My secrets in infrarrenal EVAR planning

Julio Palmero

H. Clínico Universitario de Valencia

My secrets in infrarrenal EVAR planning

Disclosure

• Consulting an Proctoring services

COOK

School of Medicine, University of Barcelona

27th to 29th MARCH 2019

2 essential secrets to achieve a successful EVAR

1. Planning the EVAR with an optimal CT

– Arterial phase, well contrasted

– Slice thickness ≤ 1 mm

2. Planning EVAR within IFU



Optimal CT



Multiplanar reconstructions (MPR)• Coronal• Sagital• Axial

Never planning over Axial CT



Optimal CT

Rotate the axis in the coronal, sagittal and axial plane following the axis of the aorta and the axis of renal’s

C-Arm Orientation• Craneo-caudal• Lateral

15 degrees craneo-caudal

10 degrees lateral



15 mm of sealing• Perpendicular to the

axis of aorta• Diameters over axial• Take at least 3

measurements

Infrarenal aortic Neck

15 mm

Diameter common iliac arteries



Rotate the axis in the coronal, sagittal and axial plane following the axis of the vessel.

MPR

Length measures



• MPR• MIP

• The tool opened polygon is very usefull

Length measures



• The tool opened polygon is very usefull

• MPR• MIP



External iliac and femoral information

External iliac and femoral information



• An increasing number of patients with AAA , withshort and angulated necks are being included tobe treated by EVAR.

• It is very important accurate imaging planning,morphology and possible landing zones, trying toknow the behaviour that the graft will haveduring the deployment.

• This is essential to achieve a successful EVAR.



Hostile neck great challenge in EVAR

Hostile-Angulated neck



• If the angulation is more than 60°, use specific graft within the IFU.

• We obtain sealing if the graft contact with whole aortic wall.

You must know and imaging the behaviour of the graft during the

deployment!!!



• Double angulation of aortic neck.

• Neck length 25 mm.• The planning on the CT was

sealing lower than the first angulation.


You must know and imaging the behaviour of the graft during the

deployment!!!



Functional neck:10 mm

Center line:15 mm



• If the angulation is more than 60°, use specific graft within the IFU

• Look for alternatives if a severe angulation is associates with other factors that affect the quality of the neck• Short neck• Circumferential calcium• Circumferential thrombus• Reverse tapered or tapered neck


Planning EVAR within IFU



Results within IFU Results outside IFU

Rupture at 5 year 0,2-0,5 % -------

Rupture at 1 year ------- 4%

Early Type 1 EL 0,3-2,6% 13-15%

Late Type 1 EL 0,8-3,5% 10%

Conclusions



1. Have an optimal CT2. Planning EVAR within IFU3. Have and manage a good 3D work station4. Be used to manage multiplanar reconstruction,

CPR, MPR, MIP and 3d volume rendering5. Understanding what information is necessary in

each case, to perform the intervention with success

6. Know and imagine what will be the behavior of the graft during the deployment and once implanted



Do not forget the information

Draw the aneurysm on paper and write all relevant information about the patient's data, measurements, graft references, angles of the C-Arm....

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My secrets in infrarrenal EVAR planning