in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno

1. (Thoracic) Endovascular Aortic Repair
(T)EVAR
Dicky A Wartono .MD
Cardio Vascular Surgeon
Harapan Kita National CardioVascular Centre Harapan Kita
Jakarta 2016

8. (Thoracic) endovascular aortic repair
(T)EVAR
• is an emerging treatment modality, which has
been rapidly embraced by clinicians treating
thoracic aortic disease.
• less invasive approach than open surgery
• extended management options in thoracic
aortic disease
• has been adopted by many specialties
including cardiologists, cardio- vascular
surgeons, radiologists and vascular surgeons.

9. Recommendations for the
Development of a TEVAR Programme
• Evaluation of symptoms and patient status
• Multidisciplinary consultation
• Preoperative imaging
• Planning

10. Indication & Contra indication
• complicated acute type B aortic dissections.
– persisting or recurrent pain,
– uncontrolled hypertension despite full medication,
– early aortic expansion,
– penetrating aortic ulcer
– IMH (?)
– Malperfusion
– signs of rupture (haematothorax, increasing periaortic
and mediastinal haematoma)

11. Indication & Contra indocation
• uncomplicated type B dissection
– close surveillance
– multidisciplinary team approach
– IMH
• Traumatic Aortic Injury
– complete transsection of the aortic wall free bleeding
into the mediastinum pseudocoarctation syndrome,
– limited disruption of the aorta is present but media
and adventitia are intact .. delayed treatment can be
suggested

12. Planning For Aortic Aneurysm
• Landing zone
• Prior transposition or bypass surgery/re-routing
of the involved aortic branch may be considered.
• Evaluation of access vessels (sizing, calcification,
tortuosity).
• Alternative access sites are the iliac arteries, the
infrarenal aorta or even the ascending aorta.

13. Planning For Aortic Dissection
• Classify the type of dissection (classical dissection,
intramural haematoma (IMH), penetrating
atherosclerotic ulcer, traumatic dissection)
• Localization of all tears, with emphasis on identifying
the primary entry tear.
• The next step is to define the extension of dissection
and possible static, dynamic or complex involvement of
supraaortic, visceral and pelvic vessels resulting in
malperfusion

14. Imaging is Critical
AAA Endograft Planning
Patient selection
Device selection – type, ? Extensions
Additional procedures – IIA coil embolization
Bell-bottom procedure
Prepare for a possibility of having something
“bad” happened.

15. Neck
Proximal anchoring zone
Iliac arteries
Distal “seal” zone
2 important zones

16. Neck
Proximal anchoring zone
2 important zones
Diameter < 32 mm
Length > 15 mm
Angle < 75
No thrombus
No calcification

17. Iliac arteries
Distal “seal” zone
2 important zones
Diameter > 7 mm
‘Seal’ zone > 15 mm
Angle < 90
Not too tortuosity
Not too calcified

18. Nice-long neck

19. Nice straight iliac arteries

20. Good “ideal” anatomy

21. Neck
Diameter
Length
Angle
Thrombus
Calcification
Iliac arteries
Diameter
tortuosity
Angle
Calcification
Mostly we look at

22. Neck
Too wide (> 25 mm – AneuRx, >32 mm - Talent)
Too short (< 15 mm)
Too angulated (>60)
Too diseased
Cone-shaped Iliacs
Too tortuous
Too small (< 7 mm)
Too calcified
There are always challenges

23. >90° 80°
Neck Angulation

24. 70°
Is this neck OK?

25. 65°
Neck Angulation
65° angulation neck Implant angio shows endoleak

26. Angulated but long neck

27. 85°
Diameter 19-20 mm
Length 6 mm
angle57°
Diameter 30-31 mm
Length 57.8 mm

28. Small type II endoleak
No type I proximal endoleak
Angulated but long neck

29. LR_4HKL2046 80°
Angulated but long neck

30. LR_4HKL2046
Angulated but long neck

32. Neck Angulation
< 60 degrees angulation
Angulated and long neck “might” be OK
Angulated and short neck “is bad”

33. Short and angulated Neck
Angulated neck, 75º
20 mm
16 mmNeck Length 10 mm

34. Short and angulated Neck

35. Cone-shaped Neck

36. Cone-shaped Neck

37. Cone-shaped Neck
Device migration

38. Neck Filling Defect

39. Neck Filling Defect (>50%)

40. Iliac artery tortuosity

41. Iliac artery tortuosity

42. Iliac Artery Stenosis
10 mm
4 mm
8 mm
6 mm

43. Iliac Artery Stenosis

44. Small Distal Aorta
14-mm lumen at distal aortic neck which is heavily calcified

45. Accessory Renal Artery
Accessory renal artery

46. Low right accessory renal artery
Accessory Renal Artery

47. Enlarged CIA: 16 -30% of ESG cases
22 mm
18 mm

48. R L
Bilateral Common Iliac Artery Aneurysms

49. 40 mm
20 mm
Bilateral Common Iliac Artery Aneurysms

50. Right CIA
Aneurysm
Coil occlusion
right internal iliac
Endograft
extended
IIA occlusion and limb extension

51. Yano, 2001
Karch, 2000
Criado, 2000
Mehta, 2001
IIA occlusion
cases
103
22
39
154
Pelvic ischemia complications
total
cases
22 (21%)
10 (42%)
6 (15%)
71 (46%)
buttock
claudication
95%
70%
83%
79%
colonic
ischemia
5%
30%
0%
6%
others
17%
15%

53. Bell-bottom

54. Bell-bottom

55. How to get good results
Rule # 1: Conservative patient selection
• Avoid “I can do it” or “Just do it” mentality.
• Open surgery is still a standard treatment.
• Choose a “good candidate” for EVAR in
the learning phase.
• Good open surgical skill is mandatory.

56. How to get good results
Rule # 2: “Know” our devices
• Understand the design of the stent graft we use.
• Avoid using too many different devices in the
learning phase.
Each design has its own “trick or treat”
• “Back up” devices, including “extra” proximal
and distal extensions for unexpected need in
every case.

57. Rule # 3: Procedure planning
How to get good results
• Know all steps, devices
we are going to deploy,
before we really do it.
• Planning and thinking prior to surgery
• OR day – work as plan

58. AAA Endograft Planning

59. Murphy’s law

60. How to get good results
Rule # 4: Prepare for the worst
• Know the possible problems
If it occurred to the others,
it will certainly occur to us, sooner of later.
• Remember, problems may happen in “THIS” case.
• Keep balloon in hand, ready to use

61. Talent AAA Stent Graft
Flared & Tapered Limbs
MRI Compatible Polished Nitinol
Durable Polyester
Graft
Medial C-Bar for Column
Strength with Flexibility
Universal Docking
Suprarenal Fixation

62. Device Selection - Talent
12 – 20 mm Distal Iliac
Diameter
140, 155 and
170 mm Graft Covered
Lengths
24 – 36 mm Proximal
Aortic Diameter
8–24 mm Distal
Iliac Diameters
75 mm, 90 mm and
105 mm Graft Covered
Lengths

63. Standard AUI Systems (One & Two
Piece)
22-36 mm Proximal Diameters
12 – 24 mm
Distal Diameters
All Proximal ends are
18 mm Diameter
All Distal ends are
16 mm Diameter

64. Advanced New Delivery System

65. Endurant stent graft
Valiant stent graft
“Conformability”
AneuRx stent graft
“laser-cut nitinol stent”
Talent stent graft
“Suprarenal fixation”
Xcelerent delivery system
“Trackability/Flexibility”
“Hydrophilic coating”

66. Endurant stent graft
High Flexibility and Conformability

67. Endurant stent graft
High Flexibility and Conformability
Suprarenal stent
“Anchoring pins”

70. Endurant stent graft
“M-shaped” proximal stent
• Enhance wall apposition
• Prevent infolding
• Provide a 5-mm sealing zone

71. Endurant stent graft
“M-shaped” proximal stent
Kink-resist limb

72. 2 steps of
Simple & Controlled Deployment
Rotate slider counter clockwise
1. Main body

73. 2 steps of
Simple & Controlled Deployment
2. Suprarenal stent
Rotate back-end wheel clockwise

75. 23, 25, 28, 32, 36 mm
Proximal Aortic Diameter
“Endurant”
Bifurcated Device
Universal docking
14 mm
13, 16, 20 mm
Distal Iliac Diameter
120, 145 and 170 mm
Graft Covered Lengths

76. 1: Conservative patient selection
2: Know our devices
3: Procedure planning
4: Prepare for the worst
Summary

78. Definition of treatment success
• Aortic Aneurysm
– the aneurysm is excluded from the circulation (absence of
type I or III endoleak).
– follow-up examinations of the patient demonstrating
complete thrombosis and shrinkage of the aneurysm sac,
and in the absence of complications.
• outcome parameters
– persisting or newly developing endoleakage,
– freedom from reintervention or secondary surgical
conversion

79. Definition of treatment success
• Aortic Dissection
– closure of the primary entry tear (absence of type Ia or III
endoleak)
– induction of false lumen thrombosis.
• The aim of endovascular treatment
– To resolve complications of aortic dissection including mal-
perfusion, imminent rupture and bleeding.
– This does not imply complete immediate thrombosis of the
false lumen, as further thrombosis and remodelling
processes are a matter of time

80. • Measures of outcome
– identical to those of TAA.
– fate of the distal aorta involved in the dissection.
– reasonable to accept continued perfusion of the
false lumen in the abdomen distal from the stent-
graft site as long as aortic dilatation does not
occur

81. Follow-up
• Lifelong clinical and morphological
surveillance is mandatory after (T)EVAR
• CTA is recommended prior to discharge.
• Further follow-ups at 6 and 12 months is
based on CTA

82. Vascular Complication
• Endoleak
• Retrograde aortic dissection
– frequently in acute aortic dissection and where the
aortic arch or the ascending aorta is involved.
• Aorto-oesophageal or aorto-bronchial
– rare
– frequently seen after acute aortic syndromes
• Access
– Bleeding / rupture
– Infection

83. Endoleak

84. Non-Vascular Complication
• Neurologic Injury
– Brain Injury
• manipu-lation within the arch or intended or inadvertent overstenting of one
or more of the great vessels
• Over- stenting of the left subclavian artery is permissible in the emer- gency
setting (e.g. traumatic aortic injury), but is inadvisable in elective cases due to
a heightened risk of stroke and spinal cord injury.
– Spinal
• extended lengths of the covered thoracic aortic segments.
• collateral blood supply via the left subclavian artery, lumbar arteries as well as
hypogastric arteries
• preventive cerebrospinal fluid (CSF) drainage
• Reversal of paraplegia can be achieved by the immediate initiation of CSF
drainage and pharmacological elevation of blood pressure (.90 mmHg mean
arterial pressure).
• Post Implanttion Syndrome
• Comorbidity