Celiac artery: 1st major abdominal aortic branch; arises at lower margin of 12th thoracic vertebra
Infrequently involved in AAA treatment zone
Superior mesenteric artery (SMA): Origin from aorta anteriorly, just below celiac artery
Suprarenal stent may extend to/cross origin
Renal arteries: Paired arteries that typically demarcate upper limit of proximal aortic neck
Must preserve renal perfusion during/after EVAR
Small accessory renal arteries arising from aneurysm sometimes sacrificed during EVAR
Inferior mesenteric artery (IMA): Origin above aortic bifurcation; known cause of type II endoleak
Prophylactically embolized by some operators
Lumbar arteries: Paired vessels arise along dorsal aspect of abdominal aorta at each vertebral level
Known cause of type II endoleak
CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
Preferred distal seal zone for endograft limbs
External iliac artery: Extends from CIA bifurcation to inguinal ligament; adequate vessel diameter necessary for endograft delivery
Large common IAAs may require limb extension into external iliac artery
Internal iliac (hypogastric) artery: Originates at CIA bifurcation; has 2 trunks
May require embolization or branch device if endograft limb is extended into external iliac artery
Common femoral artery: Continuation of external iliac artery below inguinal ligament
Preferred/usual choice for EVAR arterial access
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Postprocedure Imaging
OUTCOMES
Problems
Complications
Expected Outcome
Selected References
Cannavale A et al: Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks? Expert Rev Cardiovasc Ther. 18(8):465-73, 2020
Li B et al: A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg. 70(3):954-69.e30, 2019
Chaikof EL et al: The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 67(1):2-77.e2, 2018
Powell JT et al: Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER & ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg. 104(3):166-78, 2017
Sala-Almonacil VA et al: Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms. J Cardiovasc Surg (Torino). 58(6):801-13, 2017
Hajibandeh S et al: Percutaneous access for endovascular aortic aneurysm repair: a systematic review and meta-analysis. Vascular. 24(6):638-48, 2016
Li Y et al: Endovascular versus open surgery repair of ruptured abdominal aortic aneurysms in hemodynamically unstable patients: literature review and meta-analysis. Ann Vasc Surg. 32:135-44, 2016
Patel R et al: Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 388(10058):2366-74, 2016
Peters AS et al: Current treatment strategies for ruptured abdominal aortic aneurysm. Langenbecks Arch Surg. 401(3):289-98, 2016
Spanos K et al: Transition from open surgery to endovascular treatment of abdominal aortic aneurysm rupture. Ann Vasc Surg. 36:85-91, 2016
Sörelius K et al: Endovascular treatment of mycotic aortic aneurysms: a European multicenter study. Circulation. 130(24):2136-42, 2014
Lee JT et al: Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg. 55(4):935-46; discussion 945-6, 2012
Malkawi AH et al: Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 39(6):676-82, 2010
United Kingdom EVAR Trial Investigators et al: Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 362(20):1863-71, 2010
Walker TG et al: Clinical practice guidelines for endovascular abdominal aortic aneurysm repair: written by the Standards of Practice Committee for the Society of Interventional Radiology and endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol. 21(11):1632-55, 2010
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
Outcomes
TERMINOLOGY
Definitions
Abdominal aortic aneurysm (AAA): Localized aortic dilatation exceeding normal diameter by > 50%
Various etiologies
Majority due to multifactorial degenerative process
Proteolytic degradation of tunica media; basic pathophysiology of AAA development
Significant association with age, atherosclerosis
Genetic influence; high familial prevalence
Inflammatory aneurysms occur in up to 10%
May be symptomatic with fever & pain
May be immune-mediated process
Infectious (mycotic) AAA occur in 2%
Usually due to local bacterial seeding of diseased aortic wall or seeding via vasa vasorum
Known for rapid growth, rupture, & high mortality
Anatomically classified based on renal arteries
Infrarenal AAA: Normal aortic segment ≥ 10 mm between renal arteries & most cephalad AAA extent
~ 90% of AAAs occur infrarenally
Majority treated using endovascular techniques
Juxtarenal AAA: Aneurysm extends to renal artery level; normal-caliber aorta above that
Evolving endovascular management techniques
Suprarenal AAA: Involves renal arteries & extends to include superior mesenteric & celiac arteries
Complex endovascular &/or surgical treatment
AAA may or may not involve iliac arteries
Aneurysms also classified by configuration
Fusiform: AAA involves extended aortic section
"True" aneurysm involving all 3 wall layers
Typical appearance of degenerative aneurysm
Saccular: Focal AAA localized to aortic segment
May be asymmetrical; may be pseudoaneurysm
Infectious aneurysms often have this appearance
Iliac artery aneurysm (IAA): Abnormal arterial enlargement ≥ 50% of normal vessel diameter
Common iliac artery (CIA) aneurysm defined as transverse diameter > 1.5 cm
Most IAAs associated with AAAs
Iliac aneurysms present in ~ 20% of AAA
Isolated IAAs uncommon
1-2% of all abdominal aneurysmal disease
Internal IAAs rare (≤ 0.4%)
Typically associated with aortic & common IAAs
Endograft (stent-graft): Fabric-covered self-expanding stent; excludes vascular pathology from circulation
All endografts have 3 components
Delivery system for graft introduction, deployment
High radial force, self-expanding, metallic stent framework & attachment system
Supports endoprosthesis, attaches to vasculature
Impermeable graft fabric surrounding stents
Either expanded polytetrafluoroethylene (ePTFE) or woven polyester fabric composition
Excludes pathology, provides new conduit
Endografts for AAA repair have different methods of fixation to vascular wall
Proximal endograft attachment methodology
Suprarenal fixation: Bare metallic stent extends proximally above fabric-covered endograft; anchors to perirenal arterial tissues
Infrarenal fixation: No components extend above renal arteries; fixation achieved via radial force of metallic stent, which may have barbs
Distal endograft attachment methodology
Iliac limbs may be straight, flared, or tapered to conform to anatomy; radial force secures limb
3 basic abdominal aortic endograft configurations; modular designs allow combination of components into patient-specific vascular conduits
1-piece graft body & unilateral limb extension; paired with separate contralateral docking limb
Forms bifurcated graft; simulates aortic anatomy
Most commonly used endograft configuration
1-piece unibody self-expanding endograft; positioned directly upon aortic bifurcation
Celiac artery: 1st major abdominal aortic branch; arises at lower margin of 12th thoracic vertebra
Infrequently involved in AAA treatment zone
Superior mesenteric artery (SMA): Origin from aorta anteriorly, just below celiac artery
Suprarenal stent may extend to/cross origin
Renal arteries: Paired arteries that typically demarcate upper limit of proximal aortic neck
Must preserve renal perfusion during/after EVAR
Small accessory renal arteries arising from aneurysm sometimes sacrificed during EVAR
Inferior mesenteric artery (IMA): Origin above aortic bifurcation; known cause of type II endoleak
Prophylactically embolized by some operators
Lumbar arteries: Paired vessels arise along dorsal aspect of abdominal aorta at each vertebral level
Known cause of type II endoleak
CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
Preferred distal seal zone for endograft limbs
External iliac artery: Extends from CIA bifurcation to inguinal ligament; adequate vessel diameter necessary for endograft delivery
Large common IAAs may require limb extension into external iliac artery
Internal iliac (hypogastric) artery: Originates at CIA bifurcation; has 2 trunks
May require embolization or branch device if endograft limb is extended into external iliac artery
Common femoral artery: Continuation of external iliac artery below inguinal ligament
Preferred/usual choice for EVAR arterial access
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Postprocedure Imaging
OUTCOMES
Problems
Complications
Expected Outcome
Selected References
Cannavale A et al: Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks? Expert Rev Cardiovasc Ther. 18(8):465-73, 2020
Li B et al: A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg. 70(3):954-69.e30, 2019
Chaikof EL et al: The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 67(1):2-77.e2, 2018
Powell JT et al: Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER & ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg. 104(3):166-78, 2017
Sala-Almonacil VA et al: Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms. J Cardiovasc Surg (Torino). 58(6):801-13, 2017
Hajibandeh S et al: Percutaneous access for endovascular aortic aneurysm repair: a systematic review and meta-analysis. Vascular. 24(6):638-48, 2016
Li Y et al: Endovascular versus open surgery repair of ruptured abdominal aortic aneurysms in hemodynamically unstable patients: literature review and meta-analysis. Ann Vasc Surg. 32:135-44, 2016
Patel R et al: Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 388(10058):2366-74, 2016
Peters AS et al: Current treatment strategies for ruptured abdominal aortic aneurysm. Langenbecks Arch Surg. 401(3):289-98, 2016
Spanos K et al: Transition from open surgery to endovascular treatment of abdominal aortic aneurysm rupture. Ann Vasc Surg. 36:85-91, 2016
Sörelius K et al: Endovascular treatment of mycotic aortic aneurysms: a European multicenter study. Circulation. 130(24):2136-42, 2014
Lee JT et al: Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg. 55(4):935-46; discussion 945-6, 2012
Malkawi AH et al: Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 39(6):676-82, 2010
United Kingdom EVAR Trial Investigators et al: Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 362(20):1863-71, 2010
Walker TG et al: Clinical practice guidelines for endovascular abdominal aortic aneurysm repair: written by the Standards of Practice Committee for the Society of Interventional Radiology and endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol. 21(11):1632-55, 2010
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