VASCULAR SURGERY I

Endovascular treatment of It is estimated that the screening programme will prevent 1900
deaths per year.

abdominal aortic aneurysms Treatment

Victoria White
An audit by the Vascular Society of Great Britain and Ireland
Mike Wyatt showed that of the 21,266 infra-renal AAA repairs carried out
between 2008 and 2013, 59% were repaired with an endovas-
cular stent-graft, and the remaining 40.4% were open repairs.2
Abstract
The principle of both methods is to re-establish laminar blood
The management of abdominal aortic aneurysms has been revolutionized
flow through a normal calibre conduit. In endovascular repairs,
by the development of endovascular stent-grafts. The deployment of
the stent-graft acts as the conduit and excludes the aneurysmal
these devices requires precise clinical and endovascular skills. This review
segment of aorta. To keep the aneurysmal segment excluded
aims to provide an overview of the essential aspects of an endovascular
from the systemic circulation, the stent-graft creates a watertight
repair of an abdominal aortic aneurysm (EVAR), from initial presentation
proximal and distal seal. The proximal seal at the neck of the
and assessment for the procedure through to follow-up and long-term
aneurysm (Figure 1) is in a normal, non-aneurysmal component
outcomes. Consideration is also given to the newer devices (e.g. fenes-
of the aorta cephalad to the aneurysmal segment. The distal seal
trated and branched stent-grafts), which have further expanded the
is a normal, non-aneurysmal artery or arteries that is/are caudal
numbers of patients who are suitable for treatment by EVAR.
to the aneurysmal segment. For example, in infra-renal aneurysm
Keywords Aneurysm; aortic; endoleak; stent-graft repairs, the proximal seal is in the infra-renal neck of the aneu-
rysm, and the distal seal is usually in the common iliac arteries. If
the common iliac arteries are aneurysmal the distal landing zone
can be extended into the external iliac arteries. For more complex
Diagnosis of aortic aneurysmal disease repairs (e.g. aneurysms of the visceral aorta), the proximal seal
may be in the thoracic aorta and the distal seal in the infra-renal
An aneurysm is defined as a permanent localized (i.e. focal) aorta.
dilation of an artery, having at least a 50% increase diameter The multiple functions of the stent-graft (establishing a
compared with the expected normal diameter measurement. The watertight, normal calibre conduit that is deployed using endo-
estimated incidence of abdominal aortic aneurysm (AAA) is 5% vascular techniques and which will remain fixed in place in the
in men over 65 years old. Any part of the aorta may become presence of systolic blood pressures) are feasible because of a
aneurysmal. Once the aneurysm develops, the risk of rupture number of important design features:
increases with increasing diameter size.  Stent-grafts are packaged as modular components with
various sizes of main-body and limbs (Figure 2).
NHS Abdominal Aortic Aneurysm Screening Programme Depending on the patients anatomy, the appropriate size
(NAAASP) of each modular component is selected to create a
Prior to establishment of the NHS AAA Screening Program customized device.
(NAAASP),1 AAAs were usually detected through clinical suspi-  The metal stent is a self-expanding frame made of nitinol.
cion, or as an incidental finding whilst investigating the cause of When deployed, the stent opens up and at the same time it
other symptoms or when the patient presented emergently with a unfolds the covering impermeable graft fabric (Figure 2).
rupture. Given that the mortality rate for a ruptured AAA is Once open, the stent generates the necessary radial forces
greater than 50% for patients who reach hospital, and that the to prevent slippage from the sealing zones and the
UK mortality rate for elective repairs is 2.4%, the benefits of the impermeable fabric creates the conduit.
AAA screening programme are self-evident. The NAAASP invites  Each stent-graft component is enclosed in a small diam-
men in their 65th year to present for an abdominal ultrasound eter, hydrophilic delivery system to enable smooth passage
scan. Those patients who are found to have an aneurysm are through the iliac arteries to the aorta.
offered surveillance scans at intervals based on the rate of growth  Some stent-graft designs have barbs on a proximal, bare
of the aneurysm. For example, a patient with a 4.5 cm aneurysm (no fabric) stent. These barbs penetrate into the aorta wall
can expect to have a scan every 3e6 months depending on the above the sealing zone and provide extra fixation
rate of growth of the aneurysm between each surveillance scan. (Figure 3).

Indications and contraindications for the endovascular repair of

aneurysms
Not all patients will be suitable for an endograft. Certain criteria
Victoria White FRCS is a Vascular Fellow at Christchurch Hospital, New
have to be met to ensure safe deployment and long-term stability
Zealand. Conflicts of interest: none declared.
of the stent-graft. These include;
Mike Wyatt MB BS MSc MD FRCS FRCSEd. (ad hom) FEBVS is a Consultant  7 mm external iliac arteries. As mentioned above, the
Vascular Surgeon at Freeman Hospital, Newcastle upon Tyne, UK. stent-graft is packaged in a low profile, hydrophilic de-
Conflicts of interest: none declared. livery system. Iliac arteries that are smaller than 7 mm will

SURGERY 33:7 334 2015 Elsevier Ltd. All rights reserved.

 VASCULAR SURGERY I

Figure 2 The modular components of a bifurcated aortic stent-graft

showing a main-body (left) and stent-graft limb (right).

same reason, anything in the aneurysm neck that interferes

with direct contact between the graft and the aorta such
protruding calcified plaques and extensive mural thrombus
will also impact on the quality of the sealing zone.
Figure 1 Three-dimensional CT reconstruction of an abdominal aortic
aneurysm, showing the infra-renal neck that will provide the proximal
sealing zone.

not accommodate the delivery apparatus and will therefore

inhibit passage of the stent-graft into the aorta.
 Flexible, smooth iliac arteries. Excessively tortuous iliac
arteries will resist the passage of the delivery system.
Similarly, rigid, calcified, iliac arteries or vessels littered
with obstructing plaques will also prevent stent-graft pas-
sage and may put the arteries at risk of damage by the
delivery system.
 15 mm proximal sealing zone. Sufficient radial force has to
be generated by the stent-graft with the wall of the aorta to
secure the grafts position for the duration of the patients
life. Proximal sealing zones less than 15 mm in length will
compromise generation of these radial forces and increase
the risk of slippage of the stent-graft.
 A straight sealing zone. A conical aneurysmal neck will not
make full contact with the stent-graft. Again this will
Figure 3 Bare metal suprarenal fixation of a stent-graft; the barbs allow
compromise the degree of radial force generated. For the improved wall anchorage.

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 VASCULAR SURGERY I

Certain patient factors also need to be taken into

consideration: Classification of endovascular aneurysm repair-related
 Young age (<60 years) of the patient. Because of the lack endoleaks
of data on long-term durability of the deployed devices Type Feature
there is a preference to repair young patients using the
open technique. 1 Failure of proximal or distal attachment sites
to seal, allowing blood to leak around the
Preoperative assessment and insertion of the stent-graft device into the redundant aortic sac
2 Filling of the sac via collateral vessels (inferior
Prior to insertion of a stent-graft, meticulous planning is
mesenteric artery or lumbar arteries)
required, preferably using multiple-plane reconstructions. Look-
3 Graft defect, break in the graft material or
ing at the scans of the patients AAA in several planes enables
dislocation of a modular component of the
accurate calculation of the size of the device to be deployed and
stent-graft
will also determine if the patients aortic morphology is suitable
4 Graft wall porosity
for EVAR. The endovascular repair is ideally carried out in a
5 Endotension or increasing aneurysm size
dedicated hybrid operating theatre by an interventional radiolo-
without a visible leak
gist and vascular surgeon with expertise in EVAR. Insertion of
the stent-graft can be done under local or general anaesthetic, Table 1
and with either a percutaneous method of access to the common
femoral arteries or direct cut down onto the vessels. Deployment
of a stent-graft consists of a series of precise, sequential steps: compromising blood flow into the internal iliac arteries
 Each modular component of the device is directed into the (Figure 4a).
aorta over a stiff endovascular wire. The main-body is  Once all the components have been deployed, a comple-
deployed first and landed precisely below the lowest renal tion angiogram is preformed to check the patency of the
ostium. renal and internal iliac arteries and to confirm that the
 The distances between the main-bodys lowest borders and aneurysm has been excluded (Figure 4b). The presence of
the origin of the internal iliac arteries are then defined. a type 1 endoleak (Table 1) may be managed expectantly
This determines the lengths of the endograft limbs that are or with an endovascular balloon that compresses the stent-
required to reach the distal landing zones without graft against the proximal sealing zone.

Figure 4 Angiography of an aortic stent-graft. (a) Intraoperative image, during deployment of the left limb, showing aneurysm sac (blue arrow) and lumbar
arteries (white arrows). (b) Postoperative image (completion angiogram) showing supra-renal bare stent (green arrow), renal arteries (red arrows),
branches of the superior mesenteric artery (blue bracket) and stent-graft in the aorta and common iliac arteries (white arrow).

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 VASCULAR SURGERY I

Complications Intermediate & late complications (i.e. up to and greater

than one year after surgery)
Immediate complications (i.e. intraoperative or within the
The following complications can occur at any time in the
first 24 hours after surgery)
postoperative period, but they are often identified in the post
 Inadvertent coverage of the renal or iliac ostia. Acute
EVAR follow-up programme that are initiated in the intermediate
kidney injury will depend on the degree of coverage and if
and later periods after an EVAR. These complications include:
a second kidney is unable to compensate. Where the
 Endoleaks. The most common endoleak is the type 2
ostium of an internal iliac artery has been covered, buttock
(Table 1). These are usually benign and spontaneously
claudication may develop on the affected side.
seal in more than 80% of cases. Endoleaks associated with
 Endoleaks. An endoleak is defined as a persistent leak or
sac expansion require active investigation. Contrast-
flow of blood into the aneurysmal sac after endovascular
enhanced ultrasound scans, CT scans and direct angiog-
repair of the aneurysm. This persistent blood flow risks re-
raphy are used to identify the source (type) of the leak.
pressurization of the sac and therefore the risk of sac
Strategies employed to manage the leak include:
rupture. There are five types of endoleak (Table 1). Type 1
 Endovascular procedures:
endoleaks can arise at any time post operatively, but in the
- Embolization of the feeding artery (e.g. the
immediate postoperative period they occur if the proximal
IMA or lumbar arteries in a type 2 endoleak).
or distal seals are inadequate. Management is either con-
- Cuffed stent-grafts and stapling devices that
servative on the basis that the leak will stop once the stent-
can be applied to the neck of the aneurysm
graft and aorta mould together. Alternatively, an additional
for a type 1 endoleak
endovascular device is used to promote better contact be-
- Relining the endograft with another stent-
tween the aorta wall and the stent-graft. Such devices
graft if the modular components have
include endovascular balloons (see above) and short, un-
become distracted to cause a type 3
covered, self-expanding stents (the Palmaz stent).
endoleak
 Bleeding from the common femoral arteries. Endovascular
- Extending the limbs of the endograft with
closure devices are integral to the percutaneous method.
another stent-graft if there is a type 1
These devices have a recognized failure rate. Active
endoleak at the distal seal.
bleeding from the artery, whether it has been accessed by a
 Open procedures:
percutaneous or an open method, requires an immediate
- Open banding of the neck of the aneurysm
return to theatre for open surgical repair.
- Open repair of fabric defects
Early complications (i.e. within 30 days of surgery) - Conversion to an open conventional repair.
 Renal failure due to contrast induced nephropathy 3e5  Occlusion of the stent-graft. This is usually due to throm-
days after the procedure should be anticipated and bosis secondary to low blood flow. Contributory factors
managed accordingly. Other causes of renal failure include include kinking of the graft body or its limbs, poor outflow
coverage of the renal ostia and kidney injury from into diseased distal arteries and patient factors such as
cholesterol embolization. heart failure. Management includes graft thrombectomy,
 Cholesterol embolization. Manipulation of the endovas- relining of the graft to straighten distortions, consideration
cular wires and the delivery devices within the aorta of a femoro-femoral cross-over and optimizing patient
inevitably results in the apparatus knocking against the factors.
arterial intima. Loose cholesterol plaques or mural
thrombus can be disrupted and dislodged with distal Follow-up
embolization. Management is directed by the degree of The late complications of EVAR described above occur in 20% of
clinical ischaemia. cases. Early detection of these complications is essential for
 Wound problems such as infection, seromas and pseu- management planning. In addition to CT angiograms to identify
doaneurysms are related to patient factors such as dia- endoleaks and graft occlusions, plain radiographs will identify
betes, and surgical factors such as emergency procedures. mechanical complications such as fractures of the stent struts
Management will depend on clinical presentation. and migration of the graft. A typical follow-up programme in-
 Post-implantation syndrome. This is manifest by pyrexia volves a CT scan at 1 and 12 months postoperatively. Thereafter
and biochemical evidence of an inflammatory response follow-up offers annual CT scans with plain radiographs. Newer
after EVAR. It has been diagnosed in up to 35% of post follow-up protocols now use plain radiographs and ultrasound
EVAR patients.3 To date there is no consensus on the scans to reduce costs, nephrotoxicity and radiation exposure,
management of post-implantation syndrome, but is usually with the availability of a CT scan if complications are detected.
managed conservatively.
 Stent-graft infection. This is rare and the patient should be Outcomes
considered for long-term antibiotic therapy and/or a sur-
gical management strategy such an explanting the graft The 30-day mortality associated with elective open repair varies
and replacing it with conduit constructed from the pa- between centres, but evidence from randomized trials places the
tients superficial femoral vein. figure at between 4% and 6%. For endovascular repairs, the

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 VASCULAR SURGERY I

30-day mortality rate is below 2%. The difference in these 30-

day mortality figures reflects the less invasive nature of an
endovascular repair. This has important implications for patients
with co-morbidities that preclude open repair; for example, if a
surgically unfit patient has an aneurysm that is suitable for an
endovascular repair, EVAR can be offered as an alternative to
conservative management. However, the decision to proceed
with EVAR or open repair has been re-evaluated in the light of
long-term outcome data from the EVAR1 trial,4 the Dutch
Randomised Endovascular Aneurysm Management (DREAM)
trial,5 the North American Open Versus Endovascular Repair
(OVER) trial6 and the French randomized trial for open versus
endovascular repair (ACE). The 30-day mortality rate of 1.8% for
EVAR and 4.3% for open repair in the EVAR 1 trial favoured
EVAR. Comparable results were seen with the DREAM and Figure 5 Fenestrated stent-graft showing a renal artery fenestration and a
OVER trials. In 2010, long-term follow-up data for EVAR1 were scallop for the superior mesenteric artery. Another renal fenestration is
published and identified that the all-cause survival advantage is present, but out of view, on the opposite side of the stent-graft. Repro-
lost at 2 years, and the aneurysm-related mortality is lost at 6 duced by kind permission from Cook Medical.
years. In addition, EVAR was associated with on-going compli-
cations that required re-interventions with their additive costs.
The DREAM trialists reported a similar loss of the long-term Like the fenestrated grafts, the branched stent-grafts are
mortality advantage and higher rates of re-intervention for usually tailor-made for the patients unique anatomy. Conse-
EVAR. By contrast, the OVER and ACE data did not show a loss quently they are more expensive than conventional infra-renal
of the early mortality advantage in the EVAR cohorts over the stent-grafts. A recent Clinical Commissioning Policy report by
longer term. the NHS England recommended that the use of these complex
These findings have important implications for counselling
patients who are fit for both open and endovascular repairs; low
to intermediate risk younger patients may gain longer-term
advantage from an open repair even in the light of improving
endovascular technologies.

Newer developments
Fenestrated stent-grafts
The low 30-day mortality and morbidity associated with EVAR
has encouraged surgeons to treat many patients with aneurysmal
disease who would otherwise be very high risk for an open
procedure. Juxta-renal or peri-renal aneurysms lack the
anatomical 15 mm neck required for a robust proximal seal. To
overcome this limitation, stent-grafts have been developed that
take advantage of any normal calibre aorta above the renal ostia.
A 15 mm sealing zone can be created by using a stent-graft that
has fenestrations or windows which land at the origins of the
renal arteries and the major mesenteric vessels (Figure 5). Pre-
cise landing of the stent-graft plus stenting of the renal and
mesenteric arteries to keep the stent-graft in place, will ensure
normal blood flow to the viscera and secure a proximal seal in
patients with juxta-renal aneurysms.

Branched grafts
Branched endografts (Figure 6) are used to repair type IV aneu-
rysms (i.e. where the aorta is aneurysmal from the level of the
diaphragm to its bifurcation). The proximal landing zone is
usually in a normal calibre segment of the thoracic aorta, and the
distal landing zone may be in the distal aorta or the iliac arteries.
In these complex stent-grafts, the branches are manufactured to
flare out at an angle that facilitates endovascular placement of a Figure 6 Branched stent-graft showing branches for the renal, superior
bridging stent between the main-body of the stent-graft and the mesenteric and coeliac arteries. Reproduced by kind permission from
origin of the corresponding visceral artery. Cook Medical.

SURGERY 33:7 338 2015 Elsevier Ltd. All rights reserved.

 VASCULAR SURGERY I

stent-grafts be limited to the major specialist arterial centres for Royal College of Surgeons of England and the Vascular Society of Great
appropriately selected patients. Britain and Ireland (VSGBI) http://www.vsqip.org.uk/wp/wp-content/
uploads/2013/07/NVR-2013-Report-on-Surgical-Outcomes-Consultant-
Summary Level-Statistics.pdf. Last accessed on 18/01/2015.
Endovascular treatment of abdominal aortic aneurysm repre- 3 Arnaoutoglou E, Kouvelos G, Milionis H, et al. Post-implantation syn-
sents a paradigm shift in the management of aneurysmal disease. drome following endovascular abdominal aortic aneurysm repair;
The number of patients treated with stent-graft devices has preliminary data. Interactive Cardiovasc Thorac Surg 2010; 12:
increased significantly since the first stent-graft was inserted in 609e14.
the UK in 1991. The high degree of expertise required to deter- 4 The EVAR Trial Participants. Endovascular aneurysm repair versus open
mine which patients are suitable for EVAR and how the subse- repair in patients with abdominal aortic aneurysm (EVAR trial 1):
quent interventions should be managed has also resulted in the randomised controlled trial. Lancet 2005; 365: 2179e86.
boundaries being pushed to treat patients with more complex 5 Prinssen M, Verhoeven EL, Buth J, et al. Dutch Randomised Endovas-
aneurysmal disease. A cular Aneurysm Management (DREAM) Trial Group. A randomised trial
comparing conventional and endovascular repair of abdominal aortic
aneurysms. N Engl J Med 2004 Oct 14; 351: 1607e18.
REFERENCES
6 Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following
1 http://aaa.screening.nhs.uk. Last accessed on 18/01/2015.
endovascular vs open repair of abdominal aortic aneurysm. A rando-
2 National Vascular Registry Report on surgical outcomes. Consultant-
mised trial. JAMA 2009; 302: 1535e42.
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SURGERY 33:7 339 2015 Elsevier Ltd. All rights reserved.