EVAR (Endovascular Aortic Repair) - Cathlab Step-by-Step

Pre-Procedure Setup

• Hybrid OR or cathlab with high-quality fluoroscopy/DSA capability
• C-arm or fixed overhead biplane imaging
• Iodinated contrast and power injector
• Intravascular ultrasound (IVUS) if available
• Compatible stent-graft system per pre-op CT planning (main body + iliac limbs)

• Supine on radiolucent table
• Both groins + entire abdomen prepped and draped
• Anesthesia: general, regional (epidural/spinal), or local + sedation

• Micro-puncture introducer set (Cook 4Fr MPIS-401)
• 9Fr sheath for initial ipsilateral access; 6Fr for contralateral
• 18-24Fr large sheath (ipsilateral, main body delivery)
• 12-17Fr sheath (contralateral limb)
• Stiff guidewires (Lunderquist or equivalent)
• Pigtail catheter (flush/angiography)
• Steerable catheters (Cobra, SOS-Omni, Bernstein) for contralateral gate cannulation
• Heparin, protamine
• Balloon catheters (molding balloons, occlusion balloons if needed)

Step-by-Step Procedure

Step 1 - Vascular Access

1. Bilateral common femoral artery (CFA) access - via surgical cutdown (standard) or percutaneous (PEVAR)
2. If percutaneous: deploy Proglide/Perclose sutures using the "preclose technique" BEFORE inserting large sheaths - place 2 sutures at 10 o'clock and 2 at 2 o'clock positions
3. Initial arteriotomy - blunt dissection to expose CFA; arteriotomy or Seldinger puncture
4. Insert 9Fr sheath bilaterally with starter guidewires advanced under fluoroscopy

Step 2 - Systemic Anticoagulation

• Administer IV heparin targeting ACT ≥ 300 seconds
• Check ACT every 30 minutes; maintain throughout until femoral repair complete

Step 3 - Baseline Angiography

1. Advance a pigtail catheter (via one femoral sheath) to the suprarenal aorta
2. Perform aortogram - AP and lateral views
   • Identify the lowest renal arteries (usually at L1-L2)
   • Visualize the aortic neck, aneurysm sac, iliac anatomy
   • Mark the renal artery ostia and aortic bifurcation on fluoroscopy
3. Measure: proximal neck length/diameter, iliac landing zone, total aneurysm length
4. Cross-reference with pre-op CT (CTA) measurements for device sizing

Step 4 - Stiff Guidewire Placement

1. Exchange starter wires for stiff guidewires (Lunderquist or Amplatz Super Stiff) bilaterally
2. Ipsilateral side (main body delivery side - usually right): wire advanced to descending thoracic aorta
3. Contralateral side: wire to distal aorta/ipsilateral iliac temporarily

Step 5 - Large Sheath Insertion (Ipsilateral)

1. Sequentially dilate the ipsilateral femoral access with fascial dilators
2. Insert the 18-24Fr delivery sheath (per device IFU) over the stiff wire into the abdominal aorta
3. Sheath tip should sit in the mid-aorta above the aneurysm neck

Step 6 - Main Body (Trunk) Delivery and Deployment

1. Flush the main body delivery system with heparinized saline to remove air
2. Advance the main body endograft through the large sheath over the stiff wire under continuous fluoroscopy
3. Position the proximal end just below the lowest renal artery - typically 10-15mm of proximal neck needed for seal
4. Confirm position with repeat angiogram or road-map fluoroscopy
5. Rotate the device to orient the contralateral limb gate anteriorly/toward the contralateral groin (use radiopaque markers at the crown/bifurcation)
6. Perform a final confirmatory angiogram before deployment
7. Deploy the main body per manufacturer technique (pull-back deployment for most systems)
   • The constrained stent-graft opens and anchors against the aortic wall with radial force
   • Suprarenal fixation barbs engage above renal arteries (device-specific)
8. Contralateral limb gate is now open and visible under fluoroscopy

Step 7 - Contralateral Limb Gate Cannulation

1. From the contralateral femoral access, use a steerable catheter (Cobra, SOS-Omni, Bernstein) + maneuverable guidewire (angled Glidewire)
2. Under fluoroscopy, identify the gate using radiopaque markers
3. Retrograde approach (standard): angle catheter up into the gate from below
4. Alternative antegrade/crossover approach: advance catheter from ipsilateral side across the bifurcation and into the contralateral gate
5. Confirm wire position is inside the gate, not in the aneurysm sac - use lateral and oblique views, or IVUS
6. Advance catheter through the gate into the main body lumen
7. Exchange for a stiff guidewire to the thoracic aorta

Step 8 - Contralateral Limb Sheath and Deployment

1. Insert a 12-17Fr sheath over the stiff guidewire on the contralateral side
2. Select the contralateral iliac limb extension of appropriate length and diameter (per CTA/intraop measurements)
3. Advance contralateral limb device into the gate - minimum 2-3cm overlap with main body
4. Confirm position under fluoroscopy using markers
5. Deploy the contralateral iliac limb - open fully into the landing zone in the external iliac/CFA

Step 9 - Ipsilateral Iliac Limb Deployment

1. Deploy the ipsilateral iliac limb extension (if modular) similarly from the ipsilateral sheath
2. Again confirm adequate overlap and landing zone position
3. Ensure limb extends to healthy, non-aneurysmal iliac artery

Step 10 - Balloon Molding (Post-Dilation)

1. Use a compliant molding balloon (sized to the aortic and iliac diameters)
2. Inflate within the proximal neck to ensure full wall apposition and seal
3. Balloon the overlap zones between modules to prevent separation
4. Balloon the distal iliac landing zones bilaterally
5. Do NOT over-balloon - risk of rupture or trauma

Step 11 - Completion Angiogram

1. Advance a pigtail catheter to the suprarenal aorta
2. Perform completion DSA aortogram in AP and lateral projections
3. Confirm:
   • Bilateral renal arteries patent and unobstructed
   • Internal iliac arteries (hypogastric) patent bilaterally
   • No endoleak (contrast filling the aneurysm sac outside the stent-graft)
   • Graft limbs widely patent, no kinking or stenosis
   • Adequate proximal and distal seal
4. If Type I endoleak (proximal or distal seal failure): balloon again, consider extension cuffs
5. If Type II endoleak (retrograde from lumbar/IMA): monitor, often resolves spontaneously
6. If Type III endoleak (modular junction): re-balloon overlap zones or add bridging extension

Step 12 - Sheath Removal and Hemostasis

1. Remove all sheaths sequentially over wires, then remove wires
2. Percutaneous closure: tie down preloaded Proglide sutures; confirm hemostasis
3. Surgical cutdown closure: arteriotomy repaired with running 5-0 or 6-0 Prolene suture; wound closed in layers
4. Check distal pulses bilaterally (dorsalis pedis, posterior tibial) before leaving the lab
5. Reverse heparin with protamine (1mg per 100 units heparin given) if needed
6. Final sterile dressing applied to bilateral groin access sites

Post-Procedure Monitoring

Key Fluoroscopic Landmarks

Endoleak Classification (Quick Reference)