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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 LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
David J Minion, MD
Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
David J Minion, MD
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Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
• Complete “Retro‐Sandwich” in LRA
David J Minion, MD
Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
• Complete “Retro‐Sandwich” in LRA
• 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
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
• Complete “Retro‐Sandwich” in LRA
• Extend Above SMA and RRA
• Over‐dilate LRA iCast to 10 mm
David J Minion, MD
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Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• 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
David J Minion, MD
6 mmBalloon
Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• 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
David J Minion, MD
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Operative Approach
• Cannulate LRA (6x59 iCast) From Rt Groin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• 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
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• 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
• IVUS
David J Minion, MD
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Operative Approach
David J Minion, MD
• Cannulate LRA (6x59 iCast) From RtGroin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
• Complete “Retro‐Sandwich” in LRA
• Extend Above SMA and RRA
• Over‐dilate LRA iCast to 10 mm
• Replace with original 6 mm balloon
• Crush LRA stent with CODA
• Re‐inflate LRA with 6 mm balloon
• IVUS
• Completion Angio
Operative Approach
David J Minion, MD
• Cannulate LRA (6x59 iCast) From RtGroin
• Cannulate RRA (5x38 iCast) and SMA (7x38 iCast) from Left Arm
• Deploy 1st Cuff
• Complete “Retro‐Sandwich” in LRA
• Extend Above SMA and RRA
• Over‐dilate LRA iCast to 10 mm
• Replace with original 6 mm balloon
• Crush LRA stent with CODA
• Re‐inflate LRA with 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
8 mm “Parallel” Seal
30 mm “Parallel” Seal
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Transgluteal Embolization of Type II
Transgluteal Embolization of Type II
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Transgluteal Embolization of Type II
Post‐op CTA
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Extending the Techniques
Case 2
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Aneurysmal Type B Dissection
Aneurysmal Type B Dissection
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Aneurysmal Type B Dissection
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Post‐op CT
Aneurysmal Type B Dissection
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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
Fenestrated Endovascular Aneurysm Repair
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Fenestrated Endovascular Aneurysm Repair
Fenestrated Endovascular Aneurysm Repair
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Fenestrated Endovascular Aneurysm Repair
Fenestrated Endovascular Aneurysm Repair
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Fenestrated Endovascular Aneurysm Repair
Fenestrated Endovascular Aneurysm Repair
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Fenestrated Endovascular Aneurysm Repair
Fenestrated Endovascular Aneurysm Repair
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Fenestrated Endovascular Aneurysm Repair