Abdominal Aortic Aneurysm Repair Procedures - PowerPoint Presentation

1. Abdominal Aortic Aneurysm Repair ProceduresOpen AAA and EVAR

2. Indications for AAA RepairIncrease in size to 1.5 normal size or > 5 cm for women > 5.5 cm for menIncrease in size of 0.5 to 1 cm in 6 – 1 year of a monitored AAAAneurysms typically found incidentally when screening for other health conditions, generally asymptomatic

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5. Normal Aorta Aorta with Aneurysm www.ahajournals.org/doi/10.1161/01.CIR.0000154569.08857.7AAbdominal Aortic Aneurysm

6. Ruptured AAAPresence of abdominal or back pain means a patient is symptomatic, but does not necessarily mean the aneurysm has rupturedContained rupture is not the same as a ruptured AAA Must be evidence of extravasation on pre-procedure imaging or evidence of rupture on arrival to the operating roomhttps://www.mdedge.com/cardiology/article/55882/cardiothoracic/no-survival-benefit-seen-evar-over-open-surgery-ruptured-aaa

7. Open AAA

8. Open AAA RepairMajor surgeryLonger length of stayICU post procedureLonger recoverylarge incision through peritoneum or retro peritoneumPotential ischemic clamp times for visceral vessels/kidneysDefinitive fix, especially for patients with long life ahead

9. Procedure details: Open AAAhttp://surgery.med.umich.edu/vascular/patient/pdf/IAAsurgical.pdf

10. Procedure details: Open AAADistal Anastomosis = Common Iliac (Bifurcated Graft)http://surgery.med.umich.edu/vascular/patient/pdf/CIAsurgical.pdf

11. Procedure details: Open AAAClamp Positions: Infrarenal and Bilateral Iliacshttps://vascular.org/file/968

12. Procedure details: Open AAASupraceliac clamp: ischemictime for all visceral vesselsClamp above both renals: ischemic time for bothkidneysIMA at completion: with graft in place, the vessel isligated, reimplanted,or was occluded.

13. Procedure Details: Open AAAExposure:Trans-peritoneal (trans-abdominal) – enters through the peritoneumMidline incisionPatient positioned supineGreater incidence of ileus due to manipulation of bowelhttps://www.slideshare.net/AnushaDsza/abdominal-incisions-83117914

14. Procedure Details: Open AAAExposure:Retroperitoneal – enters behind the peritoneum“Sloppy lateral” positioning Avoids manipulationof abdominalcontentsRelieves pressure forpatients withsevere lung issueshttps://www.sciencedirect.com/science/article/pii/S0741521499700662

15. Procedure Details: Open AAACold Renal Perfusion:To preserve kidney function in the event of suprarenal clamping of the aorta, cold saline is infused via balloon tipped irrigation catheters into the renal artery orifices from within the opened aneurysm. a bolus to achieve instant hypothermia is instilled, followed by an infusion until the restoration of renal blood flow.

16. Procedure Details: Open AAARenal Status:Patent/no intervention – often in infra-renal repairsChronically occluded – patients with heavy thrombus burden or prior renal stenosisDe-branch/Bypass – additional surgery to create inflow for renal vessels

17. Open AAA Repair OutcomesPeri-operative cardiac events related to cross clamping the aortaTransfusionAnesthesia related complicationsRespiratory failureInfectionIschemia related to clamp timesRenal failureBowel ischemia

18. OAAA Case Review

19. Open AAA Qualifying CriteriaOpen infrarenal, juxtarenal, and suprarenal AAA repairRuptured AAA.Even if the patient expires after the primary incision was madeAn EVAR that was converted to an OAAA during the same OR timeEnter both EVAR and OAAA procedures

20. OAAA Procedures that Do Not QualifyAn open aneurysm repair in the thoracic abdominal aortaAn OAAA with the indication of aortic stenosis or pseudoaneurysm repairPatch on anastomosis

21. Case Review #159 YO M to ED with abd pn and h/o PVDCT findings. 7.5cm juxtarenal abdominal aortic aneurysm, bilateral iliac aneurysms, and significant occlusive disease bilateral CFA to SFA. No films for comparison.Admitted to hospital and taken to ORProcedure.Thoracoabdominal flank incision madeAortobifemoral graft implantedBilateral CFA and SFA endarterectomyBovine pericardium patch angioplasty

22. Case Review #1 – Q1What is the Procedure Type?A. Open AAAB. Open Bypass

23. Case Review #159 YO M to ED with abd pn and h/o PVDCT findings. 7.5cm juxtarenal abdominal aortic aneurysm, bilateral iliac aneurysms, and significant occlusive disease bilateral CFA to SFA. No films for comparison.Admitted to hospital and taken to ORProcedure.Thoracoabdominal flank incision madeAortobifemoral graft implantedBilateral CFA and SFA endarterectomyBovine pericardium patch angioplasty

24. Case Review #1 – Q1What is the Procedure Type?A. Open AAA  Even though patient had significant occlusive disease, the indications of AAA and bil iliac aneurysms make this case an OAAA.B. Open Bypass

25. Case Review #1 – Q2The juxtarenal aneurysm size is 7.5cm. No films to compare the aneurysm size. Do you enter the Indication of Rapidly Increasing Aneurysm Diameter?YesNo

26. Case Review #1 – Q2The juxtarenal aneurysm size is 7.5cm. No films to compare the aneurysm size. Do you enter the Indication of Rapidly Increasing Aneurysm Diameter?YesNo  Indicate if there has been an increase in aneurysm diameter by 0.5 cm within 6 months to one year as determined by CTA. There were no comparison films for this case. No way to determine if aneurysm size was rapidly increasing.

27. Case Review #1 – Q3Do you enter the Indication of Rapidly Increasing Aneurysm Diameter if the surgeon documents “Patient with rapidly increasing aneurysm size”?YesNo

28. Case Review #1 – Q3Do we enter the Indication of Rapidly Increasing Aneurysm Diameter if the surgeon documents “Patient with rapidly increasing aneurysm size”?YesNo  Without the documentation of the two sizes of the aneurysm we cannot tell if the aneurysm is increasing in size according to BMC2 definition, “Indicate if there has been an increase in aneurysm diameter by 0.5 cm within 6 months to one year as determined by CTA.”

29. Case Review #2Procedure. OAAAPatient with 80% stenosis of right renal arteryRight renal artery is patentClamps are placed Above right renal artery Below left renal arteryClamps on at 1100 am. Clamps removed at 1158 am.Renal Ischemic time is not documented by any staff.No interventions done to either renal artery.

30. Case Review #2 – Q1What do you enter for Renal Status?A. Patent, No InterventionB. Purposely OccludedC. Accessory Renal Artery CoveredD. Not Documented

31. Case Review #2Procedure. OAAAPatient with 80% stenosis of right renal arteryRight renal artery is patentClamps are placed Above right renal artery Below left renal arteryClamps on at 1100 am. Clamps removed at 1158 am.Renal Ischemic time is not documented by any staff.No interventions done to either renal artery.

32. Case Review #2 – Q1What do you enter for Renal Status?A. Patent, No Intervention  No surgery or intervention was performed on the renal arteries. Even though the right renal artery has 80% stenosis, it is still patent. B. Purposely OccludedC. Accessory Renal Artery CoveredD. Not Documented

33. Case Review #2 – Q2What do you enter for Proximal Clamp Position?A. InfrarenalB. Above 1 renalC. Above both renalsD. Clamp not utilized

34. Case Review #2Procedure. OAAAPatient with 80% stenosis of right renal arteryRight renal artery is patentClamps are placed Above right renal artery Below left renal arteryClamps on at 1100 am. Clamps removed at 1158 am.Renal Ischemic time is not documented by any staff.No interventions done to either renal artery.

35. Case Review #2 – Q2What do you enter for Proximal Clamp Position?A. InfrarenalB. Above 1 renal  Indicate the position of the proximal clamp during the repair C. Above both renalsD. Clamp not utilized

36. Case Review #2 – Q3Clamps on at 1100 am. Clamps removed at 1158 am.Renal Ischemic time is not documented by any staff.What is the Renal/Visceral Ischemic Time?A. 0 minutesB. Not documentedC. 58 minutesD. Clamp not utilized

37. Case Review #2 – Q3Clamps on at 1100 am. Clamps removed at 1158 am.Renal Ischemic time is not documented by any staff.What is the Renal/Visceral Ischemic Time?A. 0 minutesB. Not documentedC. 58 minutes  If Ischemic Time is not documented, enter the difference between the clamp on time and the clamp removed time.D. Clamp not utilized

38. Case Review #369 YO F at physician officePulsatile abdomen palpated by physician. Patient denies N/V/pn and dizziness.Patient sent to hospitalCT findings. 73mm AAAOAAA performed 2 days laterWhat is the Indication for this procedure?A. Rapidly Increasing Aneurysm DiameterB. Abdominal / Back PainC. AsymptomaticD. Both B and C

39. Case Review #369 YO F at physician officePulsatile abdomen palpated by physician. Patient denies N/V/pn and dizzinessPatient sent to hospitalCT findings. 73mm AAAOAAA performed 2 days laterWhat is the Indication for this procedure?A. Rapidly Increasing Aneurysm DiameterB. Abdominal / Back PainC. Asymptomatic  Even though the patient had a pulsatile abdomen and a OAAA was performed, the patient did not have any symptoms.D. Both B and C

40. Case Review #4 – Q171 YO M to ED with lower abd pn and groin pnCT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No qualifying abdominal aortic aneurysm. (AAA size 3.8cm).Admitted to hospital and taken to ORProcedure.Thoracoabdominal flank incision madeAortobifemoral graft implantedIs this case a qualifying Open AAA?A. YesB. No

41. Case Review #4 – Q1 71 YO M to ED with lower abd pn and groin pnCT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No qualifying abdominal aortic aneurysm. (AAA size 3.8cm).Admitted to hospital and taken to ORProcedure.Thoracoabdominal flank incision madeAortobifemoral graft implantedIs this case a qualifying Open AAA?A. Yes  Even though the pt did not have a AAA that is big enough to qualify for a repair, the Indication of bilateral iliac aneurysm repair makes this case an OAAA.B. No

42. Case Review #4 – Q2What is the Indication for this OAAA?Abdominal / Back PainSize of Iliac AneurysmRapidly Increasing Aneurysm DiameterBoth A and B

43. Case Review #4 – Q2What is the Indication for this OAAA?Abdominal / Back PainSize of Iliac AneurysmRapidly Increasing Aneurysm DiameterBoth A and B  Size of Iliac Aneurysm should be entered as an Indication for OAAA that is performed for iliac aneurysm repair but does not have a AAA that is big enough to qualify for a repair. (The patient also c/o back pain upon arrival to the ED).

44. Case Review #4 – Q3CT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No qualifying abdominal aortic aneurysm. (AAA size 3.8cm).What do you enter for Maximum AAA Diameter (mm)?A. 30mmB. 31mmC. 0 mmD. Not Documented

45. Case Review #4 – Q3CT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No qualifying abdominal aortic aneurysm. (AAA size 3.8cm).What do you enter for Maximum AAA Diameter (mm)?A. 30mmB. 31mmC. 0 mmD. Not Documented  For AAA repair performed due to iliac aneurysm size only, (No qualifying AAA), Enter Not Documented.

46. Case Review #4 – Q4CT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No qualifying abdominal aortic aneurysm. (AAA size 3.8cm).For Iliac Aneurysm you will enter Yes and Bilateral.What size will you enter (in mm) for Iliac Aneurysm?A. 0mmB. 30mmC. 31mmD. 61mm

47. Case Review #4 – Q4CT findings. Bilateral iliac aneurysms. Left aneurysm 3.0cm. Right aneurysm 3.1cm. No abdominal aortic aneurysm.For Iliac Aneurysm you will enter Yes and Bilateral.What size will you enter (in mm) for Iliac Aneurysm?A. 0mmB. 30mmC. 31mm  Enter the maximum diameter (in mm) of the iliac aneurysm.D. 61mm

48. EVAR: Endovascular Abdominal Aneurysm Repair

49. EVAR (Endovascular Repair)Goal: prevent aneurysm enlargement and rupture Performed since 1991 in Europe, FDA approved in 1999in USShorter hospital stayMinimally invasiveNo ischemic timesLifelong imaging surveillance (CT yearly)Potential for endoleaks, aneurysm expansion, andmigration of graft

50. EVAR (Endovascular Repair)

51. Procedure details: EVARInfrarenal Neck Diameter and Infrarenal Neck Length:Measurements determined by pre-operative CT to determine if the patient is an appropriate candidate for an EVAR An infrarenal neck length of 15 mm is generally a safesealing zone for endografts.Shorter infrarenal neck lengths cause increased incidence of type I endoleaks, graft migration, or thrombosis of renal arteries.May be on an EVAR plan sheet or on CT report

52. EVAR Graftshttps://www.goremedical.com/products/excluderhttp://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=DAE346275258568C64F8BAAB810A8959?doi=10.1.1.505.9539&rep=rep1&type=pdfAorto-bi-iliac graft configuration:Main body + Iliac limbs (may also require limb extensions)Requires:Graft body diameterLeft limb distal seal zone diameterRight limb distal seal zone diameter

53. EVAR GraftsNellix Endovascular System - InvestigationalUsed in the US onlyUses polymer to fill the aneurysm sac after the graft has been placed to Prevent aneurysm growthPrevent device migrationPrevent endoleak

54. EVAR: Fenestrated GraftsFenestrated grafts are custom made for each patient as determined by a 3D CT scanAimed to incorporate one (or several) vital visceral/renal vessels in the seal of the graftFlow to these vessels is preserved through holes, or fenestrations, in the stent graftGold markers assist with positioning over the pertinent arteries while the graft is not fully deployed

55. EVAR: Fenestrated GraftsProximal body graft with scallop and fenestration

56. EVAR: Fenestrated Grafts

57. EVAR: Fenestrated GraftsThe fenestrated main body grafts are made in two pieces to allow ease of maneuverability to align the fenestrations with the arteries.

58. EVAR: Fenestrated Grafts

59. EVAR: Fenestrated GraftsNote: Gold MarkersCompletion angio: 3 vessel fenestration

60. Procedure Details: EVARDistal Seal Zone Diameter definition: Enter the diameter of the most distal portion of iliac treated with any covered stent such as iliac limbs, iliac extensions, contralateral limbs, ipsilateral limbs and bridge devices. Please note: a bridging device is essentially a flared iliac limb.

61. Bridging Device vs Iliac bridge deviceA bridging device is a device that hooks graft components together. For example,A bridging device may be implanted between the main body and a limb extension An iliac bridge endoprosthesis is a device component that looks like a miniature main body. It covers both the external iliac artery and internal iliac artery.

62. Distal Seal Zone DiameterTo find distal seal zone diameter:Read physician narrative in procedure note to determine the name and placement of each device componentGo to intra op nursing > Implants > to find manufacturer name and catalog numberDo internet search “Manufacturer name” catalog numbersSearch manufacturer catalog for catalog numberFind distal seal zone diameter

63. Distal Seal Zone DiameterTo find distal seal zone diameter:Read physician narrative in procedure note to determine the name and placement of each device componentExample:Gore Excluder main body 26x14x14 implanted just below the renal arteriesGore Extender 23x12 implanted in the RT CFAContralateral Limb 14x14 implanted in the LT CFA

64. Distal Seal Zone DiameterTo find distal seal zone diameter:Go to intra op nursing > Implants > to find manufacturer name, catalog number, and confirm placement of each device componentExample:

65. Distal Seal Zone DiameterTo find distal seal zone diameter: Do internet search “Manufacturer name” catalog numbersNote: Will have manufacturer device catalogs on home page of new BMC2 website end of April 2021

66. Distal Seal Zone DiameterTo find distal seal zone diameter:Search manufacturer catalog for catalog numberLocate distal seal zone diameter

67. Distal Seal Zone Diameter Review

68. Distal Seal Zone DiameterMain body EVAR endograft inserted through left groin. Endograft positioned below the level of the renals. Angiogram confirmed position of the renals. The 26 millimeter Gore C3 main body was deployed down to the level of the bifurcation. A 10x27 limb extension was inserted on the patient's right side.Going back to the patient’s left, a 16 millimeter x 27 millimeter x 120 millimeter bridging component was implanted. Next, the Gore IBE 23 millimeter x 14.5 millimeter device was implanted in the left iliac artery and deployed.The 14.5 millimeter internal iliac component was pulled through the IBE and implanted in the left hypogastric. The remainder of the iliac branch device was deployed into the external iliac and confirmed that this had a good position.

69. Distal Seal Zone DiameterMain body EVAR endograft positioned below the level of the renals. The 26 millimeter Gore C3 main body was deployed down to the level of the bifurcation.

70. Question #1What is the Main Body Diameter?

71. Question #1What is the Main Body Diameter?A: 26B: 14.5C: Not DocumentedD: Graft Not Utilized

72. Distal Seal Zone DiameterA 10x27 limb extension was inserted on the patient's right side.

73. Question #2What is the Right Distal Seal Zone Diameter?

74. Question #2What is the Right Distal Seal Zone?A: 26B: 10C: 27D: Not DocumentedA 10x27 limb extension was inserted on the patient's right side

75. Distal Seal Zone DiameterGoing back to the patient’s left, a 16 millimeter x 27 millimeter x 120 millimeter bridging component was implanted.

76. Question #3What is the Left Distal Seal Zone Diameter?

77. Question #3What is the Left Distal Seal Zone?A: 26B: 10C: 27D: Not DocumentedGoing back to the patient’s left, a 16 millimeter x 27 millimeter x 120 millimeter bridging component was implanted.

78. Distal Seal Zone DiameterNext, the Gore IBE 23 millimeter x 14.5 millimeter device was implanted in the left iliac artery and deployed.

79. Question #4What is the Left Distal External Iliac Diameter?

80. Question #4What is the Left Distal External Iliac Diameter?A: 14.5B: 26C: 10D: Not DocumentedNext, the Gore IBE 23 millimeter x 14.5 millimeter device was implanted in the left iliac artery and deployed.

81. Distal Seal Zone DiameterThe 14.5 millimeter internal iliac component was pulled through the IBE and implanted in the left hypogastric. The remainder of the iliac branch device was deployed in the external iliac and confirmed that this had a good position.

82. Question #5What is the Left Distal Hypogastric Diameter?

83. Question #5What is the Left Distal Hypogastric Diameter?A: 10B: 14.5C: 26D: Not DocumentedThe 14.5 millimeter internal iliac component was pulled through the IBE and implanted in the left hypogastric.

84. EVAR: Artery OcclusionInadvertent occlusion of arteries:Renals: if untreated can result in renal ischemia, renal failure, and/or a lifetime of hemodialysisMesenteric: if untreated can result in ischemic bowel which is usually fatalHypogastrics: if untreated can result in buttock claudication and necrosis, lower extremity neurologic deficits, ischemic colitis, and impotence Hypogastric arteries are sometimes reimplanted in the external iliac artery

85. Procedure Details: EVARRenal Status:Patent: no interventionChronically occluded: renal artery occluded prior to theprocedurePurposefully occluded: renal artery purposefully coveredduring the procedureDe-branch/bypass: additional procedure to preserve inflowto renal vessels

86. Procedure Details: EVARStent Only: renal stent placed to maintain renal artery patencyChimney: Placement of a stent that maintains renal arterypatency where the graft occludes the origin of the renal(s) Fenestrated/scallop: hole or orifice in the graft to maintain renalor visceral vessel patencySide branch from graft: custom made grafts with branches offthe main body to maintain patencyAccessory Renal Artery Covered: Multiple arteries to thekidney are present and one or more is covered by the graft

87. Chimney/SnorkelA peripheral stent, typically balloon expandable covered, are placed into the branch vessel(s) before full deployment of the aortic endograft. The branch vessel stent is then deployed alongside the endograft (parallel) position between the inside of the aortic wall and the outside of the endograft. The desired result is adequate endograft seal with antegrade target vessel flow from a more proximal point.

88. Chimney/SnorkelPotential for “gutters” with the chimney/snorkel technique:The use of chimney grafts creates “gutters” where the two grafts coming together do not fully approximate to the aorta wall and can allow for an endoleak and aneurysm expansionChimney StentChimney StentGutter

89. Aneurysm after repair

90. EVAR: Graft Body MigrationMovement of the graft body can occlude adjacent blood vessels or fenestrations can shift/corresponding stents can be compromised

91. EVAR: EndoleaksEndoleaks: continued flow of blood into the aneurysm sac which can be immediate or throughout the life of the patientType I: occurs at proximal or distal attachment site, usually found during procedure, fixed with reinflating balloon at the seal, or inserting a cuff to provide adequate sealType II: continued blood flow into the aneurysmal sac from retrograde patent branch vessels, such as lumbars or mesenteric vessels. may resolve spontaneously, found on post procedure CT, repair required if aneurysm sac continues to expand

92. EVAR: EndoleaksType III: due to graft defects, such as a hole or tear, or structural failures causing separation between the components, or inadequate overlap, requires another stent graft to stop the flow of blood into the aneurysm sacIndeterminate: unable to determine cause of aneurysm expansion

93. EVAR Qualifying CriteriaEndovascular AAA repair An EVAR that was converted to an OAAA during the same OR timeAbstract 2 procedures: EVAR and OAAAA qualifying EVAR where the sheath was inserted; even if the wire or device did not cross the index lesionEVAR Revision: Collect if a new main body was implanted

94. EVARs that Do Not QualifyAn endovascular aneurysm repair in the thoracic abdominal aorta An EVAR that is done for the indication ofChronic iliac occlusive diseaseAortic stenosisPseudoaneurysm repairA qualifying EVAR where the sheath was unable to be insertedAn endovascular device other than a main body was used

95. Case #1 ReviewEndovascular aortic graft placement AFX bifurcated device usedIndication = Aortoiliac occlusive disease

96. Case #1 ReviewQ: Does this procedure qualify as an EVAR?A: Yes B: No

97. Case #1 ReviewQ: What procedure type is this case?A: Open AAAB: Open BypassC: PVID: CEA

98. Case #1 ReviewQ: What procedure type is this case?A: Open AAAB: Open BypassC: PVI  Indication of Aortoiliac occlusive diseaseD: CEA

99. Case #2 ReviewPre-op diagnosis: Infrarenal aortic infection, s/p EVAROperation Performed:Midline laparotomy with lysis of adhesions.Removal of infrarenal aortic endograft.Placement of a 13 mm aortic homograft.Proximal anastomosis is infrarenal, distal anastomosis is external iliac arteries.Placement of antibiotic beads.Wide debridement of the retroperitoneal tissue to remove the infection.

100. Case #2 ReviewQ: Does this procedure qualify as an EVAR?A: Yes B: No

101. Case #2 ReviewQ: What procedure type is this case?A: Open AAAB: Open BypassC: PVID: CEA

102. Case #2 ReviewQ: What procedure type is this case?A: Open AAA  s/p EVAR, Midline laparotomy B: Open BypassC: PVID: CEA

103. Case #3 ReviewIndication = RT iliac artery aneurysm, increasing in sizeDetails of operation:Lower midline abdominal incision madeRT EIA clamped, then aorta clampedRT iliac aneurysm opened, thrombus removed14 mm Dacron graft placed and sewed end-to-end to very proximal common iliac arteryDistal anastomosis is external iliac artery

104. Case #3 ReviewQ: Does this procedure qualify as an EVAR?A: Yes B: No

105. Case #3 ReviewQ: What procedure type is this case?A: Open AAAB: Open BypassC: PVID: CEA

106. Case #3 ReviewQ: What procedure type is this case?A: Open AAAB: Open Bypass  Repair of iliac aneurysm, Lower midline abdominal incision madeC: PVID: CEA

107. ReferencesCriado, F.J. (2012, June). EVAR 2012: Indications, Devices, and Techniques. Vascular Disease Management, 9(6). [Online image]. Retrieved from https://www.vasculardiseasemanagement.com/content/evar-2012-indications-devices-and-techniquesCriado, F.J. (2013, August). The EVAR Landscape in 2013: Noteworthy Developments in the AAA Field. Vascular Disease Management, 10(8). [Online image]. Retrieved from https://images.app.goo.gl/KzpMTjpgAMyGnLm68Dsouza, P.A. (2017, December 1). Abdominal Incisions. [Slide presentation]. Retrieved December 5, 2019 from SlideShare: https://www.slideshare.net/AnushaDsza/abdominal-incisions-83117914Endologix provides update on the Nellix sealing system US regulatory status. (2017, May 18). Retrieved from https://vascularnews.com/endologix-provides-update-on-the-nellix-sealing-system-us-regulatory-status/Endovascular repair of complex aortic aneurysms. (2014, October 23). Retrieved from https://www.mayoclinic.org/medical-professionals/cardiovascular-diseases/news/endovascular-repair-of-complex-aortic-aneurysms/mac-20429867

108. ReferencesGhouri, M., and Krajcer, Z. (2010). Endoluminal Abdominal Aortic Aneurysm Repair. Texas Heart Institute Journal, 37(1), 19-24. Ginter, J.F., and Linzmeyer, J. (2009, July). Abdominal aortic aneurysm repair: Matching patients with approaches. Journal of the American Academy of Physician Assistants, 22(7), 28-30. doi: 10.1097/01720610-200907000-00007GORE Excluder AAA Endoprosthesis. Retrieved from https://www.goremedical.com/products/excluderGupta, A., and Bersin, R.M. (2007). Endovascular Repair of Abdominal Aortic Aneurysms. (Fig. 1). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=DAE346275258568C64F8BAAB810A8959?doi=10.1.1.505.9539&rep=rep1&type=pdfIsselbacher, E.M. (2005, February 15). Thoracic and Abdominal Aortic Aneurysms. AHA Journals, 111(6). [Figure 11]. https://www.ahajournals.org/doi/10.1161/01.CIR.0000154569.08857.7A

109. ReferencesKartashow, D. (2009, October 6). AAA EVAR COOK. [video file]. Retrieved from https://www.youtube.com/watch?v=tFW9UNicucgKassem, T.W. (2017, September). Follow Up CT angiography post EVAR: Endoleaks detection, classification and management planning. The Egyptian Journal of Radiology and Nuclear Medicine, 48(3), 621-626. [Fig. 1.]. Retrieved from https://www.sciencedirect.com/science/article/pii/S0378603X17300700#f0005Kirby, L.B., Rosenthal, D., Atkins, C.P., Brown, G.A., Matsuura, J.H., Clark, M.D., and Pallos, L. (1999, September). Comparison between the transabdominal and retroperitoneal approaches for aortic reconstruction in patients at high risk. Journal of Vascular Surgery, 30(3), 400-406. [Fig. 1]. Retrieved from https://www.sciencedirect.com/science/article/pii/S0741521499700662?via%3Dihub#aep-figure-id16Lee, W.A. (March 2011). Treating Short and Angulated Necks. Endovascular Today. Retrieved from https://evtoday.com/articles/2011-mar/treating-short-and-angulated-necksLesney, M.S. (2012, September 5). No Survival Benefit Seen for EVAR Over Open Surgery for Ruptured AAA. Retrieved from https://www.mdedge.com/cardiology/article/55882/cardiothoracic/no-survival-benefit-seen-evar-over-open-surgery-ruptured-aaa

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114. Please proceed to the Open Revascularization Procedures slides