1. EVAR Planning: Keys to Success
Shawn Sarin, MD
Vascular and Interventional Radiology
The George Washington University Medical Center

2. Shawn N. Sarin, MD
I/we have no real or apparent conflicts of interest to report.
Off-Label: Some peripheral intervention devices are off-label.

3. Planning Not all patients are candidates for EVAR
Choose the right patients
Patient characteristics and aneurysm anatomy
Only 60% ideal for EVAR based on anatomy
Preprocedural imaging is paramount
Detailed imaging of the aorta
From descending thoracic to common femorals
Nice to know the runoff as well

4. Pre Procedure Imaging
CTA
3D Workstation
MRA
Angiography
IVUS

5. Develop a Systematic Approach
Visceral and Renal arteries
Proximal Neck Anatomy
Proximal Seal Zone
Distal Neck Anatomy
Distal Seal Zone
CIA/EIA
Access Arteries
CFA/EIA

6. Visceral and Renal Arteries
Assess patency of Celiac, SMA and IMA
Renal Arteries
Position
In relation to neck
Which is lowest?
Patency
Number

7. Diameter of Proximal Neck
Measure at the lowest renal and 10-15mm below the lowest renal

8. Measurements
Axial measurements can overestimate due to angulation and tortuosity
Measure diameter perpendicular to central vessel axis

9. Device Sizing Oversize neck by 10-20%
Look at vendor sizing chart
Current devices range from 20-36mm and can treat aortic neck diameters from 19-32mm
Remember:
Undersized graft may have no seal
Oversized graft may have pleats/folds

10. Length of Proximal Neck
Need to create a seal between the endograft and the aortic wall
10-15mm length

11. Contour of Proximal Neck
Change in neck size of >10-15% over its length associated with higher proximal endoleak rate
Straight
Tapered
Reverse Tapered
Morphology of proximal aortic neck

12. Quality of Proximal Neck
Calcification
Mural Thrombus
Angulation
Greater than 90 degrees is a risk factor for an endoleak
Extensive calcification increases probability of stent migration

13. Angulation of Proximal Neck
Often seen with larger aneurysms
Mild <40°
Moderate 40-60°
Severe >60°

14. Tips and Tricks
Assess angulation on preprocedure imaging will help during procedure and optimize endograft placement
Place endograft as close to lowest renal as possible

15. Craniocaudal Angulation
Most infrarenal necks have 5-15° cranial angulation

16. LAO/RAO Angulation
Determine LAO/RAO angulation based on lowest renal

17. LAO/RAO Angulation
Determine LAO/RAO angulation based on lowest renal

19. Iliac Arteries Common/External Iliacs are the location of distal seal
Are they aneurysmal?
rare for EIA to be aneurysmal
consider coiling of IIA when extending to EIA
Distal seal zone:
10-15mm
Oversize 10-20%

20. Iliac Arteries

21. Iliac Arteries Ideally Newer devices are lower profile and hydrophilic
Larger than 6mm
Non calcified
Non tortuous
Newer devices are lower profile and hydrophilic

22. Graft Selection Fixation Type Sizes Anatomy Delivery System
Positive fixation (hooks, barbs)
Radial force, friction
Column support
Sizes
Anatomy
Delivery System
Flexibility
Trackability
OD of delivery system

23. Graft Selection

24. Endurant
Endologix
GORE
COOK
Proximal neck length
10 mm 15
neck diameter
19-32
18-32 mm
19-29 mm (inner to inner)
infrarenal angle
<60
access
6.5 mm/17 18 fr OD
6.5 mm/17 fr ID/8 fr. contralateral
12 fr/18 fr/20 fr 5mm/6.8mm/7.6mm
18, 20 and 22 fr OD
min access profile (28mm graft)
20F OD
19.2F OD
20.4 F OD
23.1F OD/18F OD (LP)

25. Access Selection Anatomic factors Vascular access Femoral cutdown
Percutaneous

26. Anesthesia Considerations
General Anesthesia
Regional:
Lumbar
Spinal
Conscious Sediation

27. Take Home Points Not all patients are ideal for EVAR as of 2/24/13
Work in a team
Need a quality pre procedure imaging (CTA)
Helps decide if patient is an EVAR candidate
Device sizing and selection
Aids in intraprocedural planning
Planning will become more important in the future

28. Thank you!