Chapters Transcript Video Case Study: EVAR with IVUS as presented by Dr. Michael Turchek This video is a comprehensive review of the use of IVUS in EVAR with voiceover guidance from Dr. Michael Tuchek, D.O., F.A.C.S. D052466-00 Hi. My name is my to check. I'm going to show you a case of an abdominal aortic aneurysm that I placed an endovascular stent graft using the volcano intravascular ultrasound on slide. You can see this is an 82 year old male who had a past medical history of high blood pressure hyper lipid EMEA, and he was a smoker. CAT scan showed a 5.3 by 4.6 of Donald Eric aneurysm. The next slide shows a CT image of that Triple A. I start. My case is putting the intravascular ultrasound up the left side and ultimately the right side, which you can see here. And on this slide, you can see the intravascular ultrasound pull back, which clearly identifies the celiac super Mesen Terek artery, the renal vein, along with the takeoff of both renal arteries, the aortic neck itself, with the length and diameter and the quality of the vessels and then the aneurysm itself, along with the amount of clot you may see there and then the common iliac artery, both its diameter and the take off of the internal iliac artery and then the diameter of the external iliac artery. so I can decide which side to put the main body up. The next slide shows that the aortic diameter is about 24 millimeters, just below the renal arteries. The next slide shows that it narrows down to about 19 millimeters in the distal neck and finally right above the take off of the aneurysm itself. It's about 22 millimeters in diameter. The next slide shows the left common iliac artery that's about 14 millimeters in diameter. I then complacency intravascular ultrasound up the right side and confirm all of those measurements. But especially, I'm looking at specifically the common iliac and external iliac artery diameters, which you can see the next. Few slides show that it's about 14 millimeters in diameter and the right common iliac artery. So all of these questions listed here, I can answer with Intravascular ultrasound pullback, which takes only a couple of minutes perform. I have not used any contrast, and I've only done a couple of spot floors At that point. The volcano IBIs tells me that I need to use a 28 main body graft that I have about a two centimeter neck. But there isn't a lot of cloud or calcium or debris there. Nor is there a lot of angular ation, so it looks like a fairly straightforward neck. I should land it essentially right at the take off of the renal arteries. Question. Do you need a graph of super renal in this case you could use and in farina or super renal device? But I prefer to use the Medtronic endurance device for super anal fixation. And, of course, is there any distal arctic next to no sis above the aneurysm segment that's going to interfere with gate or the calculation of the gate or the device itself? The answer clearly is, no. There's not gonna be a problem in this particular case. The next slide. The questions that we ask, how big, long angle, ated diseased are the ill yaks. In this case, they're not terribly diseased. I know what the length is. Based on spot floor measurements and the one centimeter markers on the Ivies Cather itself. I know both the IPs letter on Contra lateral limbs with two quick I've US runs. I don't think there's any significant iliac stenosis and either the external or the common, so I don't need to do any pre ballooning or dilator sheaths, etcetera, and I know the diameter and how disease the externals are. In this case, I chose the right side for the main body device. The next slide here shows the aneurysm itself with a nice neck above somewhat tortuous iliac. This next slide shows the two centimeter neck below that right renal, which looks very straightforward. No significant stenosis on angio. But we've already confirmed that with intravascular ultrasound, the next slide shows the deployment of the endurance device just below the renal arteries. The next slide shows after we've put the wire inside the gate. And, of course, to confirm that the wire is in fact, in the gate. You can either spin a catheter there or you could do an exchange and put a pigtail up, which takes time, or I just put the intravascular ultrasound up. If there's any question and you can see that run here and clearly I'm inside the gate, no question about the next slide shows the angiogram of the left iliac, and I show that for demonstration purposes only, I normally would not do this during a case. I would simply identify the internal take off where you see the Ives's actually at right now and then use the marker catheters built in to decide how long the iliac limb extension needs to be. The next slide shows the IBIs pullback of the left common and external iliac arteries toe identify those structures. The next slide shows the endurance limb after it's been deployed, extending it just down to the internal iliac artery. Take off. The next slide shows the right internal iliac artery. Take off with the cingulate ID comedy iliac artery again. This was for demonstration purposes only. I normally would just mark the internal based on where the intravascular ultrasound identified it with a spot Floro, and then deploy down to that point with the graft. The next slide shows the endurance limb after it's been deployed with the Intravascular Hassan catheter inside of it to check for any iliac limp stenosis at that area of cingulate ID iliac. The next slide shows the I V s pull back on the right side, which shows the internal iliac already take off and the graft deployed just above it so that we know we nailed the area we wanted to just above the internal that there is no common iliac artery stent graft, limb stenosis and up in the neck that the graft has no graft unfolding, and it's just below the renal arteries bilaterally. The next slide shows the iliac limb extension after it's been placed, and shows the ballooning in the next slide and using the Reliant balloon get throughout the rest of the graft in the next slide. And in the final slide, you see the angiogram with a nice long neck, the stent graft in place with no significant lim stenosis or kinks on angiogram, which we've confirmed by intravascular ultrasound. And we know we've got right down to the take off of the internal iliac arteries bilaterally, both on the final angiogram, which is sometimes difficult to see because it's an anti or post your picture. But certainly we confirmed that by intravascular ultrasound, as you saw above, these last two slides and conclusions showed that the I vis helped me identify key and atomic landmarks, renal arteries, the internal iliac artery, takeoffs, etcetera. The extent of the calcium, how much diagnosis or debris is in both the epic neck and or the iliac arteries in the last slide. It also helped me make key decisions about graph sizing, graft, length, the location placement of the device proximity and decided I wanted to make sure I hit the RINOs right below that area and, of course, right above the internal takeoff bilaterally. Most importantly, however, it really helped me reduce the amount of flora, time and overall time doing the procedure, because I don't have to have unnecessary multiple catheter exchanges for the marker pigtail and the time spent doing additional angiograms. And because I don't have to do those additional angiograms, it allows me to do a case with significantly less contrast for identifying structures which I could see easily by I vis. I typically do a run or to just identify the renal arteries at the beginning, which is 22 40 cc's total and then a 40 cc run at the end of the case. So I averaged 60 to 80 ccs of die per case and with rare exception, I can place the device and get great results. Thanks to intravascular ultrasound. Thanks very much for allowing me to present this case Published January 18, 2021 Created by
