consulting: endologix, cook › assets › 12943 › minion_gill keeneland 2017.pdf · uk evar...

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Taming The Aorta

David Minion, MD

Program Director, Vascular Surgery

University of Kentucky Medical Center

Lexington, Kentucky, USA

Faculty Disclosure

• Consulting: Endologix, Cook

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Objectives

• Review the presentation of the three most common diseases affecting the aorta –aneurysms, dissection, and occlusive disease.

• Discuss the appropriate work‐up and indications for repair of aortic pathology.

• Describe the latest endovascular treatment for complex aortic pathology.

Aortic Aneurysm

• Defined as Dilation to at least 1.5 times the Diameter of Normal Vessel

• Normal abdominal Aorta = Approximately 2 cm.

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Presentation

Incidental/Screening

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Rupture/Symptomatic

Atheroembolism

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Avoiding Rupture

Aortic Aneurysm Screening

• USPSTF Guidelines

– Men aged 65‐75 who have smoked (at least 100 cigarettes in their lifetime.)

• Society of Vascular Surgery Guidelines for Screening

– All men age 65 or older

– Men with a family history as early as age 55

– Women age 65 or older with a family history of AAA or who have smoked

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Interpreting the Scan

Annual Risk of Rupture

• Diameter < 4.0 cm = < 0.5 % Risk

• Diameter 4.0‐4.9 cm = 0.5‐5 % Risk

• Diameter 5.0‐5.9 cm = 3‐15 % Risk

• Diameter 6.0‐6.9 cm = 10‐20 % Risk

• Diameter 7.0‐7.9 cm = 20‐40 % Risk

• Diameter < 8.0 cm = 30‐50 % Risk

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Surveillance for Smaller AAAs

• Aorta < 2.6 cm = no further imaging

• Aorta 2.6 to 2.9 cm = repeat in 5 years

• Aorta 3.0 to 3.4 = repeat in 3 years

• Aorta 3.5 to 4.4 = repeat in 1 year

• Aorta 4.5 to 5.4 = repeat in 6 months

Indication for Repair

• Symptomatic patients

• Size

–5.5 cm or greater for males

–4.5 to 5 cm for females?

–Growth of 1 cm in one year or 7 mm in 6 months

• Consider earlier repair in younger, healthy patients or saccular morphology

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Saccular Aneurysm

The Thoracic Aorta

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Normal Diameters

Aortic Root (#1):‐Females: 3.5‐3.7 cm‐Males: 3.6‐3.9 cm

Mid‐Ascending Aorta (#3):‐Females/Males ~2.9 cm Mid Descending

Aorta (#7):‐Females: 2.4‐2.6 cm‐Males: 2.4‐3.0 cm

Diaphragmatic (#8):‐Females: 2.4 cm‐Males: 2.4‐2.7 cm

Ascending Aorta/Arch:‐Isolated: 5.5 cm (or 0.5 cm/yr growth)‐With AVR: 4.5 cm‐CTD: 4‐5 cm

Descending Aorta/TAA:‐Open: 6.0 cm ‐TEVAR Candidate: 5.5 cm‐CTD or Dissection: 5.5 cm

ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Recommendations for Aneurysm Repair

Hiratzka, et al. JACC 2010;55:1509‐44.

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Endovascular Aneurysm Repair

(EVAR)

The Basic Steps for EVAR

• Access

• Delivery of the Endograft

• Deployment of Main Body

• Cannulation of Gate

• Deployment of Limbs

• Seating of the Graft

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David J Minion, MD

The Finished Product

Impervious Tube

Seal in Normal Vessel

What Could Possibly Go Wrong?

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Short Neck

Reverse Taper

27 mm

23 mm

30 mm

27 mm

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Calcified Neck

Angled Neck

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Double Angle

Thrombus

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Compromised Distal Seal Zone

Compromised Distal Seal Zone

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Access Issues

Endoleaks

• Type I: Attachment site leaks

–IA = Proximal

–IB = Distal

• Type II: Retrograde Branch leaks

• Type III: Graft defect

–IIIA = Junctional leak

–IIIB = Fabric disruption

• Type IV: Graft fabric porosity

• Type V: Endotension

White et al., J Endovasc. Surg. 1998;5(4):306.

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Type II Endoleaks

IMA via the Arc of Riolan

Iliolumbar(Inosculated)

Iliolumbar(Retiform)

Type I Endoleak

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Type III Endoleak

Endovascular versus Open Repair of Abdominal Aortic

Aneurysms

UK EVAR Trial Investigators. N Engl J Med 2010;362:1863‐71.

• 1252 Patients Randomized to EVAR vs Open

• 30 Day Mortality

– EVAR = 1.8%

– Open = 4.3%

• No Late Survival Benefit (at 5 years)

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Endovascular versus Open Repair of Abdominal Aortic

Aneurysms

UK EVAR Trial Investigators. N Engl J Med 2010;362:1863‐71.

Endovascular versus open repair of abdominal aortic aneurysm

in 15‐years’ follow‐up of the UK endovascular aneurysm repair

trial 1 (EVAR trial 1): a randomisedcontrolled trial

Patel R, et al. for the EVAR Trial Investigators. Lancet 2016;388:2366‐74.

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We Need More Seal

David J Minion, MD

Options for More Seal

Fenestrated Graft Parallel Grafts

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Parallel Endografts

Juxtarenal Aneurysm

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Marginal Seal

Parallel Endografts

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The Pericles Registry

• 517 patients from 13 centers.

• Mean Follow‐up of 17 Months

– 94% Primary Patency of 898 Chimney grafts

– Mean Sac Regression = 4.4 mm

– No aortic ruptures

– Overall survival of 79%

• Type IA Endoleaks

– Intra‐operative = 7.9%

– Late/Persistent = 2.9%

Gutter Leak

Imperfect Apposition

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Standard Parallel Endograft

Poor Apposition and Large Gutters

Lens Shaped Parallel Endograft

Perfect Apposition and

No Leak

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Urgent Type IA

David J Minion, MD

Urgent Type IA

Type IA

Minimal ParavisceralThrombus

David J Minion, MD

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Urgent Type IA

Upward Oriented LRA with No Infrarenal Seal Zone

Short Seal Zone Distal to RRA/SMA

David J Minion, MD

Operative Approach

• Cannulate LRA (6x59 iCast) From Rt Groin

David J Minion, MD

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Operative Approach


• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm

David J Minion, MD

Operative Approach



• Deploy 1st Cuff

David J Minion, MD

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Operative Approach



• Deploy 1st Cuff

• Complete “Retro‐Sandwich” in LRA

David J Minion, MD

Operative Approach



• Deploy 1st Cuff


• Extend Above SMA and RRA

David J Minion, MD

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“Eye of the Tiger” Technique

A. Deploy

C. Crush D. Partially Re‐Expand

B. Over‐Dilate

David J Minion, MD

Operative Approach



• Deploy 1st Cuff



• Over‐dilate LRA iCast to 10 mm

David J Minion, MD

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Operative Approach



• Deploy 1st Cuff




• Exchange for original 6 mm balloon

David J Minion, MD

6 mmBalloon

Operative Approach



• Deploy 1st Cuff





• Crush LRA stent with CODA

David J Minion, MD

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Operative Approach



• Deploy 1st Cuff• Complete “Retro‐Sandwich” in

LRA• Extend Above SMA and RRA• Over‐dilate LRA iCast to 10 mm• Exchange for original 6 mm

balloon• Crush LRA stent with CODA• Re‐inflate LRA with 6 mm balloon

David J Minion, MD

Operative Approach

• Cannulate LRA (6x59 iCast) From RtGroin


• Deploy 1st Cuff






• Re‐inflate LRA with 6 mm balloon

• IVUS

David J Minion, MD

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Operative Approach

David J Minion, MD



• Deploy 1st Cuff




• Replace with original 6 mm balloon



• IVUS

• Completion Angio

Operative Approach

David J Minion, MD



• Deploy 1st Cuff




• Replace with original 6 mm balloon



• IVUS

• Completion Angio

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Standard Approach

David J Minion, MD

8 mm “Parallel” Seal

Post CTA Recon

10 mm “True” Seal

10 mm “True” Seal



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Transgluteal Embolization of Type II


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Post‐op CTA

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Extending the Techniques

Case 2

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Aneurysmal Type B Dissection


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Post‐op CT


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Ahead of the Curve

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Case 3

The trifurcated endografttechnique for hypogastricpreservation during EVAR

Minion, et al. JVS 2008;47:658‐61

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Trifurcated graft

Trifurcated Graft

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Prototype for the first FDA approved device

20082016

Thoracoabdominal Endografts

2010Feasibility Study

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Case 4: 72 YO Female

Lateral View Anterior View

Operative Exposure

45° 90°

8th 4th

Type: cI & cIIType: cIII, cIV, cV

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Fenestrated Endovascular Aneurysm Repair


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consulting: endologix, cook › assets › 12943 › minion_gill keeneland 2017.pdf · uk evar...

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