strong performance of evar in the challenging indian
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STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY
SINGLE CENTER EXPERIENCE
Dr Rajendra Kumar Premchand M.D., D.M,D.I.U.
Senior consultant Interventional cardiologist
Director, KIMS Hospitals,
Hyderabad, India
EVAR-Single Centre Experience
• Total cases-50
• Mean age -63
• 45 M: 5 F
• Risk factors- SM-15, DM-15, HTN-15, CKD-5
• Thoracic- 18, abdominal-19, thoraco-abdominal- 7, Dissection-4.
• Chimney- 5, hybrid -3, on table fenestration-3
Approach to Aortic Aneurysm
Case -1 Type B Dissection Acute -EVAR
• 52 yrs male
• HTN+, chronic smoker
• C/O- sudden onset chest pain and abdominal discomfort radiating to back.
• O/E- feeble pulses in both L/L.
• ECG- Sinus tachycardia
• Echo- Normal LV function
• CT Aortogram- Type B aortic dissection starting below LSCA and extending distally into B/L CIA, left EIA with thrombus.
Case -1 EVAR – Aortic dissection Type B
Pre - EVAR Post - EVAR
Medtronic 36 mm stent graft x 2
Case 2-Hybrid EVAR to Acute Aortic dissection Type B
• 52 yrs male
• HTN+, Chronic smoker
• S/O chest pain radiating to back associated with worsening dyspnea
• CXR- widened mediastinum
• Echo- Good LV function
• CT Angiogram- Type B aortic dissection with DTA aneurysm and mildly dilated aortic root
Type B Aortic aneurysm LCCA / LSCA arising from aneurysm
Case 2-Hybrid EVAR to Acute Aortic dissection Type B STRATEGY Bypass graft to Rt Carotid & LSCA from LT Carotid artery
f/b EVAR
COOK 36 MM COVERED STENT
CASE 3 - Hybrid aortic arch debranching
• 69 yrs old male
• Chronic smoker (30 pack years)
• Non-diabetic , Non hypertensive
• Being worked up for Squamous cell carcinoma tongue
• Incidentally diagnosed to have Thoracic aortic aneurysm
CASE 3 - Hybrid aortic arch debranching
STRATEGY
Case -4 EVAR with on table Fenestration +
stent to LSCA
• 82 yrs male
• Hypertensive, dyslipidaemic & non diabetic
• S/P CABG (1996) x 3 (LIMA LAD, SVGRamus & PLB)
• DOE class II-III and chest pain (atypical)
• CXR- wide mediastinum s/o Thoracic AA
• CT scan- 4.2 x 5.1 Saccular aneurysm in arch/isthmus after the origin of LSCA with mural thrombus and burrowing in lung parenchyma.
Case -4 EVAR with on table Fenestration +
stent to LSCA
ZENITH TZ2 36 X 77 mm , LSCA- 8 X 38 mm Advanta V12
Case -5 Multilayer Flow Modulator device for
Thoracoabdominal aneurysm Case history
• 54yr male
• HTN , HLP,Non-DM.
• Severe back pain -6 days.
• On evaluation USG abd showed aortic aneurysm.
• CT aortogram - aneurysm of distal descending thoracic
and upper abdominal measuring 5.5*29 mm (fusiform )
with mural thrombus along posterior and lateral walls
with celiac artery stenosis.
Case -5 Multilayer Flow Modulator device for
Thoracoabdominal aneurysm
• Issues:
Aneurysm involving major
branches:
– Hypogastric artery
– celiac artery
– Superior mesenteric
artery
– Renal arteries.
Case -5 Multilayer Flow Modulator device for
Thoracoabdominal aneurysm
Prerequisite - side
branch stenosis should
not be >50%. Celiac
artery stenting
(hippocampus renal
stent) via LBA
MFM
(28*180)
deployed
slowly ~ 15
min
MFM - Principle
• Eliminates erratic flow vortices by redirecting the flow into laminar flow.
• Patency of side branches- The side branches act as a vacuum, augmenting
the lamination which results in shrinkage of the aneurysm and increased
side branch flow.
• Rapid endothelialization makes it quickly embedded within the aortic
wall.
• The effect of peak wall stress is grossly diminished.
Treat aneurysm rather than
excluding it.
Case -6 EVAR to Thoracic aneurysm presenting as
Hoarseness of voice
• 62 yrs male
• HTN+, DMII, Chronic smoker
• C/O Hoarseness of voice since 10 months
• Referred from ENT b/s of abnormal CXR and diagnosed to have Lt RLN palsy.
• CT Chest- 4.2 x 5.5 saccular thoracic aneurysm with diffuse atherosclerosis.
Case -6 EVAR to Thoracic aneurysm presenting as
Hoarseness of voice
VALIANT 32 X 32 X 100mm
Pre - EVAR Post - EVAR
Case -7 Hypertensive emergency with leaking
AAA
• 57 yrs old male
• Chronic smoker (38 pack years), hypertensive
• Presented with abdominal discomfort in gastroenterology department
• USG abdomen- 4 x 3.8 cm saccular abdominal
aortic aneurysm with eccentric thrombus.
• CECT abdomen – 5.2 x 5.8 saccular abdominal aneurysm with eccentric mural thrombus.
Case -7 Hypertensive emergency with leaking
AAA
Case -8 Infrarenal AAA extending into B/L CIA
• 60yr, Doctor By Occupation Non- HTN, Non DM
• Post CABG- 15 yrs back., continues to smoke.
• Epigastric symptoms , back ache-
• On evaluation-
– USG ABD – Infra Renal AAA
– CT angio- Infra renal AAA (8.6mm diameter)
• Diagnosis- symptomatic infra renal AAA and
aneurysm of bilateral CIA
Case -8 Infrarenal AAA extending into B/L CIA
Main body (cook 24*96)deployed
across the aneurysm infrarenally
Two Lt sided Extension
limbs
24*56
12*73
24*73
Deployment of Rt & Lt extension limbs
Case -8 Infrarenal AAA extending into B/L CIA
Case -9 Traumatic Aortic Laceration
• 68 years, male
• H/O RTA
• Traumatic aortic laceration
with leak into pleural cavity
• Lung contusion with hemothorax
• Cerebral contusion SAH
STRATEGY Emergency EVAR
Case -9 Traumatic Aortic Laceration
Pre - EVAR Post - EVAR
• After stent graft- ICD placed for hemothorax • Conservative management of SAH • Recovered sensorium over 3 days
Valiant thoracic stent graft 36-36 C 150TE
Post - EVAR
Case -10 Sub Acute Type B Aortic dissection with SMA Occlusion
• 45 yrs male
• HTN+, Chronic smoker
• C/O- Acute onset tearing type of abdominal pain radiating to back and chest associated with malena 3-4 episodes.
• O/E- Pulse 116/min , feeble in B/L L/L ; BP- (RUL) 190/114 mmhg and 70 systolic in B/L L/L
• ECG- Sinus tachycardia
• CT Angio- Dissection flap starting just below LSCA & extending upto Rt EIA and Lt CFA; SMA Total occlusion seen
Case -10 Acute Type B Aortic dissection with SMA Occlusion
STRATEGY Emergency EVAR + SMA Stenting
SMA Stented with 8 x 80 mm Luminex Bard stent 32 x 200 mm COOK stent graft in DTA
• 1 year follow up- Patient asymptomatic • CT Angio – DTA stent graft and SMA stent patent
Troubleshooting complications :
Complications
• Paraparesis- 4
• Renal failure- 2
• Endovascular leak-1
• brachial artery complications- 2
• Common iliac rupture -2
• Death during procedure-1
• During hospital stay-1
• Death at 30 days-2.
Post dilation of the stent grafts with CODA balloon (10-35)
Flaring of struts due to excessive dilatation
Patient developed hypotension (SBP- fell from140 to 90 mm Hg)
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR
• Check aortogram showing rupture of Rt CIA.
• CODA Balloon inflation to decrease the blood loss by
occluding the stent graft
Balloon inflation in RT extension limb
Balloon inflation in Main stem infrarenally to work on Rt CIA
Strategy ? Surgery ?covered stent ?? How to prevent endoleak
10:42 PM
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR
10:40 PM
Internal iliac artery selectively engaged with Diagnostic JR & 7 Coils deployed – [(8-10)*1,(3-4)*2,(5-8)*4]
10:45 PM
Rt Int Iliac
Deployment of another Rt sided Extension limb
Final Angio- No leak & well contained aneurysm
STRATEGIC MANAGEMENT OF RUPTURE OF COMMON ILIAC ARTERY DURING EVAR
• The sheath which was oversized to EIA diameter (6mm) led to the avulsion of the Right common iliac artery and Rt external iliac artery .
• POBA was done and 2 stents were deployed across the lesion till the femoral head but flow could not be restored.
• Hence PTFE graft was done anatomizing Right CIA and RT Common femoral artery after ligating the internal iliac artery.
• Pt developed retroperitoneal leak due to peri PTFE graft oozing induced by overzealous heparin usage , managed conservatively.
The approximate size of
peripheral access artery
should be atleast 8mm to
prevent avulsion of arteries.
Avulsion of Right CIA and Right EIA
Avulsion of LT CIA Covered with another stent
Avulsion of Left common Iliac Artery
Conclusions
• Anatomical challeges-
small arteries, calcification( No Data to support)
• Most of the procedures- Out of pocket expense
• Not uniformly remursable
• DCGI- challenges in approving new devices
• Only few Centres are doing these procedures
• Intervenitonal cardiologist/radiologist/Vascular surgeon/ CT surgeon.
STRONG PERFORMANCE OF EVAR IN THE CHALLENGING INDIAN ANATOMY
Dr Rajendra Kumar Premchand M.D., D.M,D.I.U.
Senior consultant & Interventional cardiologist
Director, KIMS Hospitals,
Hyderabad, India
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