- Konstantinos P. Donas
- Martin Austermann
Preoperative drawing of the aneurysm’s anatomic characteristics, with a focus on access and the neck, is our standard approach in endovascular aneurysm repair (EVAR), based on the Osirix planning program. Presents a sketch based on analysis of the patient’s vascular anatomy and characteristics, which is always done by the operator.
For the planning of fenestrated endografts, a 1-mm-thick, multislice computed tomography (CT) scan and modern software with the option of centerline reconstruction are necessary. Creation and correction of the centerline with the “racing line“ enables the operator to visualize how the endograft will align in the aorta after the deployment ( Fig. 9.1 ). Using the stretched reconstruction, the distances between the visceral arteries and renal arteries can be exactly measured, and the clock position of the target vessels can be determined accurately.
The next step is the selection of a fenestrated or branched endograft. In juxtarenal aneurysms with an inner aortic diameter of 30 mm at the level of the visceral and renal arteries, a fenestrated stent-graft is preferred. The goal is to achieve contact of the device with the aortic wall at the level of the fenestrations, to reduce the risk of endoleaks.
Challenging anatomies with kinking of the aorta at the level of the fenestrations are outside the instructions for use and make the planning demanding. Imaging demonstrates whether the anatomy is suitable for fenestrated endovascular repair ( Fig. 9.2 ).
