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01:29 CET
E³ 526b - TEVAR/EVAR: where we are and where we are going
Vascular Interventional Radiology
Thursday, March 1, 08:30 - 10:00
Room: M 4
Moderator: F. Fanelli (Rome/IT)

H. Rousseau; Toulouse/FR
Learning Objectives

1. To understand the evidence supporting endovascular therapy vs surgery.
2. To learn what is new for aortic arch disease.
3. To learn the impact of technological innovation in planning and performing the procedure.


Thoracic endovascular aneurysm repair (TEVAR) has proven to be a safe and effective therapy. In the last 2 decades, TEVAR has been established as first-line treatment for most descending thoracic aortic pathology due to reductions in perioperative morbidity and mortality compared to open surgical repair. Improvements in materials, reduction in delivery sheath size, improved conformability, tapered grafts, and a wider range of sizes have improved TEVAR applicability and outcomes over this initial decade of widespread use, for traumatic aortic transection, aneurysms, as well as acute and chronic type B aortic dissection. Looking into the future, industry and physicians are working together to improve thoracic stent-graft design (branched and fenestrated stent-grafts, chimney technique) to further improve safety, effectiveness, and applicability to a wider range of patients and aortic pathologies. Treatment of the ascending aorta remains less established, but is expected to evolve as technology allows integration of ascending, and arch devices. Hybrid ORs combining optimal imaging with the ideal environment to perform complex open and endovascular operations are available, allowing several features such as CTA fusion, CB-CT, and low-dose protocols to reduce the radiation exposure to a patient and an operator.This presentation will review the indications, technical aspects and results of endovascular TAA repairs. We also examine the advantages and limitations of new stent graft treatment of the arch and our experience in technological innovation in performing these complex procedures.

E. Brountzos; Athens/GR
Learning Objectives

1. To understand the evidence supporting endovascular therapy vs surgery.
2. To learn what is new for thoracoabdominal aortic disease and iliac axis.
3. To learn when and how to perform a percutaneous approach.


To understand the evidence supporting endovascular therapy vs surgery EVAR is the method of choice because three principal, randomised controlled trials have shown better 30-day mortality for EVAR compared to open surgery. However, the mortality benefit was lost (catch-up of mortality) after 2 to 5 years.
The main cause of aneurysm-related mortality in the EVAR group was secondary aortic sac rupture, caused by late device failures. Careful patient selection, diligent adhesion to instructions for use and meticulous life long imaging follow up are mandatory for a successful EVAR. Thoracobdominal aneurysms are rare and various. Open surgery carries a mortality rate of 2-12% depending on the aneurysm type. Endovascular treatment includes the use of fenestrated and branched devices with high technical success rates and significant improvement in perioperative mortality. Additional strategies such as hybrid techniques and parallel grafts (chimneys and snorkels) are also successful. Standard EVAR requires bilateral or unilateral surgical exposure of the common femoral artery. Complications specific for this surgical procedure include hematoma (5%), seroma (10%), and femoral nerve damage. Following the introduction of the new low profile devices and the development of the suture mediated closure devices EVAR can be performed without the need of surgical cut down. Recent studies have shown that percutaneous EVAR is possible with 96-100% technical success rates, with complication rates less than 2%.

C. Post-EVG complication
R. Uberoi; Oxford/GB
Learning Objectives

1. To learn about individualised post-EVG surveillance programme.
2. To learn which are the most common complications.
3. To understand how to select and perform the optimal treatment.
4. To understand the role of contrast-enhanced US (CEUS).


Abdominal endovascular repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have become an accepted alternative to surgery for the treatment of aortic pathologies, particularly aneurysm disease and dissections. Lifelong surveillance is obligatory following EVAR and TEVAR to monitor the aortic morphology and detect associated complications. The main imaging techniques used in evaluating TEVAR follow up are computed tomography angiography (CTA), magnetic resonance angiography (MRA) and catheter angiography in assessing the technical success, outcome and complications, which may necessitate
re-intervention. In the abdominal aorta ultrasound (duplex) including contrast enhanced ultrasound (CEUS) with plain X-ray may also be used as alternative imaging modalities. Of these, computed tomography angiography offers a fast, accessible and sensitive imaging modality and is established as the default surveillance tool. Long term common complications include thrombosis, limb kinking and occlusion, aneurysm sac leak which may result in persistent pressurisation of the sac called endoleaks type I-V. Device migration, and device failure can contribute to endoleaks and need to be closely monitored. Type I and III endoleaks need urgent treatment usually with placement of a proximal or distal cuff and or relining of the graft. However not all type II endoleaks need treatment, but where there is continued sac expansion or aneurysm development his will require embolization of feeding vessels. Type IV is less common with the newer devices and usually resolve over a period of weeks and months. Type V endoleaks also may require relining of the whole device or conversion to an open procedure.

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