1
Q
Rupture risk of aneurysm 3-3.9
A
0.3% / year
2
Q
rupture risk of aneurysm 4-4.9
A
0.5 - 1.5%/year
3
Q
rupture risk of aneurysm 5-5.9
A
1-11%
4
Q
rupture risk of aneurysm 6-6.9
A
11-22%
5
Q
rupture risk of aneurysm >7
A
> 30%
6
Q
UK aneurysm trial highlights
A
prospective randomized trial
early surgery vs surveillance
4-5.5, 1090 pt, 17% female
surveillance!
7
Q
VA (ADAM) trial highlights
A
prospective randomized
early surgery vs surveillance
4-5.4, 1163 patients, 1% female
surveillance!
8
Q
Types of aortic arches
A
- all vessels originate on top fo the arch
- vessels originate between the planes of the inner and outer curve of the arch
- vessels originate along the upslope of the arch, proximal to the inner plane of the arch
9
Q
most common arch anatomy variation
A
- bovine arch - common trunk of innominate and left CCA (16-24%)
- origin of the left vertebral artery from the arch between left CCA and left subclavian (7%)
- aberrant right subclavian in left sided arch (0.5 - 1%)
- right sided aortic arch (0.1%)
10
Q
aortic landing zone 0
A
proximal to innominate artery
11
Q
landing zone 1
A
proximal to left CCA
12
Q
landing zone 2
A
proximal to left subclavian
13
Q
landing zone 3
A
proximal descending thoracic aorta, <2cm from left subclavian
14
Q
landing zone 4
A
2cm distal to left subclavian extending to proximal half of descending thoracic aorta (T6 vertebral body)
15
Q
landing zone 5
A
distal half of descending aorta to celiac artery
16
Q
landing zone 6
A
celiac to top of SMA
17
Q
landing zone 7
A
SMA to suprarenal aorta
18
Q
landing zone 8
A
perirenal aorta
19
Q
landing zone 9
A
infrarenal aorta
20
Q
landing zone 10
A
common iliac artery
21
Q
landing zone 11
A
extends to external iliac artery
22
Q
crawford I aneurysm
A
distal to left subclavian to above renal arteries
23
Q
Crawford II aneurysm
A
distal to left subclavian to below the renal arteries
24
Q
Crawford III aneurysm
A
from 6th intercostal space to below the renal arteries
25
Crawford IV aneurysm
from the diaphragm to aortic bifurcation
26
Crawford / Safi V aneurysm
below the 6th intercostal space to just above renal arteries
27
borders of brachiocephalic artery division
right sternoclavicular junction
28
IMH qualifying for OR
aorta >40mm
| IMH >10 mm
29
Innominate artery aneurysm types
A: confined to IA, distal to origin
B: most common, involves IA and its origin
C: both IA and ascending aorta
30
aortic valve insufficiency doppler flow
to and fro blood flow pattern because of blood refluzing in insufficient valve
31
Aortic case planning fundamentals for GORE:
1. measure inner wall to inner wall
2. 2cm seal zone required proximally and distally (on the outer curve)
3. same diameter size device: 5 cm overlap; different size device: 3cm overlap
4. put larger device into a smaller device
5. the two devices you're joining cannot be more than 2 sizes apart
6. if you can (depending on the etiology) deploy distal first, then proximal. (but rule 4 takes precedence).
32
minimal distal aortic diameter for Gore:
18mm
33
how far into the iliac does Gore excluder have to go
3cm
34
What causes aortic intramural hematoma
Ruptured vasa vasorum
35
Only known modifiable risk factor for aaa developement
Smoking
36
How many people with AAA have CAD
25% symptomatic
37
How many people with aaa have htn
40%
38
How many people with aaa have PAD
20-30%
39
How many aaa have an associated iliac aneurysm
25%
40
Operative mortality for elective aaa repair
2-10%
41
Operative mortality of ruptured aaa repair
37-50%
42
Graft size for innominate debranching
8-10mm
43
Graft size for subclavian and carotid revascuksriation
6-8 mm
44
How do you know where your debranching of ascending aorta is
Put marker clips
45
Embriologically what creates aortic arch and branches
Third and fourth dorsal arch
Seventh intersegmental arch arteries
Left dorsal aorta
46
What crates aortic arch emriologically
Left fourth arch
47
What creates the innominate artery embriologically
Right fourth arch
48
What creates descending thoracic aorta embriologically
Left dorsal aorta
49
What creates carotid artery embriologically
Third aortic arches
50
What creates subclavian and vertebral arteries embriologically
Seventh intersegmental arteries
51
Right aortic arch
Most common anomaly of the arch
Results from inappropriate regression of arch (left instead of right dorsal arch)
Simplest and most benign form is meer image
May occu with aberrant left subclavian
Can form a complete or incomplete ring depending on origin of ligamentum arteriosum
52
Definition of Kommerells diverticulum
Occur in number of anomalies of the aortic arch system. It usually refers to the bulbous configuration of the origin of an aberrant right subclavian artery but was originally described as diverticulum outpouching at origin of a left subclavian artery in the setting of right sided aortic arch
Instead of the right 4 arch regressing, the left 4th regressed
Can compress esophagus and trachea
53
Aberrant right subclavian artery
Results from regression of the right fourth aortic arch between the carotid and subclavian arteries rather than distal to the subclavian artery
54
What is an aortic ring
Non regressed fourth aortic arch creates duplicated arch around trachea and esophagus
May lead to compression
55
What’s is a complete aortic ring
Both trachea and esophagus are fully wncircled by a vascular anomaly
56
What is an incomplete aortic arch
Without full encirclement of trachea and esophagus (usually asymptomstic)
57
What is mid aortic syndrome
Uncommon squired or congenital condition characterized by segmental narrowing of the abdominal or distal descending thoracic aorta
Frequently also Ostial stenosis of viscera beaches
58
What causes acquired mid aortic syndrome
```
Neurofibromatosia
Fibromuscular displasia
Retroperitoneal fibrosis
Williams syndrome
Mucopolysaccharisosis
Giant cell arteritis
Acquired insult in uteri
```
59
Etiology of congenita mid aortic syndrome
Developmental anomaly in the fusion and maturation of the paired embryonic dorsal aorta
60
Symptoms of mid aortic syndrome
Arterial hypertension
Headache
Early fatigue on exertion
Lower limb claudicatoon
61
Mid aortic syndrome on imaging
Robust collaterals on angiogram due to narrowing of the abdominal aorta
62
Minimum proximal body distal overlap in ZFEN
24mm diameter and overlap no less than 2 stents
63
Inclusion criteria for ZFEN
1. Nonaneurysmal infearenal aortic neck proximal to the aneurysm of more or equal to 4 mm and less than 15mm
2. Unsuitable for nonfenwatrated vascular graft
3. Proximal neck diameter 19-31
4. Proximal neck angulation <45 degrees relative to the long axis of the aneurysm
5. Angle <45 degrees relative to the axis of the suprarenal aorta
6. ipailatera iliac artery distal fixation site >30mm in lent h and 9-21mm in diameter measured outer wall to outer wall
7. Contralateral iliac artery distal fixation site >30mm in length and 7-21mm in diameter
8. Access vessel to accommodate up to 20fr sheath (8mm)
9. Max three fenestrations, 2 of the same kimś
64
Minimum distance between small fens at the same agent level for ZFEN
2h minimum
65
Minimum distance between small fen and a scallop
1.5h
66
Minimum distance between the edge of the fabric and middle of large top fen
10mm
67
Only EVAR decide that does not come on an integrated delivery system
GORE excluder
68
Endurant stent graft device characteristics
Indication: 10mm proximal neck, up to 60* angulation
Tip capture
Single piece laser cut nitinol aren’t with anchor pins
M-shaped proximal seal stent
High density multifilament polyester graft material
69
What is the endurant agent graft size and vessel target
23-36mm
Target 19-32mm
(OD profile 18-20 fr)
70
Aorta-uniiliac Endurant II device IFU
Indicated in the presence of adverse iliac anatomy precluding adequate deployment of a bifurcated graft’s two iliac limbs
Proximal neck of more than or equal to 10mm
Infrarenal nexk angulation Of less than or equal to 60*
Aortic neck diameters with a range of 19-32mm
Distal fixation length of more than or equal to 15mm
Iliac diameters with a range of 8-25mm
Morphology suitable for aneurysm repair
71
Ovation anatomical criteria
Proximal aortic neck length more or equal to 7
Inner diameter between 16-30mm (aortic body device diameter 20-34mm)
Juxtarenal aortic neck angulation less than or equal to 60* for proximal neck of 10, or less than or equal to 45* if proximal neck less than 10mm
Distal seal One of more than or equal to 10mm and diameter between 8-25mm (limb device diameter 10-28mm)
72
AortofixTM anatomical IFU
Adequate iliac or femora access that is conpatible with vascular access techniques, implants and accessories
Aortic neck landing zone diameters with range of 19-29mm
Non aneurysmal proximal neck center line length of more than or equal to 15mm
Infrarenal aortic neck angulation including those up to and including 90*
Common iliac landing zone diameters with a range of 9-19mm
Distal fixation length more than or equal to 15mm
73
Devices with suprarenal fixation
Cook zenith, Medtronic endurant II, teivascular ovation prime, endologic AFX
74
What devices are approved for trauma indication in thoracic aorta
Gore c tag
Medtronic valiant
Cook TX2
75
What devices are not approved for trauma indication in thoracic aorta
Cook TX2
| Bolton
76
What’s the aortic and device size for thoracic C TAG from gore
Vessel- 16-42
| Device: 21-45
77
How does a gore CTAG deploy
From the middle to the ends (avoids wind socking)
78
How does a VALIANT Medtronic deploy
From the beginning to the end. Needs to be deployed very fast
79
Only thoracic device with active fixation on BOTH ends
Cook zenith TX2
80
Zenith cook TX2 deployment modification
Trigger wire tethers the distal end of the sealing stent to improve apposition to the inner curve of the arch
81
Complications of CTAG study for dissection
```
8% mortality,
14% reintervention
4% disabling stroke
4% retrograde dissection
6% paraplegia
4% aortic rupture
```
82
Complications of VALIANT Medtronic for dissection
```
8% mortality
9.5% reintervention
6% stroke
4.4% retrograde dissection
6% paralysis
8% aortic rupture
```
83
What’s the minimum size for 20fr device
7 mm
84
TEVAR surveillance
CT with and without contrast and 4view chest X-ray
| Yearly for life
85
When is left subclsvian revascularizwion required
LIMA to LAD bypass
Dominant left vertebral artery
Left vertebral artery ends in PICA but not basilar
86
Where does artery of Adamkiewicz come of
T8-l1
87
Preventive mesures for spinal ischemia in aortic surgery
MAP >80
Csf drainage to ICP in one digit number
Hb >10
?steroids
88
Microbiology of aortic graft infection
Staph aureus 25-50%
Stain epidermidis responsible for late appearing indolent infections
Pseudocomans, E. coli, proteus, enterobacter
Aspergillus, candida
89
Technique for supraceliac balloon control in ruptured aaa
Insert long sheath through contra femoral and inflate the ballon. Place and deploy the main body and ipsi leg through the other femoral.
Insert another balloon through ipsi side.
Remove first balloon with sheath support
90
Predictors of aortic bifemoral graft occlusion
Age, HTN, graft size
91
Axillary artery exposure in ax-fem bypass
Transverse infraclavicular incision
Dissect superior to axillary vein
Selective pectoralis minor tendon division
Dissect artery to the chest wall
92
How do you tunnel ax gem graft
```
External support conduit
No counterincision
Anterior to anterior superior iliac spine
Mid axillary line
Between pectoralis muscle
```
93
Types of malperfusion in aortic dissection
Static obstruction - blind or propagating end of dissection enters and constricts branch Ostia
Dynamic obstruction - intermittent obstruction of branch flow due to compliance difference between true and false liken. Patency is branch on angio does not correlate with clinical behavior
94
INSTEAD trial
No benefit of TEVAR in acute type B dissection in the first 2 years
95
INSTEAD XL trial
In long term, TEVAR had improved mortality, improved aortic mortality and better aortic remodeling . Over 90% had complete false lumen thrombosis in BMT + TEVAR comparing to 22% with only BMT
96
Who should get an elective TEVAR after type B aortic dissection
```
6-8 weeks timing
Suitable anatomy
>2 years life expectancy
Poor BP control
>10 mm tear and / or >2cm proximal false lumen
Early aortic expansion
Intermittent pain and / or symptoms of malperfusion
Patient preference
```
97
Risk of rupture increased with IMH
Aortic diameter >4 cm
| IMH thickness >1 cm
98
Grading of traumatic aortic injury
I - intimate tear
II - intramural hematoma
III - pseudoaneurysm
IV - rupture
99
DeBakey I
Ascending and descending aortic dissection
100
DeBakey II
Only ascending dissection
101
DeBakey III a
Descending aortic dissection to the level of the diaphragm
102
DeBakey IIIb
Descending aortic dissection to the level of below the renals
103
Stamford A
DeBakey I abd II
| DIssextion involving the ascending aorta
104
Stamford B
DeBakey IIIa and b
| Dissection not involving the ascending aorta
105
Aortic tumors
Majority are “Intimal” tumors with polyploid or growing along the endothelial surface
Evenly distributed in the aorta
Vascular Surgery by Emi
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