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The Retrograde Approach - Dr Sam Farah and Dr Yogi Sivakumaran EPISODE 5, 29th March 2021
Episode 5: Endovascular aneurysm repair and planning
00:00:00 00:50:28

Episode 5: Endovascular aneurysm repair and planning

In this episode Dr Yogi Sivakumaran and Dr Sam Farah discuss how they prepare, plan and perform an endovascular aneurysm repair (EVAR).

General Principles

  • Quality of the CT Scan
  • 1mm slices
  • If initial scan – scan thoracic, abdomen and lower limbs; allows for exclusion of aneurysmal disease elsewhere as well as if baseline status of the aortia prior to intervention
  • Also allows planning if a fenestrated repair required 
  • Centerline – images are not cross-sectional and end up with cross-sectional diameters 
  • Narrow diameter of the elliptical cross-section more in keeping with the true diameter 
  • Draw a diagram and compare with the rep and consultant’s plan – appreciation of the complexity of the case
  • Date of the index scan
  • Documentation calcification, dissection, thrombus and stenotic disease
  • Site of the lowest renal artery
  • Clock face of the renal arteries origin as well as the origin of the internal iliac arteries 
  • Angulation of the aortic neck 
  • Type of neck
  • Straight, angulated (plan according to IFU), tapered (oversize on the basis of the diameter below the renal arteries), reverse tapered (careful to avoid oversizing), bulge and short
  • Access vessels 
  • Diameters and lengths (which will be discussed)
  • Grafts chosen
  • Talk to the reps re: planning books 

Pre-operative consideration

  • In the era of an endovascular repair, a durable repair is desired 
  • Patient’s age 
  • Patient’s co-morbidities 
  • Renal function, cardiac and respiratory history
  • Life expectancy
  • Fitness for GA vs. LA and Sedation 
  • The patient better of with an open or endovascular management strategy
  • Suitability for endovascular 
  • Complex vs. Standard EVAR 

Imaging 

Renal artery position

  • Lowest renal artery; accessory renal arteries 

Diameters

  • Infrarenal aortic neck diameter (assess for infrarenal thrombus; aim < 25% of the circumference and <2mm thickness) – multiple across the length of the neck 
  • Aneurysm sac diameter
  • Aortic bifurcation diameter
  • CIA proximal, mid and distal


Lengths

  • Aortic neck length
  • Length from lowest renal to aortic bifurcation (to ensure sure that there is enough length for the contralateral limb)
  • Length from aortic bifurcation to iliac bifurcation


Angles

  • Renal arteries origin off the aortic
  • Internal iliac arteries origin off the bifurcation 
  • Supra and infrarenal angulation if appropriate 


Access vessels

  • Femoral/Iliac artery diameter 
  • Tortuosity of the iliac arteries


Large lumbar vessels or inferior mesenteric artery >3mm