempted. Vascular access can be
obtained via the axillary, brachial, or radial artery to
allow for cannulation through the proximal graft body.
The wire can then be snared from the iliac and
exchanged for a stiffer wire, allowing for retrograde
deployment. It is also possible to go “up‐and‐over” from
the contralateral side, although this technique has a
higher degree of difficulty depending on the device flow
divider position.
If all above attempts fail, the final bailout maneuver is
conversion of the bifurcated graft into an aorto‐uni‐iliac
configuration, either by stacking aortic endocuffs or
placement of a second main body endograft with the
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contralateral gate in the opposite orientation. In either
case, the contralateral limb must be occluded, and a
femoral‐femoral bypass must be performed to
reestablish limb perfusion.
Limb Deployment
Following cannulation of the contralateral gate, the
contralateral iliac artery is evaluated with retrograde
angiography through the femoral sheath. This should be
performed under contralateral obliquity with a marker
pigtail catheter to best visualize the iliac bifurcation and
allow for accurate measurement of the length of limb
needed. Most devices require at least 1–2 cm of iliac
artery overlap for successful seal. Following
measurement and deployment of the contralateral limb,
similar measurements should be taken on the ipsilateral
side following deployment of the remainder of the main
body. If required, an ipsilateral extension can be used to
aneurysmal iliac disease.
In patients with residual stenosis or kinking of the iliac
limbs, aggressive angioplasty with a semicompliant
balloon (e.g. Coda, Reliant, etc.) should be performed.
For any recalcitrant lesions, consideration should be
taken to deployment of a self‐expanding bare‐metal stent
within the endograft. If the lesion is at the aortic
bifurcation causing iliac compression, consider
placement of kissing balloon‐expandable stents.
Following deployment of the graft body and limbs, a
semicompliant molding balloon should be used at the
aortic neck, iliac gates, graft overlap, and distal iliac
limbs to optimize seal. Angioplasty should not be
performed outside of the graft as vessel rupture can
occur.
Completion Angiogram
Following deployment and balloon angioplasty of the
main body graft and iliac limbs, completion aortogram
should be performed through a pigtail catheter placed
above the renal arteries. In addition, any stiff wires
should be removed prior to completion angiogram to
allow the graft to sit in a more “natural” position. Using a
contrast injector, we again opt for a high rate but with a
higher volume of contrast to adequately evaluate for
renal filling and any type I or II early or late endoleaks
(Figure 5.5). As device sheaths are usually occlusive, it is
also good practice to aspirate using 20 ml syringes to
allow for contrast flow through the iliofemoral system.
Completion angiography should confirm the following:
i. Patency of both renal and hypogastric arteries
ii. Placement of the graft body adjacent to, ideally
within 2 mm of, the lowest renal artery
Figure 5.5 The completion angiogram above from a
single case demonstrates excellent aneurysmal
exclusion. The left renal artery is filling briskly
(right) without evidence of Type I endoleak. The
aneurysm does not fill early or late in the contrast
run. And the bilateral iliac arteries fill and empty
without evidence of Type IB or III endoleak (right
hypogastric artery coiled).
iii. Adequately treated occlusive iliac disease
iv. Assess for early or late type I or II endoleaks
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Step 5. Troubleshooting
Endoleaks
Should the completion angiography be concerning for a
type I or III endoleak, these should be addressed
immediately (Figure 5.6). The first step for nearly all
endoleaks is to attempt balloon angioplasty. For type IA
(proximal) leaks, this alone should be done if the
distance between the lowest renal artery and the
endograft is less than 3 mm. If this distance is greater
than 5 mm, a proximal aortic cuff may be placed. This
should then be balloon angioplastied as well. If a type IA
leak persists despite these interventions, one may
consider the placement of a Palmaz stent or an
endovascular anchoring device. There are multiple
systems currently available for this purpose. Similar to
type IA, persistent type IB leaks may be remedied with a
limb extension cuff. Type III leaks usually resolve with
angioplasty provided there is enough component
overlap. If this is not the case, bridging components may
be introduced.
Figure 5.6 Completion angiogram demonstrates a Type
IA endoleak. Aneurysmal sac filling is early and brisk in
the contrast run, usually signifying leak around the
proximal fixation stents.
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Figure 5.7 In cases where aneurysmal degeneration
extends to the iliac arteries, hypogastric coiling allows
for extension of graft coverage beyond the iliac
bifurcation while minimizing the risk of endoleak.
Type II endoleaks generally present long after the patient
has left the angiography suite. These leaks can be
detected on thin cut CTA, but angiography remains the
gold standard for identifying the contributing vessel or
vessels. It is also imperative to confirm that there is no
concurrent type I or III leak. Aneurysmal sac
enlargement greater than 5 mm is the generally accepted
indication for intervention. The underlying principle for
treatment of type II leaks is occlusion of the feeding
artery. There are several accepted ways to accomplish
this, including embolization, clipping, or surgical
ligation. One should attempt to occlude the vessel as
centrally as possible, as the development of collaterals
may lead to eventual recurrence (Figure 5.7).
Inadvertent Coverage of Renal Arteries
Great care is taken to ensure the endograft is positioned
appropriately below the renal arteries as not to
accidentally cover one or, much worse, both after
deployment. Should this occur, there are various
maneuvers one may employ. The first two strategies
involve attempting to displace the graft caudally using
either a wire or a large balloon. Both are potentially very
dangerous as aortic injury may occur. Preferably, one
may place a stent in the affected renal artery. In some
cases, the artery may need to be cannulated from a
brachial approach. Surgical extra‐anatomic bypass may
be necessary should these efforts fail.
Should one encounter renal artery stenosis, this may be
addressed following deployment of the aortic graft or at a
later time. In some instances, stenosis may be discovered
during preoperative planning and should the patient
have severe renal insufficiency or hypertension, the
surgeon may elect to stent the affected artery prior to
performing the EVAR. One should be mindful that the
stent may be dislodged or damaged at the time of graft
deployment.
Iliac Artery Considerations
Depending on the anatomy of the common iliac artery,
extension into the external iliac may be required. In this
instance, it is important to remember to address the
hypogastric in hopes of preventing a future type II
endoleak. One may either embolize the hypogastric or
attempt to preserve flow through a branched graft, stent
placement, or open bypass from the external.
Conclusion
EVAR is now universally accepted as the first‐line
treatment for AAA in patients who meet the anatomic
criteria for stent‐graft placement. Careful preoperative
planning and technical considerations are essential to a
successful outcome of this procedure.
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