CTA and EVAR-

planning and follow- up

Dimitrij Kuhelj
Clinical Radiology Institute, UMC Ljubljana
Ethiology of aortic disease:

Genetics- gene search

Trauma
Connective tissue disease
Smoking
Hypertension
Iatrogenic...
PATHOLOGICAL CONDITIONS

• Aneurysms
saccular/ fusiform
• Stenosis, incl. Leriche syn.
• Disections
• Ruptures...
INCIDENCE OF AAA

2-4% in population according to screenings

NHS AAA Screening programme. Essential elements in developing an abdominal aortic aneurysm screening and surveillance
programme. http://aaa.screening.nhs.uk.
Screening for abdominal aortic aneurysm. Swedish society for Vascular Surgery, Recommendation statement. http://www.ssvs.se.
TREATMENT GOAL

Ruptures diminished★/ ★ ★
( 7% rupture incidence in AAA ≥ 5,5 cm)

★ Investigators UKET, Greenhalgh RM, Brown LC, Powell JT, et al. Endovascular repair of aortic aneurysms in patients ineglible
for open repair. N Engl J Med 2010;362:1872-80.
★ ★ Bruin JD, Baas A, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysms. N Engl J
Med 2010;362:1881-9.
AORTIC TREATMENT OPTIONS

•Conservative

•Surgery (Cooley, DeBakey- homograft replacement- 1950s’ ★)

•Endovascular- SG- Volodos- late 1980s★★ , Parodi 1991★★★ ,

Dake 1994★ ★ ★★
★ Cooley DA, DeBakey ME. Resection of the thoracic aorta with replacement by homograft for aneurysms and constrictive
lesions. J Thorac cardiovasc Surg 1955; 29: 66-100.
★★ Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixating synthetic prostheses for remote
endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery as intraoperative
endoprosthesis for aorta reconstruction. Vasa Suppl 1991;33:93-5.
★★ ★ Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc
Surg 1991; 5: 491-9.
★ ★★ ★ Dake MD, Miller DC, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of
descendent thoracic aortic aneurysms. N Engl J Med 1994; 331:1729-34.
 OPEN SURGICAL THERAPY

More invasive:

• Extracorporal circulation

• General anaesthesia
• Major surgery- long-lasting recovery
• Combined techniques- less stress
BENEFITS OF ENDOVASCULAR TH.

• No aortic clamping

• Minimally invasive

• Local anaesthesia, completely percutaneous

• Feasible in polymorbid, patients with previous operations and

obese patients
ENDOVASCULAR OPTIONS

• Self- expandable stent grafts (SG) -covered stents- Dacron,

PTFE...

• Baloon- expandable SG- stenosis

• Stents- dissections
• Flow modulators/ diverters (multilayer stents)
LIMITATIONS OF ENDOVASCULAR TH.

• Anatomical reasons ( no/short neck, small or/and stenosed iliac

arteries, large aorta...)

• Young, fit patients- only 20-year follow-up, controls needed

• Hybrid procedures

• Costs
DIAGNOSTICS

• Palpation- unreliable, especially in thin pts

• US- screening, follow-up of aneurysms (CEUS)
(dissection rarely discovered by US)

• CTA- objective, for treatment planning

• MRA- mostly controls after treatment, younger pts
DIAGNOSTICS

• US- detection of AAA

• CTA- gold standard in planning and follow-up

Ionizing radiation during dg, procedure★ and controls

★ Kuhelj D, Zdešar U, Jevtič V, Škrk D, Omahen G, Ţontar D, Šurlan M, Glušič M, Popovič P, Kocijančič IJ, Salapura V . The risk
for deterministic effects in patients during endovascular aortic stentgraft implantation. Br J Radiol 2010 Nov; 83(995):958-
63.
DIAGNOSTICS- reporting

• Presence of aneurysm, dissection

• Signs of rupture
• Signs of ischaemia
• Infra/ suprarenal
• Access options- iliac arteries included!
• Additional pathology
MEASUREMENTS- PLANNING

• Aneurysm- double vessels’ diameter:

aorta > 3cm (incl. thrombus)
iliacs > 1,5 cm (incl. thrombus)

• Treatment of AAA- 5,5 cm or smaller if enlarging > 0,5 cm/ 6

months
• Measuring inner lumen (ecc. for Cook devices)!
DIAMETER- TO TREAT OR TO WAIT?
MEASUREMENTS- ANEURYSMS

Aorta
• Neck- distance from AA to lowest renal artery at least 1 cm-
device dependent
( double arteries should be reported )
• Angulation- straight is better
• Extreme calcification in landing zone should be reported
NECK DIAMETER
NECK LENGHT
MEASUREMENTS- ILIACS
Iliacs

• 18-24 Fr- currently mostly used SG

• 6 Fr = 2 mm; min. diameter 6 mm (18 Fr)- at least 6-7 mm of
lumen needed
• Preserving AII- buttock claudication, impotence...- LENGHT
• Tortuosity- even extremes can sometimes be straightened by
stiff guidewire- angio prior to the procedure
• Extreme calcification in landing zone should be reported
ILIAC DIAMETER
ILIAC LENGHT
MEASUREMENTS- ANEURYSMS

• The neck diameter

• The lenght of the neck
• The largest diameter of the aneurysm
• Lenght, propagation- iliacs?
• IMA, large lumbars (important for type II endoleaks)
• Diameter and lenght of iliacs (landing zone)
• Calcifications- landing zones (AA) and access site
MIP 5/3
MEASUREMENTS- DISSECTIONS

• The neck diameter for SG planning- up to 15% larger

• The lenght of the neck (from left subclavian a.)
• The largest diameter of the both lumens incl. thrombus
• Pressure on the true lumen- subtotal stenose
• Lenght, propagation- neck arteries, iliacs, visceral arteries
• One renal often from the false lumen
• Diameter and lenght of iliacs (access)
• Calcifications- landing zones and access site
TREATMENT OPTION- dissection

CONSERVATIVE- Type B dissections without complications

- Pressure control- hypotensive haemostasis- stabilizes the

patient, syst. BP below 80 mmHg

-β- blockers
-Calcium channels antagonists
TREATMENT OPTION- dissection

REPARATIVE- open surgery and endovascular

• Pressure control prior, during treatment and life-long!

Aortic zones- Ishimaru classification – landing
zones for SG
TO FOLLOW-UP SG OR NOT ?

SVS, ESVS, SIR, CIRSE :

YES, lifelong!

(rupture prevention, detecting stent-related complications)

WHY?

Late ruptures do occur, even after SG implantation! ★/★★

★CloughRE, Figueroa CA, Taylor PR. Late performance of EVAR- 4D imaging will solve this. In: Vascular and Endovascular
Controversies Update. Greenhalgh RM(ed.) BIBA Medical 2012; 191-7.
★★Wyss TR, Brown LC, Powell JT, et al. Rate and predictability of graft rupture after endovascular and open abdominal aortic
aneurysm repair: data from the EVAR trials. Ann Surg 2010;251:805-12.
LONG- TERM RESULTS

EUROSTAR, DREAM, EVAR trial, OVER, ACE (large

registries and randomized studies of EVAR)

Rupture: 0-2,4%
Additional procedures: 13-16%
Mortality (long-term, AAA related): 1,4- 4%
HOW?
FOLLOW-UP IMAGING

Looking for:

• Stent graft patency, deformations

• Renal and iliac artery patency
• Leaks
FOLLOW-UP IMAGING

Plain films

• Stent graft defects, two perpendicular views

• Dose- 50 plain films of chest vs. CTA ★

★Al Zuhir N, Hayes P: Follow-up imaging and a step down to ultrasound. In: Vascular and endovascular
consensus update 2014; 103-10. RM Greenhalgh RM(ed) BIBA Medical 2014.
FOLLOW-UP IMAGING

Plain films

• No data about the flow and haemodynamics

• Limited use
FOLLOW-UP IMAGING
Ultrasound

• Leaks Type 1 and 3- equal sensitivity CEUS vs. CT★

• Sac dimensions, large endoleak (smaller with CM), graft
patency incl. flow velocity (stenosed limb...)
• Flow dinamics- endoleak II resolution
★ Karthikesalingam A, Al-Jundi W, Jackson D et al. Systematic review and meta-analysis of duplex-
ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after
endovascular aneurysm repair. Br J Surg 2012: 99:1514-23.
FOLLOW-UP IMAGING
Magnetic resonance

• Similar to CT, less accesible

• Younger pts, TA- poorely accesible to US
• Excellent in Type II endoleak detection, especially with blood
pool CM
• Nephrogenic systemic fibrosis in pts with renal impairment
FOLLOW-UP IMAGING
CTA

• Standard method, fast & accurate

• Detection, planning, follow-up
• Ionising radiation, adj. to procedure
• Iodine in CM- renal impairment adj. to procedure
PLANNING- PROTOCOL

• Single arterial phase (native sometimes if wall haematoma is

suspected)

• 60-80 ml of CM (320 and up, 400 not necesarry)

• High flow- at least 3,5 ml/s

• MIP coronary reconstructions- not too thin

FOLLOW-UP- PROTOCOL

• 2 phases- arterial and venous (native rarely helpfull)

• 60-100 ml of CM (320 and up, 400 not necesarry)

• High flow- at least 3,5 ml/s

• Measurements of HU in thrombus- compare arterial and

venous- leaks
FOLLOW-UP- PROTOCOL- reporting

• SG patency

• Visceral and iliac artery patency (renals)

• Leaks- feeders, type I in arterial, type II in arterial and venous;

if small only in venous

• Defects in the material- kinking...

LEAKS

• Type 1- proximal or distal flow by the SG

• Type 2- retrograde flow from arteries (IMA, lumbars...)

• Type 3- defective material or between components

• Type 4- material porosity

LEAKS

Treatment obligatory?

• No, most seal in 6 months★

★JonesJE, Atkins MD, Brewster DC, et al. Persistant type 2 endoleak after endovascular repair of abdominal aortic aneurysm is
associated with adverse late outcomes. J Vasc Surg 2007; 46:1-8.

Type 1 and others with sac enlargement should be treated!

FOLLOW-UP IMAGING FREQUENCY

In the first decade of stentgrafting

• CTA 30 days after the procedure

• 6 months
• Yearly
FLOW MODULATORS/ DIVERTERS

Multylayer stents (3 layers), creating laminar flow

• causing gradual, controled aneurysmal trombosis,

• alowing branch arteries to remain patent ( arch

branches, Adamkiewitz a., viscerals......)

• Thrombus forms gradually

OUR RECOMMANDATIONS

• CTA 30- 90 days after the procedure

• 1, 6 months- US (diameters)
• 1 year
• US yearly if OK and accessible +/- plain films, if in doubt-
CTA

• After 10 years- every second year

TAKE-HOME POINTS

• PRE- PROCEDURAL:
aneurysm size, neck diameter and lenght, iliac diameter
and lenght of CIA, calcified landing zone/ CFA- single
phase
• CONTROLS:
aneurysm size, SG patency, visceral artery patency, leaks-
two phases; dissections- single phase:diameters compared
• Control CTA- 1- 3 months, 1 year
• In between- well-performed US (CEUS)
• If leak or SG failure suspected- CTA
• TA, younger pts- MR for follow-up