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HIGH-YIELD IMAGING: INTERVENTIONAL ISBN: 978-1-4160-6160-1
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on
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recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of the practitioner, relying on his or her own experience and knowledge of
the patient, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither
the Publisher nor the Authors assume any liability for any injury and/or damage to persons or
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The Publisher
Library of Congress Cataloging-in-Publication Data
High-yield imaging. Interventional / Charles T. Burke … [et al.]. — 1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4160-6160-1
1. Interventional radiology—Handbooks, manuals, etc. I. Burke, Charles T. (Charles Thomas).
II. Title: Interventional.
[DNLM: 1. Radiography, Interventional. 2. Diagnostic Imaging. WN 200 H638 2010]
RB33.55.H54 2010
616.07’57—dc22
2009041677
Acquisitions Editor: Rebecca Gaertner
Developmental Editor: Timothy C. Maxwell
Publishing Services Manager: Tina Rebane
Project Manager: Fran Gunning
Design Direction: Steve Stave
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
PPrreeffaaccee
High-Yield Imaging: Interventional is a comprehensive equipment necessary for the procedure is followed by a
yet easily referenced handbook of the expanding field of summarized description of the pertinent anatomy and
image-guided procedures. It is a condensed and summa- approach. The technique to actually perform the proce-
rized version of the large two-volume textbook Image- dure is then described in an easy-to-follow, step-wise
Guided Interventions. High-Yield Imaging: Interventional manner. Controversies are reviewed that may require
covers a wide array vascular and nonvascular Interven- special considerations. Outcomes and complications are
tions. There are 111 chapters within the vascular sec- summarized, which is necessary for discussions with re-
tion, ranging from abdominal aortic endografting to ferring physicians as well as for informed consent. Each
percutaneous thoracic duct embolization. An additional chapter ends with a review of the recommended post-
52 chapters comprise the nonvascular section. Eight procedural and follow-up care and a list of suggested
chapters are dedicated to the complex management of readings.
vascular malformations. The burgeoning field of onco- The distillation of this material into an accessible
intervention is extensively represented by 26 chapters of handbook was the work of Drs. Charles Burke and Robert
transarterial, transvenous, and endoluminal procedures Dixon, interventional radiologists and faculty at the Uni-
as well as percutaneous thermal and chemical ablation versity of North Carolina. I would like to thank and con-
therapies. There are even 10 chapters on head and neck gratulate them both for their efforts. High Yield Imaging:
interventions, including acute stroke management. Pain Interventional will serve as a useful guide for residents,
management procedures, an area that has been well fellows, and practicing interventionalists alike when
established in Europe for many years, comprises the speaking to patients and preparing for the procedure.
final seven chapters of the book.
Each chapter describes a procedure, beginning with Matthew A. Mauro, MD
a list of indications and contraindications. A list of the
v
Acknowledgments
The text High–Yield Imaging: Interventional is based to acknowledge all of our colleagues throughout the
on the 2-volume book Image-guided Interventions, world listed below who contributed to Image-guided
published in 2008, with the text updated in 2009, and Interventions and without whom neither that book nor
the figures include the most representative illustrations this one would have been possible.
from that textbook plus new updated images. We wish
Contributors
Hani Abujudeh Karen T. Brown Lorenzo García-García
Andreas Adam James P. Burnes Vanessa L. Gates
Hassan M. Ahmad Patricia E. Burrows Tony Geoghegan
Sun Ho Ahn Justin John Campbell Debra A. Gervais
Kamran Ahrar Colin P. Cantwell Jean-Francois H. Geschwind
Morvarid Alaghmand Thierry Carreres Matthew B. Gillbert
Agaicha Alfidja John A. Carrino Mark F. Given
Ahmad I. Alomari Lucie Cassagnes Y. Pierre Gobin
Gennaro Ambrosanio Pascal Chabrot S. Nahum Goldberg
Soon Ghee Ang Abbas Afif Chamsuddin Theodore S. Grawbow
John Frederick Angle Richard Chang Roy K. Greenberg
Gary M. Ansel Lakhmir S. Chawla Brian Grieme
Bassel Atassi Hank (Han) K. Chen Klaus D. Hagspiel
Julien Auriol Yung-Hsin Chen Keith W. Hamilton
Juan Carlos Baez Rush Hamilton Chewning Klaus A. Hausegger
Curtis W. Bakal Kenneth H. Cho Markus H. Heim
Jörn Oliver Balzer Albert K. Chun Robert C. Heng
Joel E. Barbato Timothy W.I. Clark Joshua A. Hirsch
Brad P. Barnett Felipe B. Collares J.Todd Hobelmann
Gamal Baroud Luca Cova Andrew H. Holden
Carlo Bartolozzi Laura Crocetti Ed Horn
Jason R. Bauer Charles D. Crum Oluwatoyin R. Idowu
Richard Arthur Baum T. Andrew Currier Tiziana Ierace
Kevin Walter Bell Ferenc Czeyda-Pommersheim Elizabeth Ann Ignacio
Jacqueline A. Bello Michael D. Dake Zubin Irani
Jennifer L. Berkeley Michael David Darcy Roberto Izzo
Michael A. Bettmann L. Mark Dean James E. Jackson
Mario Bezzi Thierry De Baère Augustinus L. Jacob
José I. Bilbao Sudhen B. Desai Priya Jaga
Deniz Bilecen Alvaro A. Diano Francis Joffre
Christoph A. Binkert Robert G. Dixon Matthew S. Johnson
Haraldur Bjarnason Pablo D. Dominguez Chauncey T. Jones
James H. Black III Robert F. Dondelinger Sanjeeva P. Kalva
Francine Blei Gregory J. Dubel Anthony W. Kam
Brian M. Block Clifford J. Eskey Sridhar Kamath
Marc Bohner Jan A. Eubig Krishna Kandarpa
Amman Bolia Salomão Faintuch Jeffrey M. Katz
Irene Boos Ronald N. Fairman John A. Kaufman
Charles F. Botti, Jr Chieh-Min Fan Alexis D. Kelekis
Louis Boyer Fabrizio Fanelli Frederick S. Keller
Elena Bozzi Mark A. Farber Robert K. Kerlan, Jr
Peter Reynolds Bream, Jr Laura M. Fayad David Kessel
Rachel F. Brem Peter F. Ford Verena Khan
Mark F. Brodie Brian Funaki Kanika Khanna
Allan L. Brook Andreas Gabelmann Neil M. Khilnani
Benjamin S. Brooke Dmitri A. Gagarin Hyun S. Kim
Duncan Mark Brooks Philippe Gailloud Hiro Kiyosue
Daniel B. Brown Suvranu Ganguli Sebastian Kos
vii
Abdominal Aortic Aneurysm Endografting
DEFINITION: Endografting is an interventional procedure for treatment of abdominal aortic
aneurysm (AAA).
INDICATIONS n D evices may have suprarenal fixation or infrarenal
fixation.
n A AA >5 cm (women) or 5.5 cm diameter (men) n S ome devices have hooks, barbs, or both for
n R apidly expanding aneurysm (>0.5 cm in 6 months) additional fixation.
n A AA greater than two times the normal aortic diameter n S ingle-piece devices are not popular, and most
n M orphology suggestive of high rupture risk bifurcated (aortoiliac) devices are modular.
n S ymptomatic (painful) aneurysm n W henever possible, bifurcated endografts should be
n A lso treated endovascularly: ruptured AAAs, mycotic used.
aneurysms, penetrating ulcers, aortoenteric fistulas, n A ortomonoiliac devices are indicated if one
and traumatic aortic injuries iliac artery is severely diseased or occluded or
if the distal aorta is too narrow for two endograft
limbs.
CONTRAINDICATIONS n S heaths
n L arger sheaths can help accommodate iliac tortuosity.
n N eck diameter >33 mm or <18 mm n N ow that most devices are designed for sheathless
n S hort necks (minimal neck length is undefined); necks insertion, sheaths are becoming less necessary than
angulated >60 degrees they once were.
n C ircumferential mural thrombus, calcification in aneu- n S mall sizes include 5-8 Fr bright tips; large sizes
rysm neck, or both include 12-24 Fr.
n E xcessively calcified and tortuous iliac arteries; nar- n W ires
row iliac arteries (<7 mm in diameter) n W ires used in AAA surgery include Bentson 0.035
n A llergies to material components that comprise device inch, Newton-J 0.035 inch, Amplatz Superstiff 0.035
n P atients on long-term anticoagulation who cannot tol- inch, Glide 0.035 inch, Meier 0.035 inch, Lunderquist
erate short duration of anticoagulation cessation dur- 0.035 inch, and Rosen 0.035 inch.
ing initial procedure n I nitial access wires and sheaths include starter wires
n A llergy to radiographic contrast medium (can be cir- and size 5-8 Fr sheaths.
cumvented by use of alternative contrast agents such n T hree grades of wire stiffness can be used; in order
as carbon dioxide) of stiffness, they are Amplatz Superstiff, Meier, and
Lunderquist wires.
n A lthough some devices can be inserted over 180-cm
long wires, 260 cm or longer lengths are typically
EQUIPMENT
needed.
n E ndografts n D iagnostic catheters
n E ndografts available include AneuRx, Zenith, n S traight or pigtail aortic flush catheter (Cobra,
Excluder, Aorfix, Endologix Powerlink, and Kumpe/Bernstein 5 Fr, C1 or C2 5 Fr, Omni sizing
Anaconda. flush 5 Fr, SOS-1 or SOS-2 5 Fr)
n I deal endograft is available in a wide variety of n B alloons
diameters and lengths, with a low-caliber delivery n A ngioplasty balloons (6-16 mm)
system and can be easily and accurately deployed n M olding balloons (CODA, Reliant, Equalizer, Z-Med)
and durable. n O cclusion balloons (W. Cook)
KEY POINTS
n Patient selection is the most important aspect of EVAR.
n Appropriate sizing is best performed using multiplanar reformatted images, not axial imaging.
n Surveillance and comparison to baseline studies are critical in evaluating patients and identifying
complications before they become detrimental.
n Diseased infrarenal aortic necks (aneurysmal, short, and thrombus-laden) temper the ability to achieve
durable sealing and fixation with current commercialized stent-grafts.
n A wide range of devices is commercially available for EVR, although no device fits all requirements as the
perfect device.
n Type 1 or type 3 endoleaks visualized on completion angiography should be treated immediately.
n Type 3 endoleaks and migration are the most important factors in late endograft failure.
2
VASCULAR INTERVENTIONS Abdominal Aortic Aneurysm Endografting 3
Figure 1. Insertion of a Zenith bifurcated endograft. Figure 2. Insertion of a Zenith bifurcated endograft. After
Angiography is performed to define the renal arteries, and the deployment of the main body, the contralateral limb is
upper end of the endograft is deployed. cannulated, followed by insertion of the limbs of the endografts
into both iliac arteries.
Figure 3. Insertion of a Zenith bifurcated endograft. After Figure 4. Insertion of a Zenith bifurcated endograft.
deployment of the main body, the contralateral limb is Completion angiography confirms a patent endograft, patent
cannulated, followed by insertion of the limbs of the endografts renal arteries, and no visible endoleak.
into both iliac arteries.
4 Abdominal Aortic Aneurysm Endografting VASCULAR INTERVENTIONS
n L arge-caliber balloon catheters to dilate mold devices n S imple textbook aneurysms, without complicating
to aortic neck or iliac arteries vessel anatomy, thrombus, or calcification, can be
n C oons treated successfully with any commercially available
n C ook hydrophilic dilators (16-24 Fr) or renal fascial devices.
dilators are used. n S ome devices may be more suited to specific cases due
n D ilation of iliac stenosis is necessary to facilitate to factors in the proximal neck, the distal aorta, or the
device passage. iliac arteries.
n A utomated contrast power injector n I n general, endograft should be oversized by 10%-
n R equired for conventional endovascular aneurysm 20% with respect to the diameter of the native vessel
repair (EVAR) and fenestrated stent-grafting from outer wall to outer wall.
n I ntravascular ultrasound n I f heavy calcification is present, luminal diameter may
n I n patients with renal insufficiency, using intra- be used to select the size of the device.
vascular ultrasound (IVUS) to locate renal arteries and
to implant the device helps minimize contrast use.
n E xperience with this technique is needed to ensure TECHNIQUE
proper visualization.
n C losure devices n B est results are achieved by using a team approach;
n F or percutaneous access, closure devices (Perclose the team should consist of vascular surgeons and inter-
or Prostar) are used, when appropriate. ventional radiologists.
n O ther interventional equipment n P repare area with a skin cleansing agent.
n F or handling potential complications involving n M ost procedures are performed under general anesthe-
the great vessels, renal arteries, and access vessel sia, enabling complex interventions to be performed
complications without disruption by patient movement.
n L arge palmaz stents (cordis) n R egional or local anesthesia may be used in patients
n F or treatment of type 1 endoleaks unfit for general anesthesia, with similar success rates,
n S OS Omni catheter, sidewinder catheter reduced cardiorespiratory complications, and postpro-
n M ay be required if standard retrograde cannulation cedure recovery times.
of contralateral limb is unsuccessful n A ccess to arterial system is usually achieved by bilat-
n S nare eral femoral arteriotomy.
n A snare (Gooseneck snare, 25-mm diameter) may n W ith the improved quality of percutaneous closure
be required with the catheter if standard retrograde devices, EVR now can be performed percutaneously
cannulation of contralateral limb is unsuccessful. and the access sites can be closed using arterial closure
n A ngiography suite devices.
n I deally, the procedure is performed in an angiography n S ome operators prefer femoral arteriotomy for inser-
suite with OR conditions. tion of a large-caliber delivery system of the main
n O R may be used if mobile image is of the highest body and percutaneous access for the contralateral
quality and at least 12 inches in diameter. limb.
n I maging equipment (CT or MRI) n A lthough benefits of percutaneous closure are obvi-
n C omprehensive imaging (mainly CT) of the aorta ous, formal arteriotomies provide greater control, par-
and iliac arteries is required to assess suitability for ticularly if complication develops.
EVAR or endovascular repair (EVR) and to assist n O blique incisions are generally preferred unless femo-
device selection. ral reconstructions are planned for preexisting occlu-
n M RI is preferred by some centers and is useful for sive disease.
patients who are allergic to radiographic contrast n O nce the femoral sheath is entered, identify the femo-
material. ral artery as it exits under the inguinal ligament.
n E ncircle artery with Silastic or cloth tapes both proxi-
mally and distally.
ANATOMY AND APPROACH n S ystemic heparinization is instituted at this juncture at
most institutions; local heparinization through access
n A ll patients require comprehensive imaging of aorta sheaths also has been used.
and iliac arteries to assess suitability and plan EVR. n O nce heparinization is completed, obtain bilateral aor-
n I maging coverage extends from the diaphragm to the tic access using standard interventional techniques.
acetabulum, with thin collimation; our angiographic n C atheter exchange can then occur: Place stiff wire
protocol calls for 70-120 mL contrast medium injected through ipsilateral femoral artery and angiographic
at 4-5 mL/second. catheter on contralateral side.
n A pproach involves either percutaneous or open sur- n F ollow general interventional principles, especially
gical exposure of common femoral arteries (bilateral with respect to monitoring the end of the stiff wires
femoral arteriotomies). and fluoroscopic imaging during insertion of device.
n W hen vessels cannot be traversed in retrograde fash- n A fter the primary device is prepared and initial orienta-
ion, wire and protection catheter can be placed using tion is determined, insert main device through ipsilat-
the left brachial approach. eral iliac artery.
VASCULAR INTERVENTIONS Abdominal Aortic Aneurysm Endografting 5
Procedure for Device Insertion n R everse angled-tip catheter (eg, Sos Omni [Angiody-
(Bifurcated Devices) namics] or Sidewinder catheter [Cordis]) is advanced
n I n most cases, the main body is inserted via the right into the main body from ipsilateral access.
femoral artery, and the contralateral limb is inserted n H ydrophilic guidewire is passed inferiorly through the
via the left femoral artery. contralateral limb opening and snared from the contra-
n O perators may decide to pass the main body device lateral side.
up the left side if the right side is severely diseased n T his maneuver enables a catheter followed by another
(unsuitable for passage of large-caliber main body Lunderquist guidewire to be advanced into the main
delivery system). body from the contralateral side in preparation for
n L eft femoral artery is punctured, and 6 Fr sheath is insertion of contralateral limb.
inserted. n C ontralateral limb is inserted so that the top of limb
n V ia this access, standard aortic flush catheter is overlaps markers in the contralateral limb opening on
advanced into the abdominal aorta and placed with the main body.
the catheter tip at level of L1. n T he aim is to deploy the limb so that it lands just proxi-
n R ight femoral artery is catheterized, and a selec- mal to common iliac bifurcation.
tive catheter (eg, Cobra) and standard guidewire are n I f graft is a type that has limb sections bilaterally (eg,
advanced into upper thoracic aorta. Zenith Trifab), the ipsilateral limb is inserted after con-
n S tandard guidewire is exchanged for exchange-length, tralateral limb.
very stiff guidewire (eg, Lunderquist, Cook), and the n L imb extensions may be placed if the distance between
catheter is removed. the lower end of limb and common iliac bifurcation is
n M ain body of the device is advanced over Lunderquist large.
guidewire to level of L1 (approximate level of renal n I f patients have aneurysmal common iliac arteries
arteries). that cannot provide sealing zone for endograft limbs,
n F lush aortogram is performed with a small amount of extending limbs into external iliac arteries becomes
contrast medium (eg, 7-10 mL at 10 mL/second) to necessary.
locate origins of renal arteries. n E mbolization of internal iliac artery is required before
n C T scan should be scrutinized to assess whether any this maneuver to prevent retrograde leaks up the inter-
angulation of intensifier is required (oblique or cranio- nal iliac artery after procedure.
caudal projection) to profile origins of renal artery. n D elivery catheters are removed and may be replaced
n M any patients have impaired renal function; thus, with large-caliber sheaths (18 Fr) to provide access
effort should be expended to limit the amount of con- and hemostasis.
trast medium. n S ome devices require insertion through sheaths (eg,
n C arbon dioxide is a very effective contrast medium Excluder).
for aortography and can be used in lieu of contrast n O ther devices have a hemostatic valve on the deliv-
medium for all or many parts of the procedure. ery catheter that enables the delivery catheter to func-
n T op of the main body is deployed so that the graft tion as the sheath after deployment of the device (eg,
material is positioned immediately below the renal Zenith).
arteries. n A ll attachment sites and connections are dilated with
n M ore aortograms may be performed to achieve accu- large-caliber compliant balloons (eg, Coda balloon).
rate deployment of endograft body. n F inally, completion angiography is performed to assess
n A fter deployment of main body, aortography may be patency of endograft, iliac arteries, and renal arteries,
performed to confirm correct location of endograft and as well as absence of leak into aneurysm sac.
continued patency of renal arteries. n P erform a complete angiography with stiff guidewires
n N ext step is catheterization of contralateral limb. removed. (Kinks or stenoses of limbs may be concealed
n P igtail catheter, which is outside the graft, is withdrawn if limbs are straightened out by stiff guidewires.)
over guidewire into the lower aorta and exchanged for n P lace the flush catheter up one iliac limb of the
an angled-tip catheter (eg, Cobra, Vanshee [Cook], or device, and leave the catheter or balloon up the other
Berenstein [Cordis] catheter). limb.
n W ith aid of angled-tip hydrophilic guidewire or oblique n T his procedure is performed to maintain access to
angulation of image intensifier (or both), operator can- endograft from each side of groin to manage any prob-
nulates opening in the main body for contralateral lems revealed by angiography.
limb. n I f type 1 or type 3 endoleaks are visible on completion of
n F actors that cause difficulty in cannulation include the angiography, they should be treated immediately.
large aneurysm with little mural thrombus, tortuous n K ink or angulated end of graft should be supported by
iliac arteries, and angulation of aneurysm in antero- insertion of uncovered self-expanding stent.
posterior plane.
n I n some cases, retrograde cannulation of contralateral Insertion of Aortouniiliac Devices
limb opening may not be possible. n M ost, but not all, aortouniiliac (AUI) devices are two-
n C ontralateral limb opening can be cannulated ante- piece devices with the upper body and the lower limb
gradely by snaring wire passed through the opening designed to be placed just above the ipsilateral com-
from ipsilateral side. mon iliac bifurcation.
6 Abdominal Aortic Aneurysm Endografting VASCULAR INTERVENTIONS
n O ccluder or vascular plug is placed in the contralateral Tortuosity
common iliac artery to prevent endoleak from occur- n V essel tortuosity is best negotiated by employing stiffer
ring as a result of retrograde flow up the common iliac wires.
artery. n P roviding slow counter-tension on wire while inserting
n F irst part of procedure is exactly the same as for bifur- stent-graft helps reduce the potential for wire kinking.
cated devices until the proximal component of device n O ptions to circumvent tortuosity include using intro-
has been deployed. ducer sheath; digital dissection; straightening of artery;
n D istal component is inserted and deployed. closed iliac endarterectomy; brachial-femoral access;
n T he site of ipsilateral common iliac artery bifurcation and iliac conduit.
is defined by angiography via a pigtail catheter that is Iliac Conduits
left in situ after deployment of the proximal endograft. n R etroperitoneal exposure of iliac vessel can be accom-
n P igtail catheter is withdrawn over the guidewire. plished under regional anesthesia, if necessary.
n L underquist guidewire is passed up the contralateral fem- n E xpose common and external iliac vessels.
oral access so that the tip is placed in the aneurysm sac. n S ew 8- or 10-mm prosthetic graft onto the iliac artery
n A ttachment sites and connection of AUI device are above the level of critical stenosis or tortuosity.
dilated with a compliant balloon. n C onduit is typically routed to the groin and brought
n T he sheath containing occluder is advanced up the out under the inguinal ligament.
contralateral iliac artery, and the occluder is extruded n A large introducer sheath may be placed at the onset
so that it is deployed in the proximal common iliac of device deployment to prevent excess manipulation
artery. of anastomosis.
n P atients with preexisting renal artery stenosis, if pos- Brachial Artery Catheterization
sible, should be stented at completion of the procedure n W ire is typically snared and brought out the ipsilateral
or during follow-up period. common femoral artery.
n W hen diseased or tortuous iliac arteries are present, n B y placing wire under tension at both ends, the endo-
additional maneuvers may be necessary to allow inser- prosthesis is inserted more easily through tortuous
tion of delivery catheter. vessels.
n T his procedure can involve stiffer or secondary buddy
wire, angioplasty of isolated stenosis, retrograde iliac
endarterectomy, and placement of iliac conduit.
CONTROVERSIES
Stenosis Management n M odular versus unibody device: Modular devices
n A ccess vessel stenosis is best addressed during endo- allow for better customization to anatomy; older ver-
vascular prosthesis implantation. sions have a higher risk of endoleak.
n I liac artery stenoses are treated with sequential Dotter n I nfrarenal versus transrenal fixation: Transrenal device
dilation rather than angioplasty at the beginning of the is more difficult to remove if device explantation is
procedure. required.
n G ently advance a 16 Fr dilator through the lesion, and n A ctive fixation is preferable to passive fixation.
then sequentially insert larger dilators until desired n I mplantation of device too far below renal arteries has
size is reached. been associated with device migration and higher fail-
n O nce the artery is successfully dilated, the device is ure rate.
inserted. n P atient selection: Good evidence has yet to be found
n A fter device deployment, angioplasty, if necessary, that patients who are unfit for surgery do better after
can be undertaken. EVR, although data are extremely limited.
n D etailed completion angiograms of entire iliac system n A neurysm size: Although the standard threshold for
should be performed with small (< 8 Fr) sheaths in intervention in AAAs is 5.5 cm, many clinicians think that
place. patients with smaller aneurysms should also be treated.
n E valuate for residual hemodynamic lesions and dissec- n A natomic inclusion criteria might be too rigid, with
tion or vessel rupture. successful EVR being possible in patients with neck
n A ccess wires should be the last intravascular compo- dimensions outside those parameters.
nent removed from the patient before closure of femo- n S afety of bilateral internal iliac artery embolization is
ral vessels. increased.
n L eaving the wire in place for several minutes after
sheath removal is customary.
n M onitor patient for signs of bleeding from undiagnosed OUTCOMES
access vessel complication.
n W hen residual problems of dissection or stenosis n A fter EVAR, patients are discharged from the hospi-
exist, placement of a stent may be necessary to ensure tal and return to full activity much quicker than after
patency and viability of extremity. open surgical repair.
n I f extravasation of contrast occurs, a covered stent or n U sing the latest generation of devices, technical suc-
modular stent-graft extension should be deployed to cess approaches 100%, with mortality rate of <1% in
prevent ongoing hemorrhage. experienced hands.
VASCULAR INTERVENTIONS Abdominal Aortic Aneurysm Endografting 7
n M orbidity rates are reduced by >50% compared with n P atients who are at higher risk for complications
open surgery, even with secondary procedures adding should be monitored at shorter-than-normal intervals
to overall morbidity. at the discretion of the physician.
n B enefits may not be sustained, however, beyond the n S tandard imaging protocol after EVR includes CT scan
first several years. either before discharge or at 6 weeks and additional CT
n O verall mortality rate is 3% for aneurysm-related scans or ultrasound at 3, 6, and 12 months and annual
death, and an all-cause mortality rate is 15.1% with intervals thereafter.
follow-up of 7-48 months. n A lternative imaging protocol includes CT scan and
n R ates of freedom from aneurysm-related death at plain film abdominal radiograph before discharge;
5 years were 97%, 95%, and 87.9% for small, medium, regular ultrasound scans are performed at 3, 6, and
and large groups, respectively. 12 months; and plain film abdominal radiographs are
performed annually.
n I f ultrasonography or plain film radiography suggests
a problem, then patients undergo CT scan and subse-
COMPLICATIONS
quent intervention to treat any problems.
n I ncidence of type 1, 2, and 3 leaks on completion angi-
ography: 4%, 10%, and 2%, respectively Suggested Readings
n D evice migration: >10-mm migration from initial
Beebe H: Selection criteria for endovascular treatment of abdominal
implant position, rarely occurring within first year aortic aneurysm. In Ernst C, Stanley J, editors: Current Therapy in
after implantation Vascular Surgery, St Louis, 2001, Mosby, pp 280-285.
n R upture: extremely low incidence (<0.5%/year) Drury D, Michaels JA, Jones L, Ayiku L: Systematic review of recent
evidence for the safety and efficacy of elective endovascular repair
n L imb thrombosis: possible after device insertion as a
in the management of infrarenal abdominal aortic aneurysm. Br J
result of sac shrinkage and morphology changes that
Surg 92(8):937-946, 2005.
occur Kaviani A, Greenberg RK: The Zenith AAA endovascular graft. Expert
n A ccess vessel complications: access failure, vessel Rev Med Devices 1:175-180, 2004.
compromise (dissections, rupture, avulsion of iliac Rockman C: Reducing complications by better case selection: ana-
tomic considerations. Semin Vasc Surg 17(4):298-306, 2004.
arteries), and hemodynamic compromise (6%)
Zarins CK, Heikkinen MA, Lee ES, et al: Short- and long-term
n E arly device-related complications such as graft throm- outcome following endovascular aneurysm repair. How does it
bosis and graft migration: 2.6% compare to open surgery. J Cardiovasc Surg (Torino) 45(4):
n D eterioration in renal function caused by coverage of 321-333, 2004.
renal artery by endograft, thrombus, or embolization
of distal renal artery branches: 2%
POSTPROCEDURAL AND FOLLOW-UP
CARE
n M ost patients are discharged within the first 48 hours
to a few days after procedure.
n R outine clinical evaluation is conducted within the
first 30 days, then within 6-12 months, then yearly.
