 with us. The questions you can post all the delegates in the chat box and we'll be taking at the end of all the lecture sessions. Now it's time to move to our next session for the day and for this we have with us Dr. Girish Varavrikar sir senior consultant intervention radiologist past president of Indian society of vascular and interventional radiology fellow of the society of intervention radiology. Sir has several affiliations in the city of Mumbai including Lila Vati Hospital, Asian Heart Institute, Breach Candy, Hiranandani Hospital, Jaslok Hospital and today he'll be taking aortic interventions a case-based approach. Thank you sir for joining us over to you. Good evening everybody. Thank you for the kind introduction. Today I'll be talking about aortic intervention, how we plan it and what we expect from a radiologist or a CT specialist. We normally prefer to do a CT scan rather than an MRI for all patients where we are planning to do a triple A or a thoracic analism graft. However in case there is a high creatinine then we may decide to do a non-contrast MR and on the basis that do the sizing. Why it is important is basically because we have to decide on the size of the graft, what is the possibilities, whether we need to do an on-table fenestration, whether we need to do a custom made device for that patient. So customizing the procedure for the patient is important. So depending on the anatomy we decide on which procedure we should follow. So what is the role of the radiologist? Usually aneurysms are picked up incidentally, they can be picked up on a plane x-ray or an ultrasound or a CT or MR when we are not doing an angiography study but we are doing it for some other reason and we pick up. So once we pick up aneurysm then we have to decide depending on the CT whether we can do it endovascular, whether we can do it surgical or we do a combined approach what we call a hybrid approach and once we have done the procedure we normally use USG or CT angio as a follower. So interpreting the CT images in erotic analism is very important. First of all we confirm the diagnosis of erotic analism then decide on the length and diameter of the graft. Basically we decide on in the western population their cutoff is 5.5 centimeters whereas in the Indian population we take it as 5 centimeters maximum transverse diameter before we decide to take the patient up for any erotic intervention. So when we see these CTs we ask for CT angios one millimeter cuts are taken and we image right from the arch right up to the femoral bifurcation why we will come to a little shortly. So once we confirm the diagnosis of the analism then we look at the length and diameter of the analism and decide on the size of the graft. Normally we take about 15 to 20 percent oversizing of the graft. Possible difficulties that we may have during the procedure in case there is marked tortuosity or there is calcification that could be a hindrance for the device to go up. Short and long term outcomes will also this will depend on the anatomy of the analism. Leaks and collaterals that can develop and cause a type 2 endo leak and of course as I said when we come right up to the femoral we have to decide on the size of the femoral artery because these grafts are large in diameter and we need a minimum of 6.5 to 7 millimeter diameter for us to get the device up from the femoral. In case it is small then we have to look at other options like we are talking about iliac conduits or other access possibilities. So we have to spend enough time in interpreting these images. So what is the suitable morphology? You should have an adequate iliac length. Pemoral access as I said should be larger in the diameter the better. Non-androsable intra-renal segments should be about minimum that means what we talk about is the nick should be about minimum 15 millimeters so that you can get a good sealing zone. The diameter normally varies from 18 to 22 outer wall to outer wall the most important is if there is an angulation of the aorta before the takeoff of the aneurysm and that is why we decide more the angulation the more the problems you are going to face during the procedure. So the angle it should be less than 60 degrees that is related to the long axis of the aneurysm which I'll show you just now or the angle should be less than 45 related to the axis of the supra-renal aorta. Those diagrams I'll just show you in the next slide. The iliac artery discolour fixation side has to be again minimum 15 millimeters so that you can get a good sealing zone below and the diameter varies from 7.5 to 20 millimeters. So this is what I'm talking about if you can see here when I say 45 degrees if you take a straight line in the center and if you see the angulation which is parallel to this that means to say this should not be more than 45 degrees or if you are looking at the aneurysm then we are looking at not more than 60 degrees. So then you have the different anatomies you have a normal parallel wall as you can see here so that you get a good sealing zone when you have an irregular hourglass bulge like this you have a chance that there is very little sealing zone here that is why you will have a problem here then you have a funneling that also is a problem because you can have sizing to this level but it means crimple at this point so if you oversize if you size it to this it will be too big for this area and then you have the reverse funneling which is also another issue so ideal would be to have a parallel selection of patients lowest renal artery if you can see here we have demonstrated that table positioning depending on the table position we decide on how many how much distance is there from the lowest renal artery to the start of the aneurysm that is what we call the neck avoid next which is which are less than 15 millimeters selecting the neck angulation I have just described so I won't go too much into detail but this is a CT image to show you the angulation patient selection condition again as I mentioned just now the flare of the neck is a problem so we prefer to have a neck which is more parallel than conical reverse conical or lobular patient again another picture to show you you can see that the renal arteries arise from here it looks parallel but you have a bulge here again and harrowing and then you have aneurysm below so sealing is the criteria sometimes if you have something like this we then we decide to do a on table or a physician modified graph that we make penetrations in the graph or we ask for a custom made device another important thing is when there is circumferential calcium or thrombus there is a problem where you may not your graph may not sit properly around abutting the wall of the aorta the luminal diameters are important basically so that you can get your device up and most important you size the the limbs of the iliac graphs so that you get a good sealing and prevent any retrograde endo leaks that can develop what we call type 1b endo leaks um calcified arteries is another issue where we have different methods now we have intravascular lithotripsy where we can do a lithotripsy and break the calcium and then take the device up or we can put stents in the iliac arteries and then inflate the stent so that it increase the diameter to facilitate your device to go up as I said the distal fixation is also important because we need to have a good seal in the iliac so that you don't get a retrograde leak iliac aneurysms often are there and we have to consider if it is bilateral then we have to save at least one iliac internal iliac artery and not cover both internal iliac arteries because that can lead to butachrodication or can lead to bowel ischemia so anatomical assessment of internal iliac arteries I don't want to go too much into detail but suffice to say that that can if you jail both the internal iliac arteries you can have a bowel ischemia or you can have butachrodication so measurements needed are as I said to summarize you have diameter d1 d2 and d3 so we the iliac arteries where you are landing the pajama graft so these are the three critical diameters then you have to look at the length from the lower most renal to the bifurcation and then from the l2 if you see from here all the way down to the iliac bifurcation so we decide on that and the length of the stem limbs of the graft diameter oversizing as I said normally if you we do it about 15 to 20 percent or if you're talking about the main body we oversize it by three to four millimeters and for the limbs by about one or two millimeters so what is the problem if you oversize if you undersize it you will see that you will get a gap like this and you will have an endoly but if you oversize it too much then what you can have is infolding of the graft that you can see here and that can cause a lot of problems including thrombosis and cause ischemia so overlap when we are doing these graphs we need to have an overlap so that you have a good ceiling zone so you have the main body which is bifurcated one is a short limb one is a long limb and the short limb is usually the contralateral limb that is the side which you are not initially going through and you have a long limb which is on the side where you are taking the main device up so the lengths use CT and or angiography with calibrated catheter if you are doing angiography but in CT we can the machines are so good we can get the exact lens on the CT itself so these are the main devices that you have the main body then you have the contralateral limb that means the opposite side from where you are introducing the main device and then you have the ipsilateral where you are going from the side of introduction of the limb so angiography cannot plan without it only and only if there is a problem of doing a CT scan do we decide to do mr angiography can often negate the need for an angiogram totally a good 3d reconstruction with scale is very good it helps us to do the exact sizing axial slices of not more than five millimeters we prefer to do a one millimeter cuts but maximum you can do is five millimeter cuts that is if the multi-slice CT is available and you have to always cover from the arch right up to the bifurcation so the aneurysm what do we need to know the aneurysm type whether it's a sacular fusiform extent proximal and distal landing zones is also important the access vessel as I said the femoral is important relevant medical history and plan as part of the total plan of doing the procedure CT angiography for AAA you true vessel diameter including vessel wall thickness longest distance across the shortest axis and show any thrombus atheromas or calcification that may exist in that aorta so this is for the thoracic we decide on measuring the length of the aneurysm and put the length in the aneurysm length the the length of the aneurysm should be if it is less than 30 millimeters with appropriate proximal and distal neck lengths a single proximal graft or a custom one-piece graft can be used so that you don't cover the subclavian and don't cover too much of the thoracic aorta you have to look at the different devices and it will when you use these graphs it increases the rigidity it increases the friction but also increases the stability of the device so this is the planning that we have just give you an example of the cook device which shows you how you can plan and take the measurements of the aneurysm as well as the aorta now coming to the couple of cases I'll show you this is a 52-year-old male hypertensive presented to the emergency with an episode of massive hemophysis referred for a bronchial agonio SOS embolization. Chest vision felt that it was a pulmonary pathology I personally felt looking at the history this was not pulmonary pathology he had a past history of surgical repair of coarctation of the aorta correction using a dachron patched plastic about 35 years ago he was advised the CT scan but due to the hemophysis it was deferred and basically the the physical the chest position was nearly sure it was from the bronchioles so the HRCT was done which is clearly showing that the chest looked pretty clear the this is the axial and the coronal images so I was pretty sure looking at the CT that I'm not going to find anything since he was so insistent on it we did a pulmonary bronchial angio we could not find anything but what happened was on table had a massive episode of hemophysis patient aspirated marked dyspnea patient was intubated on the table and then thereafter we advised a CT angio after the patient had stabilized and this is the CT angio you can see clearly it was quite obvious it was quite obvious that this was not just a simple aneurysm it was an aneurysm which had ruptured part contained rupture and that is why he was having hemophysis so basically the graft that he had patched plastic that he had done for the coarctation had given way and this was the reconstructed images you can see that there's a large aneurysm arising just next to the subclavian artery now this was an anatomy where we didn't have too much of a distance between the left carotid and the subclavian we had to jail the subclavian so we decided that we give it a chance with the thoracic surgeon who was not inclined to do a redo surgery so we decided on a hybrid procedure we did a left carotid to left subclavian bypass endovascular stent graft to exclude the pseudo aneurysm was then planned and use a vascular plug to occlude the left subclavian the left carotid and to left subclavian artery bypass was done with a unigrapped 8 by 40 and next day the patient was taken up for an endovascular repair now this is the picture you can see on the autogram you can see the aneurysm you can see the left carotid to left subclavian bypass graft here which is patent we first decided to go in and put a vascular plug in the subclavian we put the plug here and then we decided we'll take the main body of the main thoracic graft this is we are deploying the graft these are the two stages where we take the on the left side you will see that there is the graft is being deployed and then the final top cap is released and you'll see here this is the top cap released there after we do a check we find that whenever you plan everything it's not always that it goes the way you want it to go when we checked again you can see that there is a leak endo leak coming from around the subclavian so this is not acceptable this is a type 1A endo leak so we went in with a micro catheter right up to the vascular plug and then decided to glue that segment this is injecting glue at the ostium of the subclavian just distribute to the plug sorry just proximal to the plug and we keep injecting the glue till we see that there is no leak we've still you can see here that there is a leak here and if you see here you can see there is movement of blood in the aneurysmal segment so that means to say that there is not enough glue injected as yet so we further injected the glue to get a good glue cast and if you see the three different images the amount of glue keeps increasing and then finally when we are happy with it we take the angiogram and now you can see that there is no endo leak at all and this is immediately post-operative we do a CT scan to check whether we have sealed it completely or not it looked pretty good it seemed sealed and then we do a follow-up CT after one month to confirm that there is no endo leak and this is what the follow-up CT shows one second yeah this is the follow-up axial and coronal this is the arterial phase you can see there is clearly complete sealing of the leak from the subclavian thrombus in the aneurysm cavity and this is the delayed phase so it basically shows the same thing that it is completely we always do an early arterial phase and a venous phase to confirm that there is no delayed endo leak that we see quite often you can see collateral feeding the aneurysm and that may be picked up on the delayed phase so that's now coming to the second case this is a 35-year-old male had chronic renal failure workup for renal transplant was done USG abdominal aorta showed an aneurysm referred for endovascular aneurysm repair before they could take the patient up for transplant so now we know that we don't have to bother about both reals because they're going to transplant it most important is we have to save a good segment of the external iliac artery where they're going to put the transplanted kidney so if our planning only option was a chimney or a fenestration to the supramacentric and celiac artery sacrifice both renal fenestrate the celiac and supramacentric and maintain patency of the right internal iliac artery in case they use the internal iliac artery for the transplant kidney now you can see that there is definitely an aneurysm of the right as well as the left common common iliac artery so we have to preserve at least one of the internal iliac arteries so that they can use the artery for anastomosing the transplanted artery this is the CT pictures of the same large aneurysm of the iliacs and now we've decided to on table fenestration for the supramacentric and the celiac you can see this is a custom made device which is ordered the CT is sent and they make the graph for the patient you will see that this is one for the celiac and this is another fenestration for the supramacentric artery we deployed the graph now and we cannulate you can see here we have cannulated the supramacentric and this one is cannulated the celiac artery the wires have gone into the celiac and supramacentric we take the sheath across in both the superior and the superior mesentic and celiac and take the the covered strength through the fenestration and thereafter release the the top cap of the graph once we have done that we capture the delivery system of the graph we sheath it and then pull it out this is pulling out of the device and if you see here now we are un-sheathing the strength and deploying the superior mesentic and the celiac graphs once that is done you can see on this side this is the superior mesentic covered strength being deployed and thereafter you will see the celiac being deployed thereafter we go in for what we call an iliac branch graph because we have to have a patency of the internal iliac artery on the right side we cannot just cover it so we have something called an IBD iliac branch graph which we snare the wire from the opposite side and using that we come into the uh branch graph iliac branch graph if you can see here we have passed the wire through the fenestration into the iliac internal iliac artery and we confirm we are in the internal iliac we put a covered strength there again and deploy the graph and we are now deploying the graph here and ballooning that graph this is now we have managed to finish off the the branch graph on the right internal iliac and external iliac and we complete the procedure by putting the pajama uh graph in the main aota here is the pajama graph coming out we have deployed the the leg on the left side and then we will use the same wire and go into the opposite limb and deploy that graph and finally balloon out all because we are going to cover the left internal iliac artery which is annularism we always coil the internal iliac artery so that there is no retrograde filling of the annularism from collateral circulation from the opposite internal iliac artery so this is the coiling of the internal iliac artery and then finally we put the graph and balloon the the entire graphs and then take a check angiogram you're seeing that if you see here there is a slight endo leak that you can see here that is because this is not fitting properly the superior miscentric graph so we take a larger balloon and dilate it and finally if you see now there is no end only you can see here and you are seeing a good flow into both the iliac arteries and sealing of the annularism completely so planning is important you have to check for calcification access vessel size tortuosity orientation of the markers do not twist the graph while you are inserting it because it can result in the tortu the graph getting king you have to also assess the cardiac status pulmonary function venal profile of the patient because this may need quite a bit of contrast and you cannot have kidney compromise and patient going into acute venal shutdown so this is the follow-up of this patient this was done one month later you can see clearly that there is no filling of the annularism either in the iliacs or in the aorta and a good patency you can see clearly now that this is what the final picture is on reconstruction on seeking so lessons learned is no shortcut to planning device knowledge is important recheck at every step adequate hyperanalyzation and you need good assistance thank you very much