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Iliac artery deformation during EVAR

Journal article
Authors Giasemi Koutouzi
M. Pfister
K. Breininger
Mikael Hellström
H. Roos
Mårten Falkenberg
Published in Vascular
Volume 27
Issue 5
Pages 511-517
ISSN 1708-5381
Publication year 2019
Published at Institute of Clinical Sciences, Department of Radiology
Pages 511-517
Language en
Keywords Iliac artery, anatomy deformation, endovascular aortic repair, cone beam CT, image fusion, endovascular aneurysm repair, aortic-aneurysms, image fusion, fluoroscopy, radiation, accuracy, guidance, exposure, system, Cardiovascular System & Cardiology
Subject categories Vascular surgery, Cardiovascular medicine


Objectives To quantify the deformation of the common iliac artery caused by stiff guide wires and delivery systems during abdominal endovascular aortic repair (EVAR). Methods Twenty-two patients treated with abdominal EVAR were included. The following three image data-sets were acquired for each patient: (1) a preoperative computed tomography angiography (CTA), (2) an intraoperative contrast-enhanced cone beam CT (CBCT) obtained after the main trunk of the bifurcated stent graft was released and both iliac limbs were engaged with stiff guide wires, and (3) the first postoperative CTA. These data-sets were merged and compared in an image analysis work station. The length and the tortuosity index of the common iliac artery, the Euclidian displacement of the aortic and the iliac bifurcations, and the optimal C-arm angulation for projection of the iliac bifurcation were computed. Results The common iliac artery was on average 6.4 mm shorter (p < 0.001) and tortuosity index was lower (p = 0.003) in the intraoperative images compared to preoperative. Some of the foreshortening was reversed postoperatively, remaining mean length difference was 2.9 mm (p = 0.007) compared to preoperative. Intraoperatively, the aortic bifurcation was mostly displaced in a cranial direction (100%) and the iliac bifurcation in a ventral direction (93%). The optimal lateral C-arm angulation for projection of the iliac bifurcation changed. Anterior contralateral angle increased from median 42 degrees (IQR, 27-63) in the preoperative CTA to 62 (49-74) in the intraoperative CBCT (p = 0.02). Optimal cranio-caudal angulation did not change. Conclusion Stiff guide wires and delivery systems cause significant deformation of the common iliac arteries during EVAR. The aortic bifurcation is more cranial, the common iliac arteries are shorter, and optimal C-arm angulation is more contralateral oblique when the iliac limbs are to be deployed compared to baseline measurements from preoperative CTA. This affects image fusion accuracy and stent graft selection.

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