Target vessel displacement during fenestrated and branched endovascular aortic repair and its implications for the role of traditional computed tomography angiography roadmaps

Abstract

Background: This retrospective study quantifies target vessel displacement during fenestrated and branched endovascular aneurysm repair due to the introduction of stiff guidewires and stent graft delivery systems. The effect that intraoperative vessel displacement has on the usability of computed tomography angiography (CTA) roadmaps is also addressed.Methods: Patients that underwent fenestrated or branched EVAR were included in this retrospective study.Two imaging datasets were collected from each patient: (I) preoperative CTA and (II) intraoperative contrastenhanced cone beam computed tomography (ceCBCT) acquired after the insertion of the stiff guidewire and stent graft delivery system. After image registration, the 3D coordinates of the ostium of the celiac artery, superior mesenteric artery, right renal artery and left renal artery were recorded in both the CTA and the ceCBCT dataset by two observers. The three-dimensional displacement of the ostia of the target vessels was calculated by subtracting the coordinates of CTA and ceCBCT from one another. Additionally, the tortuosity index and the maximum angulation of the aorta were calculated.Results: In total 20 patients and 77 target vessels were included in this study. The ostium of the celiac, superior mesenteric, right renal and left renal artery underwent non-uniform three-dimensional displacement with mean absolute displacement of 8.2, 7.7, 8.2 and 6.2 mm, respectively. The average displacement of all different target vessels together was 7.8 mm. A moderate correlation between vessel displacement and the maximum angulation of the aortoiliac segment was found (Spearman's ρ=0.45, P<0.05). Conclusions:The introduction of stiff endovascular devices during fenestrated or branched EVAR causes significant, non-uniform displacement of the ostium of the visceral and renal target vessels. Consequently, preoperative CTA roadmaps based on bone registration are suboptimal to guide target vessel catheterization during these procedures.

Automated image fusion during endovascular aneurysm repair: a feasibility and accuracy study

“…The aforementioned authors also highlighted the benefits of automated image fusion, removing the cumbersome user interactions, and the possibility of standardization of the registration steps and a faster and smoother workflow for the physician. The fusion of a preoperative modality such as CTA with live procedural fluoroscopy images is inherently sensitive for numerous sources of error as also described in several reports [21][22][23][24][25][26]. First, vascular deformation occurs in the aorta and iliac arteries after insertion of stiff guidewires and stent grafts.…”

A State-of-the-Art Review of Intra-Operative Imaging Modalities Used to Quality Assure Endovascular Aneurysm Repair

“…They also found a strong correlation between body mass index (BMI) and the amount of radiation used by the ceCBCT. Similarly, Jansen et al [23], used pre-operative CTA and intra-operative ceCBCT. This fusion modality was able to detect an average displacement of target vessels, encompassing coeliac, SMA, and renal arteries of 7.8 mm.…”

Stellenwert der „inner Branches“ in der komplexen endovaskulären Aortenchirurgie

“…Die Präzision bei der Platzierung des fenestrierten Hauptkörpers direkt über den Ostien der Zielgefäße ist für den technischen Erfolg der FEVAR-Prozedur maßgeblich, wobei die ausgeprägte Angulation des Aneurysmahalses und der Zugangsgefäße die Positionierung zusätzlich erschweren können [12,13]. Im Vergleich bietet die iBEVAR-Plattform mehr Freiheiten bei der Platzierung des Hauptkörpers in sagittaler und axialer Ebene.…”