**7. Particular situations**

### **7.1. Ruptured AAA**

186 Aneurysm

The access was bifemoral, through open femoral incision, with peridural anaesthesia.

sets of examinations, one set consisting of both DUS and CTA.

patency rate at this point at these patients is 100%.

graft; **c)** The two iliac segments of Powerlink® system

Until present they followed our institutions surveillance protocol, that consisted of both DUS and CTA examination at 1,3,6,12 months and yearly after EVAR. None of them went through all of the surveillance dates (due to high examination costs) but each has at least 3

The technical success rate was 100%, with no perioperative and postoperative complications regarding endoleaks, graft migration and graft component failure. 4 patients had access site complications, 3 had groin haematomas that reabsorbed after approximately 1 week and 1 returned with an infection at the level of the inguinal incision, which resolved also with wound care. There were no conversions to open repair up to present. The stent-graft

**Figures 12** and **13** show two cases of AAAs treated with two different devices and two different strategies: Anaconda (Terumo) device and Powerlink (Endologix) stent graft.

**Figure 12.** AAA treated with Powerlink Endograft **a)** Proximal extension; **b)** Main body of the stent-

**Figure 13. a)** Anaconda endograft for infrarenal abdominal aortic aneurysm therapy; **b)** Angiography at the beginning of the procedure; **c)** The main body of the stent; **d)** The two iliac Anaconda system

**In open repair of ruptured AAAs the perioperative mortality ranges between 30% and 65%**[74,75].Emergency EVAR is an alternative in selected patients with RAAA. The first report of emergency repair of an AAA was in 1994. Possible advantages are avoiding general anesthesia and laparotomy. Though a major inconvenient is the need of an endovascular team to be available at all times and to assess the preoperative CT scan in order to choose the size of the device. Following the emergent CT scan the anatomical suitability for EVAR was evaluated, including the access vessels [76].Several modular or unibody devices can be used but aorto-uniiliac devices with subsequent fem-fem crossover bypass and occlusion of contralateral iliac artery could also be used. Veith [77] reported in 2009 a series of 57 patients with R-AAA treated endovascularly. 25 of these patients received the **VI graft (**distributed in Europe by Datascope-Maquet), made of a large Palmaz stent attached to a PTFE graft. This graft is used in aortofemoral configuration. This graft is "a one size fits most "because the proximal diameter can vary from 20 to27mm depending on the balloon inflation pressure. The periprocedural mortality was only 12,3%,inspite of serious medical comorbidities of the patients.

In the series reported by Kapma in 2005 on 253 patients treated with E-EVAR vs open surgery the perioperative mortality was lower (13%) in the Evar group compared with OR (30% p=0,021).According to the SVS practical guidelines [31] E-EVAR should be considered for treatment of a R-AAA, if anatomically feasible, with a **strong** level of recommendation and a **moderate** quality of evidence.

#### **7.2. Juxtarenal AAA**

Juxtarenal AAA have short (11-15mm), or very short (< 10mm) necks. The anatomically unsuitable AAAs has short and/or angulated necks. They have a high risk of stent graft distal migration and proximal type I endoleak, because the inability to provide a sufficient proximal landing zone to secure fixation and seal. The strategy for treating this challenging AAAs is to build up the endoluminal exclusion system from the aortic bifurcation to the renal artery level with suprarenal fixation. At Nürnberg Hospital we used the Powerlink unibody bifurcated stent graft with a long suprarenal cuff. A Palmaz stent can be used for proximal fixation in hostile necks (short necks with severe angulation).

Suprarenal fixation does not lead to a significant increase of acute renal events (renal insufficiency, high blood pressure) compared with infrarenal fixation [72]

**Figure 14** shows an angiography of AAA treated with a Powerlink graft with suprarenal fixation; for better sealing a proximal ballooning at the end of the procedure was performed.

#### **7.3. AAA with iliac extension**

The iliac extension of the AAAs can put technical problems in choosing the graft, especially if the iliac aneurysm reaches the bifurcation of the iliac artery (fig.11a). In this situation, the

**Figure 14. a)** After suprarenal prox. Cuff; **b)** Proximal balloning. Fenestrated grafts are now available to treat juxtarenal AAA [78-80]

leg of the graft should land on the external iliac artery, covering the hypogastric artery (post-operation complications can occur like buttock claudication). In the case of planning to cover one hypogastric artery, we should close the artery (by coiling for ex.) a few days before implanting the endograft, in order to prevent distal type II endoleak.

**Figure 15** shows a 72 year old patient treated at the Army's Center for Cardiovascular Diseases, using a Powerlink graft with left iliac graft extension - left hypogastric artery was occluded with coils 24h before the intervention.

In order to preserve the hypogastric artery, custom made, fenestrated or branched endografts can be used. Although this procedure was performed to prevent pelvic ischemia, this is not always the case. **Figure 16** presents a case of a 75 year old male patient with AAA

**Figure 15.** Patient O.P., 72 years old, preoperative multislice CT; **a)** AAA with left iliac extension; **b)**  multislice CT-Scan at 3 months after EVAR with PowerLink endoprosthesis; **c)** multislice CT-Scan 2 years after EVAR with PowerLink endoprosthesis.

treated by EVAR with a fenestrated endograft that presented to our department with buttock claudication 6 months after EVAR. The performed angiography evidentiated an occluded right hypogastric artery. Conservative treatment with Vasaprostan 20μg was instituted with good results.

188 Aneurysm

treat juxtarenal AAA [78-80]

**Figure 14. a)** After suprarenal prox. Cuff; **b)** Proximal balloning. Fenestrated grafts are now available to

leg of the graft should land on the external iliac artery, covering the hypogastric artery (post-operation complications can occur like buttock claudication). In the case of planning to cover one hypogastric artery, we should close the artery (by coiling for ex.) a few days

**Figure 15** shows a 72 year old patient treated at the Army's Center for Cardiovascular Diseases, using a Powerlink graft with left iliac graft extension - left hypogastric artery was

In order to preserve the hypogastric artery, custom made, fenestrated or branched endografts can be used. Although this procedure was performed to prevent pelvic ischemia, this is not always the case. **Figure 16** presents a case of a 75 year old male patient with AAA

**Figure 15.** Patient O.P., 72 years old, preoperative multislice CT; **a)** AAA with left iliac extension; **b)**  multislice CT-Scan at 3 months after EVAR with PowerLink endoprosthesis; **c)** multislice CT-Scan 2

before implanting the endograft, in order to prevent distal type II endoleak.

occluded with coils 24h before the intervention.

years after EVAR with PowerLink endoprosthesis.

**Figure 16.** 75 year old male patient with AAA treated by EVAR Completion angiography after EVAR using a fenestrated endograft for the right hypogastric artery. **b)** Angiography performed 6 months after the intervention showing an occluded right hypogastric artery.

## **7.4. AAA and comorbidities: Coronary artery disease, carotid stenosis.**

It is well known today that cardiac complications of patients with AAAs treated endovascularly is between 3 to 7%[31]. In order to avoid useless coronarographic investigations , we have to identify clinical parameters to indicate prior myocardial revascularization (surgery or stenting). Kieffer and Coriat, in a study published in 1999, on 270 patients operated for terminal Aorta pathology (aneurismal or stenotic) show an incidence of 55% of coronary stenosis in the AAA population which requires in 25% of cases myocardial revascularization. The risk factors which were identified were age >65 years and history of myocardial infarction. Stable angina with left main disease, or triple-vessel disease, as well as patients with two vessel disease that includes proximal LAD are candidates for preoperative coronary revascularization. The coronary intervention should be done prior to AAA treatment in one month interval. However the perioperative mortality can arrive to 25% (with extracorporeal circulation and cardiac arrest)

**The carotid stenosis with a hemodynamic impact has a** prevalence of 10.5%in the AAA patients.

**Coronary** and/or carotid lesions, treated or not, represent a significant risk factor for postoperative death. For this, systematic preoperative screening is mandatory [81,82].

**Steinmetz** published in 2008 an analysis of outcome after using high risk criteria selection to surgery vs. EVAR [83].The conclusion was that high risk criteria cannot be decisive in the choice of treatment.
