My name is Lori Lazansky. I'm joined by Dr. Anil Kumar, and we are the chair and co-chair for your SBU e-learning educational committee. Before we begin, I have a couple of notes from the SBU office to share with any first-time attendees. This webinar will be recorded and available online in the near future for attendees through the SBU website at no charge. Please take a moment to familiarize yourself with the GoToWebinar program. Everyone should see a question section along the side menu of your screen. It's near the bottom of the column just above the chat feature. So please type in any questions that come to mind during the presentation, and then at the end of tonight's talk, we should have some time for discussion. To receive your CMEs from tonight's lecture, you'll need to wait for an email from the SBU office containing an evaluation. You should get that email in about a week. Once you get the email, complete the evaluation, and your CME certificate will automatically pop up. Now, tonight, we're honored to have Dr. Ross Milner and Marissa Marzek from the University of Chicago speaking on the subject of complex abdominal aortic repair. Dr. Milner is currently the chief for the section of vascular surgery and endovascular therapy at the University of Chicago. He studied medicine at University of Pennsylvania, previously worked at Emory in Atlanta, and Loyola Medicine in Chicago. Dr. Milner is an internationally recognized vascular surgeon specializing in the treatment of complex aortic diseases. He's also an educator, mentor who travels around the world to train and work with surgeons from other countries in Latin America and Asia, just to name a few. Some of his research involves evaluating endovascular devices. He's written more than 100 abstracts and manuscripts, as well as more than 20 reviews and chapters in textbooks on endovascular therapy. And then in his free time, he's on the editorial board for several vascular surgery journals in the U.S. and Europe. He's a member of many professional societies, and he serves as secretary for the Midwestern Vascular Surgical Society. And we also have Marissa Marzek. She'll be sharing her experiences tonight as the vascular sonographer who has to try to figure out what Dr. Milner did to the patient in the OR. But this assignment's a piece of cake for Marissa. She's a board-certified vascular technologist that has been on staff at the University of Chicago since she graduated 20 years ago. Marissa earned her degree from Rush University in Chicago, and she returned there to teach for a few years after her graduation. And in her position at the University of Chicago, Marissa mentors students from that very same vascular sonography program where she earned her degree and went back to teach. Marissa is an active member of SVU, where she is given multiple presentations, helps with scanning workshops at national meetings. She performs a wide range of vascular studies in her daily work, and she has a lot of experience scanning complicated endovascular aortic grafts, which is our topic for this evening. So now, if you would, please join me in welcoming Dr. Russ Milner and Marissa Marzek. Great, Laurie. Thank you so much, and thank you so much for the kind invitation as well as the beautiful introduction. Very thoughtful of you, and I'm fortunate to be at a place where we have such an amazing collaboration with our vascular lab. And you, Laurie, as a leader for us are amazing. And I work with Marissa a lot. We've worked together for my entire time that I've been here, and I enjoy the collaboration and partnership and feedback and all of the work that we do together that makes it such a fantastic place to be and a great place to take care of patients. And Dr. Kumar, I appreciate your leadership with Laurie and the opportunity to be here. I'm going to start, and then Marissa and I have this designed so that I will present some topics, and then she will share some images, and we'll go back and forth a little bit. And like always, we'll leave some time at the end for questions. You may have seen this already, but here is the goals. Our overview is to discuss complex abdominal aortic aneurysms, the different types of repairs that are available, and then the follow-up imaging that's done. Objectives are going to be to identify AAA and iliac aneurysms for elective repair, identify different types of complex aortic aneurysm repairs, explain the different terminology that we use within vascular surgery to define these complex repairs, how to appropriately document an endoleak, and then to describe the challenges that a sonographer may encounter while scanning these complex patients. I know this is probably four or five are really what's most important to all of you, but I think as Marissa and I talked about, understanding one, two, and three hopefully make four and five a little bit simpler. And Laurie described this well. I think at times I make your guys' life a little bit more complicated with some of the repairs that I do, but I think giving everybody a little bit of a background and insight into what we think, what happens in the operating room, and then how that relates to imaging, which I think Marissa and I have, I think, done a reasonable job of putting that together, and hopefully people will benefit from that. Here's our disclosures. I'm going to show you my disclosure side a little bit more carefully in a minute so I can go over that because I think it's important to be transparent with conflicts. As you can see, the planning committee members have nothing to disclose and neither does Marissa. I am the conflicted one. Obviously, we will be using off-label techniques with some of the complex work that I talk about. I will make sure I highlight to you when I am using off-label techniques, and those are really the main things. So here's my disclosures, and I want to go over this a little bit more carefully because I do use a fair bit of devices. I also work with a fair number of device companies and have reached a point in my career, which is a lot of fun, where I'm actually working with a lot of startup companies as well. I do work with SIDAR. Syndrix is actually a closure device company. It has nothing to do with aortic repair. I have equity interest. Andospan is involved with a clinical trial right now. I do use a fair bit of Medtronic products. You will see that in this talk. Silk Road is a carotid stent company, as many of you know, and W.L. Gore, which I will talk about a little bit in here as well. Once again, when I use any devices in an off-label manner, I will make sure that I am clear on that and there's transparency with my conflicts. I bring this slide up just to give you an idea of when we talk about complex aneurysm repairs, what we think about. And this puts you through sort of the spectrum of what we do at the University of Chicago. And I think really one of the most critical parts of any complex aortic care is having a lot of options, working very collaboratively with a group. And although I'm going to focus on abdominal for the most part within this talk today, our aortic program works well because we work very well with cardiac surgery. We work well with interventional cardiology. We work well with our ICU team. We work well with our nurses in the operating room. We work well with the nurses in the ICU. We work well with our nurses in clinic, our APPs in clinic, and our vascular lab. And we couldn't do everything we do without all of those people. So what I'm showing you here on this slide is an open abdominal aortic aneurysm repair, an example of a fenestrated endovascular repair. We'll talk about these all a little bit more. A procedure we like to call CHI-VAR here, which we do a fair bit with. And then this is showing you something that's done in terms of endo anchors, which is a way to deal with sometimes more complex infernal neck anatomy and still get the overall technical result that we want from an endovascular repair. And I'll explain that a little bit more. So whenever I see a patient, I know I have a lot of options, and I think having a lot of options is critical. So I'm going to focus on open, fenestrated, and CHI-VAR and go through all of those a little bit more. But I think really one of the critical parts of this is we commonly used to have pre-COVID many in-person debates and then many webinar debates. And now we're back to in-person again on looking at what are the best options when we talk about complex abdominal aortic aneurysms. And I think what started to happen a little bit is these debates turned out to be technical debates, meaning some people were very strong proponents of fenestrated repair. Some people were very strong proponents of CHIMNEY, EVAR, CHI-VAR. And the reality is what we try to do is have these options available for all of our patients and never take one specific technique and say every patient has to have this technique. We think that's not the right way to do this. And what I do when I look at all of my patients is I say, OK, here's their anatomy. Here's their overall risk. What's my best approach? So I stand there at this fork in the road and start thinking about these options. I really try to make it a very patient-specific approach with the best outcome for a given patient and not worry so much if I think I can do one technique better than the other or I should be doing one technique more than the other. It's really what do I do to help a given patient? So what do all these look like? So many of you know this and many of you have seen patients that have opened surgery. I think it's still at times considered the gold standard, but as many of you know, it's a highly invasive procedure, has a risk of renal failure. And I think the risk of renal failure is greater with open surgery than it is even with complex EVAR and can likely lead to worse outcomes if patients develop renal failure afterwards. I actually just saw a patient back today through virtual visits this afternoon that I did an open AAA repair on about three months ago. This gentleman was a relatively young man in his mid-50s and did a fairly complicated repair that I had to clamp above the level of renals. He actually developed postoperative renal failure that has now resolved. He is off dialysis and finally feeling better. But it took him almost a whole three months till he's really back to himself. It's a big operation to recover from. Clearly, there's ICU stay that's necessary for these patients. And as I just mentioned, the recovery is fairly extensive and it takes people a good two to three months to really get back to themselves where their appetite's better, their energy level's better. They really sort of feel like they've fully recovered. It takes a long time. It tends to be less costly than EVAR because there's not the associated device cost, but there are still costs associated with a longer hospital stay, the need for dialysis, et cetera. Just so you're aware, I'm not going to talk about this very much and I don't think Marissa is either. When I do open surgical repair, I still tend to surveil these patients afterwards. I like to keep them for follow-up. So I usually do an ultrasound once a year and every five years I'll do a CTA of chest, abdomen, and pelvis. But it's an opportunity for me to see them back, make sure the repair is intact, and there's not something else going on. So what are the endovascular options that I'm going to focus on this evening? I'm going to talk about fenestrated EVAR, FEVAR, talk about chimney EVAR, CHEVAR, and then show you what we've done with a combination of both those techniques. So again, there used to be very strong debates whether or not you should do FEVAR or whether you should do CHEVAR. And so what I've done is actually try to even combine the approaches, and I'll show you that. So this is what a chimney EVAR looks like, just in case you haven't seen it. And for those of you that are then going to do imaging of these patients with duplex, you now have a better idea of what this looks like. So this is the AP view here. Hopefully you can see my mouse. This is the AP view. This is what would represent the superior mesenteric artery. Here are two renal arteries. Here's an aortic endograft now that's been intentionally placed above the renal arteries up to the level of the superior mesenteric artery to treat a pararenal aneurysm. And then why these are called chimneys is, as you can see, they go above these grafts that sit next to the main body device, go above the device. We call this chimneys. We call these parallel grafts. You'll hear sometimes they're called periscopes. There's all kinds of different ways they get described. We call this here CHEVAR, and this is what this looks like. And I'll show you later that I try to provide a drawing to the vascular lab for the different reconstructions I've done for a given patient. So what is CHEVAR able to do? So it's able to treat relatively complex anatomy, and just so you know, this is off-label. I'll reinforce it here. I have it in my bullet points. This is off-label in the United States. It is allowed and has CE mark in Europe. So the benefit of this, it's off the shelf. I don't have to wait for a device to be designed. The fenestrated devices are made in Australia and then shipped to us and take four, six, eight weeks to make. The stent interactions are not well known, although we're starting to understand that better, and there is a fair bit of work that's been done understanding how the stents that sit next to the main device, their patency, any risk of fracture. We've looked at that in our experience. Many people have looked at that that do these procedures, and they seem to work well together. And I think this can treat slightly more challenging iliac anatomy, and the reason being it's a smaller profile device than a fenestrated device. It can get through some of the challenging iliac anatomy that we treat. So as I mentioned, although it's off-label in the United States, it is CE marked in Europe since 2017. The recommendations for device sizing are slightly different with QiVar than they are for standard eVar. This will not impact what you do from an imaging standpoint. This purely helps us determine what we do from a planning standpoint. So the main limitations of QiVar are I need an upper extremity access to be able to do this, so there is a small risk of stroke. And then what you'll be looking for are these gutter leaks or these type 1a leaks that come around the parallel graphs above the fixation of the device, the proximal seal zone, and into the aneurysm sac. So a gutter leak is just a type 1a, but it's more than just a type 1a because it's really between the parallel graft or the chimney graft and the aortic endograft. When we use the upper extremity approach, what we tend to do is use an axillary incision, so we have both arms tucked. It makes it easier for us when we want to go into lateral, full lateral imaging in the operating room. It's also an easier prep, and it allows our anesthesiologist to use both arms. So our tendency is in our practice that we don't use brachial very often for the parallel graphs. We tend to use axillary, and we tend to use right side. If we're only going to put one or two sheaths in, I usually just do that as a direct puncture, and I'll show you what that looks like. So here's an axillary incision. It's a little hard for you to understand where this is on the body just by the picture here, but clavicle would be here. This is the axillary artery. It heads up this direction, feet are in this direction, and you can see here was a vessel loop on the artery, and then here's where I placed a sheath, and it's secured now with a pledged suture. If I'm going to use more than two sheaths, I tend to sew a conduit on, just like you may have heard in the past with Iliac conduits for very bad Iliac occlusive disease that we used in the past, fairly commonly for Tvar, and we can actually place as many as four sheaths on one side. So again, to orient you, heads here now, feet are here. Here's an infraclavicular incision. Here's a graft, and now here's four separate sheaths, one, two, three, four, that can be placed through this axillary artery and into the aorta to be able to treat vessels. And what I do when I place multiple sheaths like this, I label them. Here, I know this is hard for you to read, but this is SMA, this is right renal, and I don't label the left renal because I know that's my third sheath. So what I tend to do is get my sheaths in place, and then once I have the sheaths in the aorta, I selectively catheterize the visceral vessels that we're looking to treat. So as an example, here's a patient with a very short neck, pararenal abdominal aortic aneurysm, very calcified neck. I have a pigtail catheter coming from ephemeral, and then an axillary sheath times two that I'm ready to cannulate the renal arteries. You can see these renal arteries are very good for chimney evar. They're directed down, they're not very calcified, and they have a decent size orifice. What we then do is place our balloon expandable stents within the renal arteries, but don't deploy them. We just get them in place, make sure we can track them there, and once we have them in place, then we put our aortic endograft in, and I'll show you what that looks like. So here is a stent ready to be deployed in the left renal artery. I have a sheath in the right renal artery. I will advance a stent here and then place the main body device. To do that, I go into a full lateral imaging so that I can see the SMA perfectly. Once the main body device is deployed, I come back to AP imaging so that I can then deploy the renal artery stents. So here is the full lateral imaging so I can see the SMA. This is, again, an off-label approach to treat a pararenal aneurysm. Here are the markers of the proximal portion of the device. The proximal fixation will be up here, and then once I get this deployed, I come back into AP to deploy the renal stents. So it gives you a sense when you're then going to scan these people and you're looking at the proximal fixation, everything starts at the SMA and then comes down from there. I balloon all three of these together once it's deployed, and that's what this looks like. So, again, SMA would be here. Here's a renal stent. Here's a renal stent. Here's an aortic endograph that looks like a standard aortic endograph for you, and then all three are being ballooned simultaneously. Really, the goal here is to try to minimize or eliminate that risk of a gutter leak. And then I deflate the main body balloon first before I deplete the renal balloons so that those renal stents remain patent. Here's a completion angiogram in the operating room with a very good technical result with patent renal artery stents, a patent SMA. And no evidence of an endo leak. This is what it looks like just in a description so you can see everything in a static image. And then at one month with a CT, and then five-year CT scan imaging, you can see an aneurysm that was just about five centimeters that now is down to minimum residual aneurysm sac left after having a parallel graft approach for aneurysms. In between the first post-op CT scan and the five-year scan, I do duplex imaging, and Marissa's going to explain that to you a little bit more in a few minutes. We use fusion imaging a lot in the operating room, and to show you what that looks like, this is a 78-year-old woman who had an expanding pararenal aneurysm. It had grown to six centimeters. She has renal dysfunction with a baseline GFR that's low, and she had very challenging iliac access as well as tortuosity of the aortic neck. You can see what that looks like on a reconstructed CT scan, and you can see why this is such a challenging aneurysm to treat. So what we do is use something called SIDAR, which allows us to cannulate these vessels in a much more rapid fashion. So here you can see fusion imaging, and then dots around the important visceral vessels, celiac, SMA, right renal, left renal. And you can see we've cannulated the right renal here, and then we use this to cannulate all the visceral vessels. In fact, we've gotten comfortable enough using this that we can usually catheterize the renal arteries without giving any dye at all and know exactly where we are, which is good, especially in a patient like this with renal dysfunction. And here you can just see a different image of what that looks like. Here's celiac here, SMA here, left renal here, and right renal that has a wire in it, a sheath that's closed, and we'll get ready to place a stent. So for us, when we use this fusion mapping interoperatively, it allows us to really simplify an overall complex procedure. We can use this for CHIVAR, we can use this for fenestrated repair, we can use it for thoracodermal repair. It's a really great tool. It reduces our contrast use, and it reduces the radiation exposure we get as the implanting physicians. All right. This is what this looks like. And, Marissa, I think you're going to take over, so I will give you the ability to advance your slides. Okay. Thank you, Dr. Milner. That was actually really helpful for me as a sonographer just to hear you go over that again. Most branch stent graft devices will have a similar appearance to standard stents for us as sonographers, which is actually really great because we're used to scanning renal artery stents, SMA stents, celiac stents. They appear the same when a CHIVAR is performed as the standard stent does. The hardest part, I will say, when evaluating a CHIVAR, or as sometimes we refer to them as snorkel stents, will be identifying that proximal area that Dr. Milner had talked about where the, for example, renal artery stents go up into that proximal portion by the proximal fixation because that's where you're going to see those, what he talked about as gutter leaks. And so for us as sonographers, you're going to have a lot of device going on at that level. And with that, you sometimes have shadowing from the actual metal from the device. That's going to make that area technically difficult for us to visualize. I would say that the best way to visualize this area, as with any endograft, when you're searching for an endoleak, is to look in transverse. You can see these stents kind of hanging into the aorta. And then I think my next slide, I can actually show you by grayscale what they look like. I'm having a hard time advancing the slide. Marissa, I can advance it for you, no problem. So here you can see two grayscale images, one of a snorkel stent in the left renal artery and one within the right. And in the image on the left, you can see that stent kind of is hanging into the proximal aorta. And that's what we're typically going to see. So identifying this area with color and searching for any leak just a little distal to this is going to identify those typical gutter leaks you may see at this area. And then on the other slide here, you can see the bright wall. It looks, again, very typical to a standard stent. You can advance to the next slide, Dr. Milner. After we kind of get past that difficult area approximately where there may be shadowing and it's difficult to identify, it's pretty much smooth sailing in business as usual for us as sonographers. We're going to look through the stented area of the artery, whether it's in the renal arteries or a visceral artery. We're going to evaluate for flow, hemodynamic changes, stenosis, any changes in color or waveform pattern. So we evaluate these after we kind of look at that complicated area, just as you would any other artery or any other stented artery. You can advance to the next slide. Sometimes, as we all know, as sonographers, it is quite challenging to visualize any arteries in the abdomen. So looking at these complicated aortic repairs, we might not always be able to see, and Dr. Milner can probably attest to this when I go to him and say, I gave it the old college try. I really did try my hardest. My arm is killing me. I cannot see these snorkel stents. And he's always very gracious and says, that's OK. How did the kidneys look? So if we cannot see that proximal portion of the renal artery or the artery that is stented, especially the renals, you need to move on and look distally. If you can see the distal portion of those arteries entering the kidney, great. Document that. Document the renal vein flow. If you can see the intrarenal flow, that is very vital because that will let Dr. Milner know that while we can't see that stented, snorkel stent in the renal artery, the kidney is being perfused. You're going to want to take good color picture of cortical and medullary flow, and you're going to want to calculate or document the resistive index. Again, this will allow the surgeon to track any changes in resistive indices over time. If we usually scan these every six months and they're seeing a big change in the resistive index that was once normal and now is abnormal, that might guide him to do alternate imaging. Next slide, please. Things can get pretty complicated, as Dr. Milner described, so I always like to, if things are very complicated, do a sonographer drawing. I do it not only for myself to kind of organize my thoughts on paper, I do it to help the surgeon identify any areas of concern that I may find on my ultrasound, and I also do it for my fellow sonographers that I work with that might be coming in six months down the road to re-scan what I have scanned. This is a drawing I made on a really complicated repair. The patient actually had a triple A that they repaired, as well as a subsequent right common iliac artery aneurysm, and the complicated part wasn't all that. It was that he had a right pelvic kidney and the right renal artery was actually coming off of the left common iliac artery, so he had some unusual anatomical variance going on. So, after I kind of wrapped my head around that, you can go to the next slide, Dr. Milner, I was able to move on and just document the flow through that snorkel stent, through that right renal artery that was feeding the pelvic kidney, and again, I'm always just looking for the same thing. I'm looking for any areas of stenosis, any narrowing, any problems with waveform pattern, anything that I would in a normal vessel that I'm evaluating. So, it's okay to get confused and you got to kind of wrap your head around things, that's okay. Once you do, you just move along, business as usual. Next slide. And this is just documenting and showing, I was able to see with this particular patient the end of the snorkel stent. A lot of times we aren't able to discern where that stent ends and where, you know, the distal renal artery is in comparison to where the stent ends. That's often challenging because these vessels are deep and very small, you might not be able to see them by grayscale. I was able to see that on this patient, I was able to see the renal artery past the stent leading into the hilum of the kidney, and so because it was a pelvic kidney, it actually helped me because as we all know, pelvic kidneys are much easier to visualize and the renal arteries that feed them than a normal anatomical position in a regular kidney. Awesome, thank you Marissa and thanks for, you know, as you said, all your hard work and the physical demands it takes to look at some of these patients. So, it's greatly appreciated and I know I don't make your life easy at times with trying to evaluate these patients, but I do always appreciate the times when you come and talk to me or ask me and say, hey, what does this look like, is this right or not? So, I think it is really a collaborative approach when we do this in terms of the surveillance afterwards, and for me, a lot of what I'm looking for is what you described. I'm really looking, if possible, to see if there's velocity changes within the parallel graphs because if a stented renal artery starts to have velocity changes, I get concerned about the durability of that stent and would go back and try to do a balloon angioplasty or whatever's necessary, put a new stent in, reline the stent if necessary. So, I'm going to transition to fenestrated repair. So, fenestrated repair is another option that we use for a complex neck anatomy. It is FDA approved. There's only one device in the United States that's available. It's made by Cook. All patients can be treated with a transfemoral approach with this. The way it's designed is the on-label approach with this device is a four millimeter neck. So, what does that mean? It means you have, from the renal arteries to the start of the aneurysm, at least four millimeters. How does that compare to standard EVAR? Well, for many of the devices, it's 10 millimeters. For some of the devices, it's 15 millimeters. So, this is a pretty significant difference. Again, we can treat more complex anatomy. It is, though, limited by anatomy because they can only design a device that has three fenestrations. Typically, that's a combination of either a scallop, it's called, which is just looks like a horseshoe, basically, a large fenestration and two small fenestrations. And you can only do three total. So, it has limitations in terms of the anatomic applicability patients have. And as I mentioned earlier, it used to be one month for waiting for devices. It's now up to six to eight weeks at times just because of the demand, the shipping, everything that's involved with all aspects of any products, as you know, that we need to deal with post-pandemic. So, the nice part about fenestrated, it really doesn't have a gutter leak. It doesn't have the risk of stroke. And the device interactions are known, but it is a larger profile device and not everybody can have one. And we can't make one for everybody because sometimes the anatomy just isn't amenable to it. So, how do I decide what to do? Well, clearly, I look at the patient risk in anatomy, as I mentioned to you earlier. If it's a more urgent procedure, I can't wait for a fenestrated device to be made. And if it's a younger patient, and then sometimes I start saying open repair anyway, but I go through that decision making in terms of what's going to be best. So, to give you an example, here's a 65-year-old man, has an expanding aneurysm. I had a long discussion with this patient, like I do with all these patients, about the options for care. Open surgery, a chimney EVAR approach, I showed you endo anchors earlier, or fenestrated EVAR. And go carefully through each of the risks of renal failure, stroke, endo leak, need for further interventions, need for surveillance, the whole thing. So, this is the guy, this patient decided on fenestrated repair. He thought it was the best option of what I described to him. So, what does that look like? So, here's what his CT scan imaging looks like ahead of time. Here's his SMA, renal arteries, they're pretty good size renal arteries, a short neck aneurysm with a large AAA, and you'll see fairly healthy iliac arteries. So, someone who's a good candidate for a fenestrated repair. And there you can see the caliber of the iliac arteries, not too tortuous, not too much calcium. And here's just a reconstructed image of this, and you can see, I'm going to stop this here, hopefully, hang on one second, sorry. You can see SMA, renal, and really not a place to land a standard device that would require 10 or 15 millimeters of proximal landing zone. So, here's what these devices look like, and I know this is a little bit hard to see, but I'll try to show it to you all. Here's a pigtail catheter, here's the fenestrated device, there are six markers right here, one, two, three, one, two, three, which help us align up the device in an anterior-posterior direction, so that we know exactly when we turn the device what things look like. This is the proximal portion of the device here, this will be the SMA fenestration, here's one renal, here's the other renal. You'll be able to see that better when the device is open. So, now the device is open, here's the top part of the device, and there's markers up here, here's the fenestration for the left renal, this is going to be the fenestration for the right renal over here, and in this case we used an SMA scallop, not an SMA fenestration. You can see with sheets and wires, we're able to cannulate through the fenestration and into the renal artery. The downside of this approach, sometimes you get this device open and then you can't get into one of the important vessels, and that can be a really significant problem and can lead to loss of a kidney. Here you now see the right renal artery's been cannulated, and here's the right renal fenestration. So, when you're looking at the top part of these devices, it's different than looking at parallel graphs. These stents are going through the device, it's the same concept because the fixation is up at the level of the SMA, but now stents are going through the device rather than sitting next to the device. Here's the completion angiogram in the operating room, you can see a nicely placed bifurcated device, there's no evidence of an endoleak, here's your patent renal stents, you'll see that again in a second, and then through this SMA scallop, you will see excellent flow into the superior mesenteric artery, which is here with all its branches. This patient did well, only stayed in the hospital for a day, which is, as I mentioned, a huge difference compared to open surgical repair, which was one of the main reasons he did not want open surgery, he's a fairly young active patient and didn't want to be down for so long. Here's a post-op CT scan, you see widely patent visceral vessels, widely patent renal stents, no evidence of an endoleak. So for short neck anatomy, clearly there's many options that exist. I try to choose what is best for my patient, looking at everything anatomically. For FEVAR and this patient, this worked very well, and I do use all the options as I said, but FEVAR is an excellent choice. We can get very creative with what we do with these proximal repairs, which in my mind is creative, and Marissa's mind means more confusion and more hard work, but she'll talk about that a little bit more. So I ever do this though at the expense of a patient. So here's a patient of ours that we had previously done a TEVAR, had complex abdominal aortic anatomy, is a relatively young patient, so we fixed the remainder of his aneurysmal disease with open surgery. Here you can see our proximal anastomosis, here's the distal anastomosis, bypass to the visceral vessels, to the left kidney, and the bypass to the right kidney is underneath. But we also use more complex endovascular repairs as well. Here's a publication of ours from a little over a year ago, looking at fenestrated endovascular repair with the chimney graft. So I'd like to call this FEVARCH, is a name that I've made for this, it's fenestrated with the chimney. So what does this look like? Here's a good example. Here is chimney graft that's going to go into the left renal, chimney graft that's going to go into the right renal, and then I've cannulated the SMA so I can prepare to bring a fenestrated device up and we're going to treat the SMA through the fenestrated device. So here's what that looks like. Here's a fenestrated device in place, this patient is a big gentleman, so it's a little bit hard to see the imaging. Here is the fenestration for the SMA, and you can see my wire and catheter through the SMA. Oh, sorry about that, I have no idea why that just happened. Can you, Marissa, you'll have to answer since you have voices. Is this back to the image I was on and you can see the regular screen? Yes, it is. Perfect, thank you. Sorry about that everybody. Here's now looking at this as an AP view, so you can see the parallel graphs in both of the renals ready to be deployed, so we can preserve all that renal flow but still treat this complex aneurysm. And here you can see what that looks like. So Marissa, I am going to turn this back over to you and I will advance the slides for you, my friend. All right, thank you. So with fevars, like chivars, they appear very similar to us on ultrasound, so that kind of takes the guesswork out of it all. The only difference, pretty much in my opinion, when I'm scanning a fevar versus a chivar is the gutter leak that I have to look for with the chivar is no longer there because now these graphs are just kind of placed right about it up to the device itself in the aorta. So I kind of can wipe my brow and say, phew, I don't have to worry about that, but I do still need to evaluate the flow through these graphs. You can advance to the next slide. Oh, I'm sorry, you can stay on this slide, but I wanted to say alternate imaging is really important and helpful to us as sonographers because this allows us to see, A, where the fenestrated graphs were placed and what vessels they're in. Operative reports are really important as well. Talking to Dr. Milner, saying, hey, where are these graphs? What vessels did you treat? Then I know exactly what vessels I should be looking for that have been treated. So always look up your operative reports. Always look up alternate CT imaging. If there's any recons or just standard images like this one, they're very, very, very helpful to us going into these scans. And like earlier, once I know it's there, I'm going to identify and document these, the fevars just like I would a chivar. I'm going to get good color images. On this patient in particular, I wasn't able to see the bright walled kind of stunt graph material, but you know what? As long as I get an image for Dr. Milner that's going to show great color flow, no narrowing, no aliasing, my velocities are going to be cohesive, they're not going to be very high, then he's going to be okay with it. If I just can't say, hey, here's my grayscale image. So you're going to document flow just like you do with anything else, looking for any stenosis or flow abnormalities. Sorry, Marissa. So this is just a reconstructed image of what it looks like from a CT. So exactly as what Marissa is describing to you, you can see flow through all these vessels, these parallel graphs behind, and this gives you an idea of what that looks like for that given patient. So I'll show you, we get pretty complicated with what we do. So we sometimes call these sandwiches, there's different ways people call them, but we get very sophisticated with these approaches. Now this type of work gets a little bit hard to deal with with ultrasound, and a lot of these just need to be followed with CT scan, but you can see here graphs going into SMA, graphs going into celiac, a device here, a device here, there's a lot going on. And you can see this is what something like that looks like. Now sometimes what we'll do is have our vascular lab take a look at the abdominal portion of this, but you can see how complex this can get. So what does it look like? And here's some of the drawings we provide. So here's a device where there's stents coming from below into the renals, stents from above into the visceral vessels, another one where there's just stents above, another one where there's just a stent in the SMA and one stent in the renal, and another where we've done the same type of thing where there's stents below and then stents from above. So we use all kinds of different approaches to deal with the complex anatomy, but this is in general what that looks like. And lastly, a common repair that Dr. Miller didn't mention in today's talk, but that we see a lot of in our lab, is a bifurcated iliac limb. And I had some great images to kind of show exactly what this is and how we kind of approach it, because with patients who have aortic aneurysm, a lot of times will also have subsequent iliac aneurysm, and they will treat both of those with kind of one device with an extended limb. So the images you see here, we can see the CTA reconstruction of the device within the aorta, and then you can see that there is device in the left iliac, and then what you see is a bifurcated limb into the right common iliac with a distal fixation in the right external iliac, and into the internal iliac. Next slide, please. So again, we want to measure the iliac artery aneurysm sac just like we would the aortic aneurysm sac in transverse and in AP view, and make sure that we're getting accurate, good transverse images showing any increase in diameter or shrinkage of the sac. In the next two images, we're going to put our Doppler waveforms within the sac just like we would a normal AAA sac, and we're going to look for any trace flow, any small endo leaks within that iliac artery aneurysm sac. So this area does appear similar to what we see in a normal endograft, it's just now in the iliac artery. Next slide, please. And what this looks like is we basically have to document the extended limb that goes into the external iliac artery, which you can see in these pictures here. You have a grayscale image and a color image of the limb that's extending into the external, and then the next two pictures show the other limb extending into the internal iliac limb. So what we do here, instead of having one distal fixation site to document as we would in a typical EVAR repair, we now have two when they repair with a bifurcated limb. So we're going to have to look at both fixation sites, the one in the external iliac artery and also the one in the internal iliac artery, and also the respective outflow vessels. Marissa, before I go to the next slide, I just want to add one thing. One other part of this, which can be fairly complex as you guys do the surveillance for these, is sometimes when we treat patients with the iliac branch devices, we also are treating an internal iliac artery aneurysm and land that branch fairly distal in the internal. And so we also like seeing, you know, making sure there's not flow into that internal iliac aneurysm sac, which can be pretty complicated for you guys to look at sometimes. Yes, because the internal iliac artery, after that very proximal segment, definitely dives into the pelvis and can be quite difficult to image by ultrasound. All right, so I'm going to take back over again. Clearly, when we look at all these complex repairs, we really try to stay simple if we can, but if we need to be more complex, we will. And our goal is we really try to maximize our seal zone. One of the things that I have learned in my experience with GVAR is we try never to put more than two parallel grafts going one direction, which is good for Marissa and her team to know, but it's not always consistently that way. And just like she said, that's why the drawings and that nice stenographer drawing that she did is really valuable, because it's not just that day that that person's getting imaged by you, but the next time they come in by one of your colleagues, when that type of drawing is there, it's really, really helpful to know what things look like. Obviously, I showed you we get pretty creative with what we do with this complex anatomy, and I want to reinforce again how critical I think it is that you really want to choose what is best for each patient. And I really critically look at each patient, look at their risk, look at their anatomy, and then make a decision what I think is best. And on the duplex ultrasound important points and conclusions, you want to remember the goal of scanning a straightforward EVAR first. This will help you stay on track for more complex repairs like Dr. Milner has talked about and performs. We want to observe and document first and foremost the presence of any endoleak in the aneurysm sacs. We want to make sure that we're measuring appropriately the AP and transverse view. We want to document any decrease in sac size, which we should see over time. And any increase in sac size does often correlate with a leak. So if you aren't seeing a leak, but you are seeing a big jump in the size of your aneurysm sac from six months prior or a year prior, you're probably going to want to reposition the patient in lateral decubitus, scan the aneurysm sac that way, maybe grab a colleague to come in and say, hey, I'm having a big jump in my diameters from the last time. I'm not seeing a leak. Can you maybe check? Maybe I'm missing one. You're going to always want to check the hemodynamics throughout the graft itself and make sure that the native inflow and outflow vessels are void of any stenosis. Next slide. You know, hang on Marissa, I just want to make one point before you go on from this. So the point that Marissa made about the increasing sac size over time, even if you're not able to document an endoleak, I think this is really critical and I take this very seriously. And when Marissa or one of her colleagues comes to me and says, look, I can't see perfectly at the top or I don't see an obvious endoleak, but I clearly see the sac and I clearly see a change in size. I will look to understand what's going on there. If it means I'd get a CTA, whatever I need to do, but I think that's a really critical point. So thank you for stressing that Marissa. No problem. And last conclusion points I want to say is communicating with the referring surgeon is so vital for us as sonographers to adequately, A, understand and B, perform our jobs. The more we communicate with them and kind of pick their brains on what they did, what type of repair they did, ask them the questions, the more we will know about what they did and what exactly we, we should be looking for as sonographers and what they are looking for information-wise for us to give to them. I always say, take a step-by-step approach when you're scanning complex aortic repairs. Step one, one of my best friends always says, remain calm. You know, Dr. Milner does some wild stuff and I used to, as a baby tech, get really freaked out by it and kind of have like mini panic attacks before I went in, but luckily he's a nice guy and he's really cool to talk to and he can kind of talk me off the ledge and let me know what he did. So step one, always remain calm and step two as a sonographer when you're scanning anything complicated is to have a systematic plan of action. There's nothing worse than, as we all know, the daunting feeling of having a complex case and the dread that follows. So if you have a plan of action and you evaluate one thing at a time and you keep your, it allows you to keep your thoughts and images organized. Step two, you want to always evaluate your AAA EVAR for flow or EVAR flow and also most importantly, check for endo leaks. Evaluate any concurrent iliac artery aneurysm repairs. So if they did a bifurcated graph like I talked about earlier, you're gonna want to evaluate the AAA and then also act like that iliac artery aneurysm and SAC is something completely separate because you can oftentimes maybe have no leak in the AAA but have a leak in that iliac artery aneurysm SAC. So we can't just not evaluate both as their own entity almost. Evaluate any branched stent graphs, any chivars or fevars. Once you evaluate your endograft in the aorta, then move on to those branched stent graphs. I wouldn't suggest bopping around and trying to do it all at once. Do one thing at a time. Always get a second set of eyes if visualization or identification is difficult. We all know as sonographers how hard our jobs can be and especially when we're scanning in the abdomen, it can be really, really difficult. Especially when you're trying to find endo leaks. In these images to the right, you can see some can be very small and very hard to identify and then others like the picture on the bottom can be very easily seen. So always get a second set of eyes. Your co-workers are your biggest help in a lab and anytime I have a question or I can't see anything, I'm gonna get a second opinion or a third opinion. And lastly, scan, scan, scan. The more complex aortic repairs you scan, the more comfortable you will become scanning them just like anything else. I will tell you when I first started scanning Dr. Milner's snorkel stents, I would walk into his clinic with my head hung low and just say, oh your snorkel stents are killing me. He can literally tell you I said this to him probably every Monday in his clinic. But he can also attest that I have not said that in quite some time. And that's because over time, like anything else in our occupation, the more you scan it, the more comfortable you get and it just becomes a little easier when you've seen more. So thank you very much. I hope that we kind of shed some valuable insight and information on complex aortic repairs. Thank you Dr. Milner and Marissa.

abdominal aortic repair

complex aortic diseases

repair techniques

vascular technologist

endovascular grafts

open surgery

fenestrated repair

chimney repair

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