AAA Commentary EVAR training

AAA Dynamism


September 11, 2008

This patient presented with abdominal pain and found to have a 9.5cm AAA. CT showed a previous stent graft that had slipped its moorings from a very short neck, and had actually flipped down on itself.

The patient was a very sick man with an AICD, end stage CHF, and severe COPD on home O2, and had been turned down for a heart transplant. He relayed that surgeon who had performed the EVAR 6 years before had informed him to follow up with his primary care physician.

This patient was repaired with an AUI-Fem-Fem with plug occlusion of his left iliac. The patient recovered and was POD #6, to his home.


November 13, 2014

This was not the first patient I had like this. Pictured below is another patient with a similar scenario from my personal photo bank. It is important to understand that aneurysms are dynamic, particularly if tortuous. Many of the early generation grafts were placed with great enthusiasm in all sorts of anatomy and they come back to us. Here at the clinic, Dr. Eric Turney and others reported that from 1999 to 2012, 100 patient required EVAR explant. Overall mortality was 17%, with an elective case mortality of 9.9%, non-elective mortality of 37%, and 56% mortality for ruptures (reference). Excluding the 13% of cases that were infected, progression of aneurysm disease was identified as the cause of late (>5yr) failure. It is a major source of open aortic experience for our trainees.

Illustrated below is the mechanism for loss of primary seal when there is a great deal of anterior bowing. Technically, anchoring mechanisms in modern grafts have worked to prevent or delay this effect, but it is something to consider in tortuous anatomy.

Reference: J Vasc Surg. 2014 Apr;59(4):886-93

PAD techniques training

Popliteal Endarterectomy and Short Bypass in Lieu of Multisegment Vein Bypass

The patient is a very pleasant elderly lady who had a prior EVAR complicated by graft limb thrombosis treated with thrombectomy. She recovered from that but subsequently developed ulceration of her left ankle. She had been sleeping in a chair because it hurt her to sleep flat –her leg and foot would burn with pain. A wound care center had tried an Unna’s boot, but it caused her worse pain, and the ulcer increased in size. At admission, she had an exquisitely tender, edematous leg and ankle with a large ulcer weeping edema fluid. There were no palpable pedal level pulses.

I admitted her for workup and treatment of a mixed etiology arterial and venous ulcer.

These are patients for whom rest pain is relieved by avoiding recumbency, but with prolonged sitting, as in this lady, edema accumulates and starts to leak, creating an ulcer of the venous type, in the medial ankle (gaiter) region. These don’t resolve without addressing the underlying cause which is the arterial insufficiency. Fixing the arterial insufficiency then allows for leg elevation and compression. For the trainees, venous ulcers almost uniformly heal with Unna’s boot therapy. Elevation should relieve discomfort in venous ulcers. Neither of these occurred and raises the suspicion of arterial insufficiency.

At admission, her PVR’s showed severe popliteal/tibial level occlusive disease. CTA was performed and it showed the common femoral and superficial femoral arteries to be patent but plaque occluded the popliteal artery and origins of the tibial vessels.

The only patent runoff was via her peroneal artery. Centerline evaluation of the CT scan was performed, with manual centerline created through the occluded segment of popliteal artery. I find this useful for planning endarterectomy and bypasses, and with attention to detail, images that are the equivalent to tibial angiograms come to life. This is a centerline through the femoropopliteal to peroneal system.

Vein mapping revealed a paucity of good vein –only a short segment in the proximal thigh on the left and for a short segment on the right. Stress testing revealed that she was good to moderate risk. Isolated popliteal occlusive disease with poor tibial runoff, while feasible for intervention, is not likely to be durable. Multisegment vein bypass on the other hand, using at least three segments, meant a long operation for this frail old lady and a prolonged recovery. I felt that popliteal endarterectomy and distal SFA remote endarterectomy offered a good option for revascularization, with either a patch repair or a short bypass to the peroneal artery. The backup plan was composite vein, but it was unlikely to be needed because the plaque was not the calcium pipe type plaque that does not endarterectomize well.

The patient was positioned on the table supine. The short segment of proximal greater saphenous vein was harvested –it was of suitable caliber, but below its first major tributary point, the veins was thick walled and small. The total length was about 10 cm. The below knee popliteal space was opened and the popliteal through tibioperoneal trunk bifurcation was exposed. Antegrade puncture of the common femoral artery allowed for arteriography and it showed the occlusion at the knee with reconstitution of the peroneal artery.

The popliteal artery was opened and endarterectomy of the occlusive plaque was performed. Retrograde remote endarterectomy (EndoRE) with Vollmer rings was performed to the mid superficial femoral artery where on the CTA the calcified plaque ended. The technical point about retrograde EndoRE is that the ring catches as the plaque gets larger more proximally, and has to be swapped out for a larger ring. Ultimately a 7mm Moll Ring Cutter was used to cut the plaque (picture below, arrow to more proximal SFA plaque).

The plaque, because it is larger the more proximal you go, came out with some difficulty via the below knee popliteal artery. This is not a great concern if it won’t come out –you merely have to cut down on the SFA in the thigh to fish out the plaque. In this case, it was not necessary, and it came out in several pieces, facilitated by the cutter which was used to graft the plaque in segments to retrieve it. Unfortunately, I don’t have a picture from this case of the plaque, but I have inserted a popliteal endarterectomy plaque image below from an prior case of popliteal endarterectomy.

This restored pulsatile flow to the below knee popliteal artery. Opening the artery down to the tibioperoneal artery revealed the artery to occluded and I took the endarterectomy to the peroneal artery origin and everted a short segment of posterior tibial plaque. The peroneal artery was large and would accept flow readily, so I chose to bypass to it using the short segment of saphenous vein that I had harvested for a possible patch or short bypass. The vein was reversed and anastomosed in the usual manner. Arteriograms are below.

The flows were multiphasic. I attempted to cross the posterior tibial occlusion but ended up with contrast extravasation, therefore stopped with this repair. The patient’s wounds were closed and ulcer cleansed and compressed. In the week postop, she healed her ulcer and her two short incisions, and felt good enough to go home with homecare. Her noninvasive studies and duplex confirmed the patency of her revascularization, and there was a multiphasic signal in her posterior tibial artery as well as peroneal.

In the handful of patients I have managed this way, either with popliteal endarterectomy and patch or short (micro) bypass, they have stayed patent past a year, but do require surveillance. Because of her frailty and unsteadiness of gait, I chose not to anticoagulate with Coumadin which is my usual practice, but have her on Plavix and aspirin.

AAA CTA EVAR techniques training

Type II endoleak from IMA treated via SMA -concept of building the intervention machine


The patient had a successful EVAR or an eccentric infrarenal AAA which in followup grew due to the presence of a type II endoleak from the inferior mesenteric artery. This was seen on the CTA and duplex ultrasound. Planning for assessment and treatment involved analyzing the CTA in centerline, tracking the source of the arterial blood flow into the sac.


The centerline from the SMA into the middle colic artery shows a meandering but patent path via the Arc of Riolan to the left colic artery to the inferior mesenteric artery. In my experience this is straightforward to access selectively from the femoral approach, but it illustrates for the trainees the concept of building up access which I refer to as building the intervention machine.

The first step in the access involves getting stable footing in the SMA. Selective access can be performed with a shaped catheter, and once accessed, a Rosen wire is used to track in a curved long sheath. Parking this sheath in the proximal SMA forms the foundation of this machine. The next step is access into the middle colic artery.


The CTA is particularly helpful in identifying the middle colic on the 3DVR projection. Selection of this is straightforward with a an angle catheter which I place a Tuohy Borst connector. This is the second stage of the machine, because further access with 0.35guage wires and catheters could result in spasm. This second sheath access (the Tuohy turns the catheter into a sheath) of the middle colic allows for selective 0.18 gauge catheters and wires to make the final step to the IMA and the AAA.

Selective access of middle colic artery (left) and later phase showing IMA and endoleak (right)
6F Ansel Sheath in SMA, Angled Glide Catheter into Arc of Riolan, 0.18 Glidewire and catheter in IMA
NBCA glue used to seal endoleak and IMA

The embolization with NBCA sealed the IMA and the cavity in the AAA sac. This was checked with intraoperative duplex, done with a transabdominal aortic probe.

Before embolization


Transabdominal aortic duplex is easier on sleeping patient and potentially gives more information than arteriography alone.  The patient in followup had no endoleak and demonstrated sac shrinkage.

The access machine concept is important for planning interventions. Every major branch or turn needs to be crossed by your ultimate access sheath, if you want to avoid having to arduously reaccess those points, and building up a telescoping layer of sheaths is very handy. Every interventional case is done at some distance away from the access point on the skin, and so some though has to be given to how you will build that machine.

With this example, I have shown that you can readily access the AAA sac from the SMA. An earlier article showed iliofemoral access via the hypogastric artery (link). I will give in an upcoming post how this can be done laparoscopically in under 20 minutes.


4 Questions for Trainees Before An Operation.

  1. What are the indications for surgery?
  2. What kind of operation are you planning with what approach?
  3. If different (open, endovascular, or hybrid) approach is preferred by you, please briefly elaborate. If not, explain why?
  4. What are the anticipated risks, recovery, and followup?

I started having my trainees (yes, you) email me answers to these questions for an upcoming case and it has been working pretty well. This starts a conversation. This exercise gives the trainee time to think about their plan, do some reading, ask questions, and anticipate outcomes so that an unexpected one would be rare. It also gives me a record of a meaningful interaction so that later assessments don’t devolve into flash judgment, gut feeling, first impressions, or recall of latest misdemeanors.

Not infrequently, I have trainees whose opinions differ from mine, but they base their arguments on solid evidence and clinical findings specific to the patient and not just the general topic. They express a nuanced understanding of that particular case and bring in fresh perspectives from their diverse backgrounds and education. I think to myself how honored I am to have such hard working, brilliant minds to teach; I make sure to tell them how absolutely wrong they are.

CTA imaging PAD techniques training

Intuition Aquarius (TeraRecon) Trick -Applying Virtual Reality to Operative Planning

I have used many different flavors of image post processing software including Osiris, Vitrea, and now Aquarius, aka TeraRecon. But I notice that outside of endovascular planning, people rarely use the virtual 3D reconstructed images (the pretty pictures) for anything other than posting images for publication in JVS, and even there I think we have reached saturation.

I have found 3D reconstruction to be especially useful for open surgical planning, and that is by doing two things. First, on viewing the 3DVR data, I reorient and center on the surgeon’s perspective, using left button to rotate the picture around the zero at the center of the screen, and the right mouse button to grab the whole image and recenter as necessary.

Window Leveling.001
Surgeon’s eye OR view

I then window-level in tissue density -this is done by pressing both the right and left mouse buttons, but you can choose this off the menu.

Window Leveling.002

I can plan the incisions and exposures from any angle -in this case, I can see the saphenous vein and its relative proximity to the CFA to perform an in site bypass to the AK POP. And I see the loci of the tributaries that I may need to ligate.

Window Leveling.004

This is a powerful tool that is often overlooked.

EVAR TEVAR training

autoFestschrift for Dr. Matthew Eagleton

Dr. Matthew Eagleton, picture from the internet

It’s Dr. Eagleton’s birthday. So in celebration, I recommend you read his authored or co-authored papers from this year. Link to MJE 2014 papers.



A Vascular Surgery Fellowship Personal Statement

photo mw
Max at work

By Max Wohlauer, MD, fellow in vascular surgery at Cleveland Clinic Foundation

As a rugby player in high school and college, I found strength and camaraderie through hard work, blood, and sweat. Like rugby, vascular surgery is a team sport, and not for the faint of heart.

My father was diagnosed with stage IV prostate cancer while I was a first year medical student. I was his cheerleader and coach as he fought against the illness that eventually took his life, and learned that healing becomes the most important when a cure is out of reach. At this point I had established that continuity of care was important to me, but I was not satisfied with the role of cheerleader or coach, however. I was intent on being captain – a team leader in the center of the action – and surgery called to me. Where could I find a specialty that combined traditional surgery and cutting edge procedures to provide optimal patient care, while at the same time maintain the ability to care for patients with a chronic disease over time?

Dr. Ben Starnes at the University of Washington, who combined an explosive technical skill with a genuine concern for each patient’s well being provided a definitive answer. I learned that open arterial or endovascular repair could immediately and consistently improve quality of life.  The patient could have a body worn-out by seven or eight decades of systemic illness with a life or limb threatening lesion, or at the other end of the scale, have a youthful body facing similar threats from blunt or penetrating trauma. The results were equally inspiring to me. In clinic and on the wards, Dr. Starnes made a connection with each of the patients, celebrating their unique lives and personalities. He set an example inside and out of the operating room, which I strive to emulate to this day.

At the University of Colorado, Dr. Mark Nehler created an environment for success and has shown me how a vascular surgeon displays leadership outside of the operating room. He stepped into Dr. Rutherford’s large shoes to build the department, launch the careers of several young vascular surgeons, and has made several important contributions to vascular literature. He has given me myriad opportunities for growth inside and outside the operating room. I have learned from Dr. Nehler more about the importance of interpersonal relationships between myself and my colleagues as well as with my patients. These teachings have made me a better surgeon.

Then, working with Dr. Ernest Moore as a Trauma Research Fellow, I was inspired by a man committed to science, surgical practice, training the next generation of academic surgeons, and administration; a bona fide quadruple-threat. His accomplishments and mentoring ability are equally phenomenal. He is a role model that I strive to emulate.

It would be selfish to have the advantage of excellent training without contributing new information. During my two laboratory years, I had the opportunity to explore post-injury coagulation derangements, which I continue to study while on the clinical services. I have also traveled to many conferences to present research throughout the US and in Europe.  I continue to write, publish and present during my clinical years, and feel that this is only the beginning. I know that I have a genuine ability to become a leader in the field of vascular surgery.


Thank you for consideration of my application.