ARTERIAL DILATIVE
EVAR ENDOLOGIX ALTO
Introduction
Last updated: mar 14, 2025
Over the past 20 years the availability of aortic stent-grafts has allowed a major step change in the management of abdominal aortic aneurysms (AAA). Prior to this open surgical resection, first described by Charles Dubost in 1950, was the mainstay of AAA management. For elective cases open surgical repair has now largely been superseded by the deployment of a covered stent (stent-graft) through minimal surgical access in the common femoral arteries. Over the past few years there have been significant developments in stent-graft technology and an improved understanding of how best to utilise stent-grafts when treating aortic disease. Despite this, their role in the management of a patient with an AAA is still, at times, debatable.
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Diameter |
Rupture risk (%) |
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< 4 |
0 |
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4 - 5 |
0,5 - 5 |
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5 - 6 |
3 - 15 |
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6 - 7 |
10 - 20 |
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7 - 8 |
20 - 30 |
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> 8 |
30 - 50 |
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Indications
- A proximal aortic landing zone for the sealing ring 7 mm below the inferior renal artery.
- Lack of significant thrombus > 8 mm in thickness; at any point along the aortic circumference at the level of 7 mm below the inferior renal artery,
- Lack of significant calcification at the level of 7 mm below the inferior renal artery,
- Conicity < 10% as measured from the inferior renal artery to the aorta 7 mm below the inferior renal artery,
- An inner wall diameter of no less than 16 mm and no greater than 30 mm at 7 mm below the inferior renal artery, and
- An aortic angle of ≤ 60 degrees
- With a length of at least 10 mm, and
- With an inner wall diameter of no less than 8 mm and no greater than 25 mm.
Contra indications
Absolute
- Patients with abdominal aortic or aortoiliac aneurysms having morphology not suitable for endovascular repair
- Patients with known sensitivities or allergies polytetrafluoroethylene [PTFE], polyethylene glycol [PEG]-based polymers, contrast agents, fluorinated ethylene propylene [FEP], titanium, nickel, platinum, or iridium.
- Patients with a systemic infection who may be at increased risk of endovascular graft infection
Relative
Materials
Essentials
- Chlorhexidine
- Standard angiography set
- Lidocaine 10 ml x 2
- Bupivacaine 10 ml x 2
- Contrast
- Heparinized saline and flushing syringes
- 7F Introducer short
- 7F introducer >30 cm
- 0.035" Terumo Stiff guidewire (260 cm)
- 0.035" Compatible radiopaque tip 5 F angiographic pigtail catheter
- 0.035" Lunderquist guidewire (260 cm) x 2
- 0.014" or 0.018", 300 cm Non-hydrophillic, snare compatible guidewires
- Endovascular snare
- 20 ml syringe for integrated balloon inflation
- Exchange catheters and shaped catheters for contralateral gate cannulation
- ALTO Abdominal Stent Graft Aortic Body preloaded in delivery system
- Ovation iX Iliac Limbs preloaded in delivery systems— size one for each: ipsilateral and contralateral limbs (may require additional limbs if extending to external iliac or if long distance from IR to the internal iliac) Ovation iX Iliac Extension (as required)
- CustomSeal Polymer Fill Kit (14-minute cure time) Autoinjector 2
- Non-compliant balloons (for leg/limb overlap) Compliant aortic balloon
- Manta 14F (up to 14F)
- Manta 18F (15-20F)
Non-Essentials
- Balloon expandable stent with appropriately sized balloon
- 14 F sheath (e.g. 45 cm)
- Embolization devices (coils)
The procedure in steps
Access
- Infiltration with Lidocaine and Bupivacaine
- Access both sides under ultrasound
- Measure Manta, and record (in format x +1)
- Place 6F sheaths
- On the side of the main body: pigtail angiography catheter over floppy guidewire (Terumo) to the aortic arch
- Replace floppy guidewire with stiff guidewire (Lunderqvist), mark length with sticker on the table
- Remove angiography catheter
- On the left side of the leg: pigtail angiography catheter over floppy guidewire just above the level of renal artery origin
- Remove floppy guidewire, flush with heparin-saline, connect to the pump
- 5000 IU heparin i.v.
Placement body
- Set the C-arm at the level of the renal artery origin with the correct inclination and rotation
- Insert the main body proximally above the renal arteries, position the marker of the contralateral leg (line on the ipsilateral side)
- Position the endograft and de-sheath
- Turn and remove the mid-crown deployment knob (yellow)
- Remove the white cap from the integral balloon injection port
- With 5 or 10 ml (see table) contrast/NaCl partially deploy the proximal markers
- Deflate the balloon
- Adjust C-Arm for parallax, make sure to project the 8 markers on line
- Pump angiography (20cc, 10cc/sec, 3 images/sec)
- Mark the most distal renal artery on the monitor (both upper and lower border)
- Position the markers at the mid-level of the renal artery
- Retract the pigtail angiography catheter (over the wire)
- Turn and pull the proximal crown deployment knob (yellow) to fully deploy the proximal stent, which fixates the stent
Polymer preparation and injection
- Open the stop cock and mix polymer by 20 strokes in the two syringes
- Start a timer for 14 minutes
- Transfer contents to syringe with green band, then expel to the minimum fill syringe volume appropriate to the aortic diameter (according to the table on the mixing system
- Close stopcocks. Remove green tear tab and disconnect fill syringe (there is a plastic cover over the syringe connection with the green marker).
- Remove green fill cap from the polymer injection port and attach fill syringe.
- Push auto-injector over the syringe plunger and lock into place by rotating 90 degrees, until you hear an audible click. Filling will begin aortic body in aproximately one minute
- Retract aortic body guidewire until the stiff to floppy transition is in the ipsilateral leg
Placement contralateral prosthesis leg
- Cannulate the contralateral leg (if unsuccessful see tips and tricks)
- Place stiff guidewire (Lunderquist) to the level of the aortic arch
- Measurement catheter on the wire
- Angulate for AII image
- Blowback angiography on the leg side
- Mark upper limit of AII on the screen
- Fluoroscopy
- Measure the leg (upper half ring leg to AII)
- Remove sheath
- Insert the leg
- Position iliac limb radiopaque markers between the third and fourth half ring of the aortic body leg to ensure appropriate overlap.
- Deploy the leg
- Maintain position of sheath and retract catheter handle to position nosecone in end of delivery system outer sheath.
- Continue to retract the blue handle until entire inner catheter is removed
Ballooning the Proximal Sealing Ring
- Do this after 14 min auto-injection
- Remove the green auto-injector from fill syringe
- Readvance aortic body guidewire
- Position balloon radiopaque markers proximal to the primary sealing ring and distal to secondary ring
- Manually inflate balloon with 4:1 saline and contrast mixture to recommended volume (see table).
- Completely deflate balloon by pulling vacuum and confirm seal angiographically
Aortic Body Delivery System Removal
- Rotate the third deployment knob ¼ turn counterclockwise and pull knob and wire from handle.
- Advance the delivery system sheath to the first ring of the aortic body.
- Stabilize the delivery system and retract inner catheter until the nosecone is within the aortic body,
- Slightly retract the sheath 2-4 cm, then continue to retract the inner catheter handle to reseat the nosecone into the outer sheath
- To use the integrated sheath, while maintaining guidewire position, move entire delivery system to desired position
- Retract handle to remove the inner catheter from the outer sheath
Placement ipsilateral prosthesis leg
- Exchange to 14F sheath
- Measurement catheter on the wire
- Angulate for AII image
- Blowback angiography
- Mark upper limit of AII on the screen
- Fluoroscopy
- Measure the leg (upper half ring leg to AII)
- Place limb delivery system over guidewire
- Position iliac limb radiopaque markers between the third and fourth half ring of the aortic body leg to ensure appropriate overlap
- Retract sheath to deploy iliac limb
- Retract catheter handle to position nosecone in end of delivery system outer sheath
- If maintaining the sheath, reposition sheath tip to desired location and continue to retract the blue handle until entire inner catheter is removed.
Wrap up
- If deemed necessary balloon the first covered stent body and both legs entirely over stiff guidewires
- Angiography with syringe pump (20cc, 10cc/sec, 3 images/sec) and aspiration sheaths with two empty 20 cc syringes. Long series to exclude endoleaks
Closure
- Hemostasis with Manta devices
Sign-out
Tips and tricks
Very short neck
- Before ballooning do an angiography, in case of proper seal do not balloon
- The integrated crossover lumen may be used to facilitate the process using a maximum 0.018” guidewire through the crossover lumen port on the handle, which then can be snared from the contralateral side. Insert a 5 F sheath over the contralateral crossover guidewire. Insert a buddy guidewire into the aortic body leg and advance proximally. Then remove the cross-over wire
- 0 to 14 minutes - No ballooning allowed
- ≥14 minutes - Integrated balloon (or compliant if integrated balloon has been removed or damaged)
- >30 minutes - Ballooning much less effective
Complications
Endoleaks
- Occurrence: 8–45%
- 40–67% managed conservatively
- Aneurysm growth <5% is present in 1% of ruptures
- Presence of two lumbar arteries at L3 or L4** or an IMA correlates with a higher risk of endoleak, with IMA posing a greater risk than lumbar arteries
- IMA diameter >2 mm → 46–67% chance of endoleak
Sac regression
Sac regression is correlated to improved survival and a reduced rate of secondary interventions and EVAR-related complications. The prognostic significance of sac regression should be considered in surveillance strategies. Intensified surveillance should be applied in patients who fail to achieve sac regression following EVAR.
TLA Technique:
Embolization of the sac versus sac and branches shows no difference in outcomes.
3
Laser-Assisted Transgraft Embolization
Successful embolization was achieved with aneurysmal sac regression demonstrated on 1-year follow-up CT angiography.
Martini Pre-EVAR Embolization Criteria:
- IMA ≥ 2.5 mm
- IMA open AND one or more lumbar arteries ≥ 2 mm at origin
- IMA open and an AAA of aorta AND AIC
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O'Connor, P. J., & Lookstein, R. A. (2015, September). Predictive factors for the development of type 2 endoleak following endovascular aneurysm repair. Seminars in interventional radiology. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540615/
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Aoki, A., Maruta, K., Hosaka, N., Omoto, T., Masuda, T., & Gokan, T. (2017, December 25). Evaluation and coil embolization of the aortic side branches for prevention of type II endoleak after endovascular repair of abdominal aortic aneurysm. Annals of vascular diseases. Retrieved April 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835439/
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Yu, H., Al-Roubaie, M., Desai, H., Isaacson, A., & Burke, C. (2017). Comparison of type II endoleak embolizations: Embolization of Endoleak Nidus only versus embolization of endoleak nidus and branch vessels. Journal of Vascular and Interventional Radiology, 28(2). https://doi.org/10.1016/j.jvir.2016.12.1019
Follow-up
Pre-Discharge and Follow-Up Plan
- Pre-discharge CTA (CT angiography)
- 6-week follow-up with the operating surgeon, including a CTA, to be discussed in the vascular meeting
- Annual follow-up CTA
- Type 1 or 3 endoleak on first postoperative CTA → Refer to vascular meeting and plan reintervention
- Type 2 endoleak without aneurysm growth → Conservative management
- Type 2 endoleak with aneurysm growth (≥5 mm in 1 year) → Refer to vascular meeting and plan reintervention
- Target vessel occlusion or stenosis → Refer to vascular meeting
- Verify if the patient is on antiplatelet therapy or anticoagulation and a statin
- If not prescribed, initiate:
- Clopidogrel 75 mg once daily
- Atorvastatin 40 mg once daily
Report
TOP
Toegang
Huiddesinfectie en steriel afdekken
Locale anesthesie met levobupivacaine 0,5% en lidocaine 1%
Beiderzijds echogeleide punctie AFC
Toegang aan beide kanten onder echografie
Meten Manta's
Plaatsen 6F sheaths
5000 IU heparine i.v.
Inbrengen body - TV-AB2980
Rechts pigtail angiografiekatheter over Terumo tot in de aortaboog
Vervangen Terumo voerdraad door Lunderqvist, markeren van de lengte op de tafel
Verwijderen angiografiekatheter
Links pigtail angiografiekatheter via Terumodraad net boven de nierarterien
Verwijder Terumo, flush met heparine-zoutoplossing, verbind met de pomp
Plaatsen body
Instellen van de C-arm in op het niveau van de oorsprong van de nierarteriën met de juiste inclinatie en rotatie
Inbrengen de main body proximaal tot boven de nierarteriën in, positioneren markers van het contralaterale been (lijn aan ipsilaterale kant)
Positioneren van de endograft
Verwijderen de mid crown deployment knop
Verwijderen van de witte dop van de integrale ballon-injectiepoort
Met 10 ml contrast/NaCl gedeeltelijk ontplooien van de proximale markers
C-arm positie corrigeren voor parallax
Pomp angiografie
Markeren meest distale nierarterie op de monitor
Positioneren van de markers ter hoogte van het midden van de laagste nierarterie
Terugtrekken van de pigtail angiografiekatheter
Proximale stent volledig te ontplooien, waarmee de stent wordt gefixeerd
Polymeer voorbereiding en injectie
Openen van de stopkranen en mengen van het polymeer met 20 slagen in beide spuiten
Juiste hoeveelheid in de rechter spuit
Starten timer gedurende 14 minuten
Verwijderen van de groene vuldop van de polymeer injectiepoort en bevestigen de vulspuit
Plaatsen van de Autoinjector
Terugtrekken van de voerdraad in de main body
Plaatsing contralaterale prothese poot - TV-IL1418160
Cannuleren van het contralaterale been met ingebouwd up-and-over systeem
Inbrengen 5F sheath over de up-and-over 0.014" draad
Plaatsen Lunderquist tot aan de aortaboog
Meetkatheter over de draad
Anguleren voor AII
Blowback angiografie
Markeren bovengrens van AII op scherm
Fluoroscopie
Meten het been (bovenste halfring been tot AII
Verwijderen sheath
Inbrengen poot over de voerdraad
Positioneren van de radiopaque markers op de iliacale poot tussen de derde en vierde halfring van het aortabeen om overlap te garanderen
Ontplooien
Ballonneren proximale ring
Verwijderen van de groene autoinjector van de vulspuit
In verband met de kort hals wordt besloten niet te balloneren
Angiografie toont geen endoleak
Verwijderen Body Delivery System
Door draaien van de derde deployment knop ¼ slag tegen de klok in en knop en draad uit de handgreep t trekken loslaten van de prothese
Terugbrengen nose-cone
Binnenkatheter uit de outer sheath
Plaatsing ipsilateraal prothese poot - TV-IL1418160
Meetkatheter over de voerdraad
Anguleren voor AII
Blowback angiografie
Markeren bovengrens van AII op scherm
Fluoroscopie
Meten het been (bovenste halfring been tot AII)
Inbrengen poot over de voerdraad
Positioneren radiopaque markers op de iliacale poot tussen derde en vierde halfring van het aortabeen om overlap te verzekeren
Ontplooien
Nose-cone in uiteinde sheath te positioneren
Afronding
Ook de poten worden niet geballoneerd
Angiografie met pomp. Lange serie om endoleak uit te sluiten
SOP
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