Live Cases Offer Virtual Observation of EVAR Procedures

MCVI live cases take attendees step-by-step through EVAR procedures.

By Brenda Silva

Live cases from Miami Cardiac and Vascular Institute (MCVI) continued to be highlighted as ISET attendees observed interventionalists address two different patient conditions and perform case-applicable therapies. Moderator Alex Powell, MD, was joined by a panel of experts who asked questions, offered insight, and received feedback from the onsite staff at MCVI.

The first live case was of an abdominal aortic aneurysm in a 73-year-old man with persistent lower extremity neuropathy. His past medical history included hypertension and long-term smoking. The patient had a CTA in September 2017 which showed a 2.3 cm aneurysm that caused him increased anxiety, feeling like a “ticking time bomb.” For the live case, the patient presented with 5.3 cm infrarenal abdominal aortic aneurysm for endovascular repair.

The MCVI team for this case, which included James Benenati, MD, chose a percutaneous approach with the patient and used an excluder endoprosthesis Gore device. There was some discussion among the panel about anatomic considerations in terms of what devices are available, with the surgical team pointing out that the patient would not qualify for a branch device for this procedure.

Continuing, the team used a bell-bottom technique and visualized a seal of the neck with no endoleaks. The team felt they sealed the endografts well, and while long-term patency was considered, additional runs showed no leaks in the seal.

In a second live case, Barry Katzen, MD, and his team reported on a thoracic aortic dissection. The patient is 64-year-old paraplegic man who was paralyzed at 37 years of age and since has had multiple orthopedic surgeries related to his accident. He presented in September 2017 with acute chest pain and was found to have an acute type B aortic dissection. The patient is currently asymptomatic, with blood pressure controlled well with medication. A CTA showed a larger false lumen with tear, with the dissection measuring 44 cm and the distal landing zone measuring 20 cm. Because of the patient’s paraplegia, small vessel size was expected to make the endovascular repair procedure very challenging.

Dr. Katzen said, “When we see a dissection is changing, we keep a close eye on it even if the patient is asymptomatic. The other issue has to do with access with this patient. Even though he was and is athletic – he’s had multiple fractures related to his paraplegia but currently competes in wheelchair marathons – we have to consider what device to use and what access to use.”

The question of iliac access versus alternative access was raised by the panel; however, after the right common femoral artery was exposed and looked good, the team used a 16Fr dilator, which they continued to 22Fr before feeling resistance. Dr. Katzen felt the tension was too much and elected to use a 22Fr solo path expandable sheath made by Terumo, with the device deployed as high as possible short of the curve. Satisfied with the procedure, the team felt the results were the best course of treatment for the patient and his dissection.