1. ENDOVASCULAR AAA REPAIR (ALSO KNOWN AS E.V.A.R.)

2. ENDOVASCULAR AAA REPAIR OBJECTIVES: 1. REVIEW THE ANATOMY OF ANEURYSMS 2. EXPLAIN THE NURSING CONSIDERATIONS FOR THE ENDO AAA PATIENT 3. UNDERSTAND THE SURGICAL PROCEDURE 4. LOCATE THE SUPPLIES NEEDED TO DO THIS PROCEDURE

3. ANATOMY OF A VESSEL

4. TYPES OF ANEURYSMS

5. TYPES OF VESSEL ANEURYSMS Fusiform These aneurysms involve an entire circumferential segment of the vessel, which results in a diffuse dilated lesion

6. TYPES OF VESSEL ANEURYSMS Saccular These aneurysms involve only a portion of the circumference of the vessel, and the vessel appears to have an outpouching.

7. TYPES OF VESSEL ANEURYSMS MYCOTIC ANEURYSM These rare, infectious aneurysms of the aorta are caused by Staphylococci, Streptococci, or Salmonellae.

8. TYPES OF VESSEL ANEURYSMS Pseudoaneurysms The tunica externa or adventitia is dilated, although the media and intima layers do not herniate.

9. SCREENING THE PATIENT When assessing the anatomy of an EVAR candidate, several factors need to be considered. These include the quality of iliofemoral access, the proximal attachment site (infrarenal neck), the anatomy of the aneurysm itself, the anatomy of the distal aorta, and the distal attachment site, which is most commonly in the iliac arteries, but can be more distal, depending on the patients pelvic anatomy.

10. SCREENING THE PATIENT There must be enough healthy aorta between the renal arteries and the proximal end of the aneurysm to place the graft. Different grafts have different parameters for this.

11. SCREENING THE PATIENT: THE ILIAC ARTERIES If they are tortuous a guidewire or graft may not pass through to the aorta. The stiff guidewire can help straighten out some tortuous vessels If the diameter is too small the deployment device may not pass

12. SCREENING THE PATIENT: ACCESSORY VESSELS VESSELS MAY BE ARISING FROM THE ANEURYSM (accessory renal/ inferior mesenteric branch) CAN FEED THE ANEURYSM AFTER GRAFT PLACEMENT THEY MAY BE EMBOLIZED PRIOR TO SURGERY

13. Need to avoid occlusion ideally of both the Hypogastric (INTERNAL ILIAC) arteries which branch off the External Iliacs Check anatomical measurements carefully Must be able to accommodate graft deployment SCREENING THE PATIENT: HYPOGASTRIC VESSELS

14. SCREENING THE PATIENT: LABS CHECK LABS FOR COAGULOPATHIES RENAL INSUFFICIENCY CARDIAC CLEARANCE HCG TYPE AND SCREEN/ CROSS

15. SCREENING THE PATIENT- RN CONSENTS/ H&P ALLERGIES BLOOD AVAILABILITY TEDs/ SCDs CHECK FOR ICU BED POST-OP HAIR REMOVAL IN PRE-OP

16. NURSING CONSIDERATIONS RISK OF INFECTION PRE-OP ABX WITHIN 1 HOUR OF INCISION NORMOTHERMIA ROOM TRAFFIC

17. NURSING CONSIDERATIONS RADIOLOGIC EXPOSURE SHIELD PATIENT IN NONOPERATIVE AREAS DOCUMENT RADIOLOGIC EXPOSURE (ASK X-RAY TECH) STAFF WEAR LEAD STAFF WEAR DOSIMETER BADGES

18. NURSING CONSIDERATIONS RENAL FUNCTION CHECK LABS – BUN CREAT  FUNCTION =  AMNT CONTRAST USE CONTRAST EXCRETED THROUGH KIDNEYS ANESTHESIA MEDS EXCRETED THROUGH KIDNEYS MAY ↑ LENGTH OF RECOVERY OR NEED FOR VENTILATOR DOCUMENT AMOUNT OF CONTRAST USED (DR M DOES THIS)

19. NURSING CONSIDERATIONS MEDICATION SAFETY LABEL ALL CONTAINERS DISCUSS ALLERGIES WHEN DISPENSING MEDS TO FIELD TWO PEOPLE READ MED LABEL AND EXP DATE MED VERBALIZED WHEN PASSING TO DR MEDS REVIEWED WITH RELIEF STAFF

20. NURSING CONSIDERATIONS TISSUE PERFUSION CHECK FOR SKIN BREAKDOWN PRE-OP KEEP PATIENT WARM TEDs ON/ SCDs CONNECTED AND RUNNING PRIOR TO ANESTHESIA (PERFUSION  WITH GENERAL ANESTHESIA) POSITIONING – PAD BONY PROMINENCES ASSESS SKIN FOR BREAKDOWN POST-OP AND DOCUMENT CHANGES

21. PREPARING THE OR EQUIPMENT: POWER INJECTOR AND TUBING C-ARM OSI TABLE BIG VASCULAR GRAFT CART X 2 SMALL VASCULAR CART LEAD APRONS AND DOSIMETER BADGES

22. PREPARING THE OR FROM BIG GRAFT CART: LOCATE- INTRODUCERS GLIDEWIRES PERCUTANEOUS SHEATH STIFF GUIDEWIRES BALLOON CATHETERS ANGIOGRAPHIC CATHETERS

23. PREPARING THE OR FROM CATH LAB CART: MEDRAD INJECTOR TUBING ( TO SCRUB) MEDRAD 150 ML SYRINGE ( TO CIRCULATOR)

24. The Procedure Prep as for an open AAA Access groins and dissect down to Femoral Artery Access the Femoral artery with a Pinnacle introducer needle Pass soft Glidewire under fluoroscopy through the Femoral to the Iliac and into the Aorta

25. The Procedure Identify the renal arteries under fluoro Pass the percutaneous sheath introducer over the Glidewire Remove the Glidewire and replace with an Amplatz stiff guide wire Now there is a passage for the graft If vessel diameter is small, a balloon dilator may be used

26. The Procedure Once access is established on one side a Pigtail angiographic catheter is passed through the opposite femoral artery A power injector angiogram may be used during the procedure to ensure flow to the renals and to establish placement of the graft

27. The Procedure Using the stiff guidewire, introduce the main body graft. Once in place, deploy graft and remove the Amplatz stiff guidewire Use Amplatz stiff guidewire on opposite side to introduce the Iliac graft Deploy graft

28. The Procedure Cook Coda balloon catheters may be used to press the graft against the wall of the vessel and to prevent leaks Endoleaks must be identified and treated before closure. Remove guidewires and close vessel Close groin incisions and apply dressing

29. SCRUB NOTES: KEEP ALL WIRES, CATHETERS, AND BALLOONS FLUSHED AND WIPED WITH HEPARINIZED SALINE CLOSE STOPCOCKS AFTER FLUSHING LUMENS REDUCES RISK OF BLOOD CLOTTING IN LUMENS REMOVES AIR FROM LUMENS EASES PASSAGE OF WIRES THROUGH VESSELS

30. POST-OP CARE PATIENT WILL GO TO PACU POST OP PATIENT WILL BE TRANSFERRED TO PACU ON ICU BED

31. POST-OP CARE 5 Ps of checking an extremity: pain pulse pallor paresthesia poikilothermia VS DRESSING Pain level PONV

32. QUESTIONS?