my secrets in infrarrenal evar planning
TRANSCRIPT
Disclosure
• Consulting an Proctoring services
COOK
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
2 essential secrets to achieve a successful EVAR
1. Planning the EVAR with an optimal CT
– Arterial phase, well contrasted
– Slice thickness ≤ 1 mm
2. Planning EVAR within IFU
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Optimal CT
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Multiplanar reconstructions (MPR)• Coronal• Sagital• Axial
Never planning over Axial CT
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Optimal CT
Rotate the axis in the coronal, sagittal and axial plane following the axis of the aorta and the axis of renal’s
C-Arm Orientation• Craneo-caudal• Lateral
15 degrees craneo-caudal
10 degrees lateral
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
15 mm of sealing• Perpendicular to the
axis of aorta• Diameters over axial• Take at least 3
measurements
Infrarenal aortic Neck
15 mm
Diameter common iliac arteries
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Rotate the axis in the coronal, sagittal and axial plane following the axis of the vessel.
MPR
Length measures
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• MPR• MIP
• The tool opened polygon is very usefull
Length measures
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• The tool opened polygon is very usefull
• MPR• MIP
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
External iliac and femoral information
External iliac and femoral information
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• An increasing number of patients with AAA , withshort and angulated necks are being included tobe treated by EVAR.
• It is very important accurate imaging planning,morphology and possible landing zones, trying toknow the behaviour that the graft will haveduring the deployment.
• This is essential to achieve a successful EVAR.
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Hostile neck great challenge in EVAR
Hostile-Angulated neck
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• If the angulation is more than 60°, use specific graft within the IFU.
• We obtain sealing if the graft contact with whole aortic wall.
You must know and imaging the behaviour of the graft during the
deployment!!!
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• Double angulation of aortic neck.
• Neck length 25 mm.• The planning on the CT was
sealing lower than the first angulation.
Hostile-Angulated neck
You must know and imaging the behaviour of the graft during the
deployment!!!
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Functional neck:10 mm
Center line:15 mm
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
• If the angulation is more than 60°, use specific graft within the IFU
• Look for alternatives if a severe angulation is associates with other factors that affect the quality of the neck• Short neck• Circumferential calcium• Circumferential thrombus• Reverse tapered or tapered neck
Hostile-Angulated neck
Planning EVAR within IFU
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
Results within IFU Results outside IFU
Rupture at 5 year 0,2-0,5 % -------
Rupture at 1 year ------- 4%
Early Type 1 EL 0,3-2,6% 13-15%
Late Type 1 EL 0,8-3,5% 10%
Conclusions
School of Medicine, University of Barcelona
27th to 29th MARCH 2019
1. Have an optimal CT2. Planning EVAR within IFU3. Have and manage a good 3D work station4. Be used to manage multiplanar reconstruction,
CPR, MPR, MIP and 3d volume rendering5. Understanding what information is necessary in
each case, to perform the intervention with success
6. Know and imagine what will be the behavior of the graft during the deployment and once implanted