European Radiology

, Volume 22, Issue 2, pp 387–397 | Cite as

Radiology of advanced EVAR techniques in complex abdominal aortic aneurysms

  • Uei PuaEmail author
  • Kongteng Tan


Advanced Endovascular Aortic Repair (EVAR) refers to devices and techniques used for endografting of aortic aneurysms that are considered anatomically unsuitable for conventional EVAR. Customised devices and modified use of conventional EVAR devices now overcome challenging landing zones. Fenestrated and branch devices, together with chimney and periscope techniques can be used to overcome proximal landing zone challenges, while iliac branch grafts and sandwich techniques have been used to address challenging distal iliac landing issues. Due to the novelty of these techniques, life-long surveillance is crucial, with CT Aortography (CTA) being the key investigation. Currently, the body of literature surrounding the imaging aspects of these techniques is scarce. The purpose of this imaging review is to illustrate the appearance of advanced EVAR in both routine surveillance and complicated cases, using conventional and novel CTA techniques.

Key Points

This review updates readers about advanced endovascular repair of abdominal aortic aneurysms

It illustrates the common CT appearances following advanced EVAR

Novel CTA techniques in troubleshooting problems unique to advanced EVAR are described


Aortic aneurysm Endograft Fenestrated Branch Chimney 

Supplementary material

Movie 1

Multiplanar movie loop of Fig. 10, showing left renal fenestration endoleak. (WMV 294 kb)

Movie 2

Volumetric movie loop of Fig. 11, showing right renal fenestration endoleak. (WMV 224 kb)


  1. 1.
    Chahwan S, Comerota AJ, Pigott JP, Scheuermann BW, Burrow J, Wojnarowski D (2007) Elective treatment of abdominal aortic aneurysm with endovascular or open repair: the first decade. J Vasc Surg 45:258–262, discussion 262PubMedCrossRefGoogle Scholar
  2. 2.
    EVAR trial participants (2005) Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 365:2179–2186CrossRefGoogle Scholar
  3. 3.
    Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, Buskens E, Grobbee DE, Blankensteijn JD, Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group (2004) A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 351:1607–1618PubMedCrossRefGoogle Scholar
  4. 4.
    United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ (2010) Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 362:1863–1871PubMedCrossRefGoogle Scholar
  5. 5.
    Lovegrove RE, Javid M, Magee TR, Galland RB (2008) A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm. Br J Surg 95:677–684PubMedCrossRefGoogle Scholar
  6. 6.
    Greenberg R, Fairman R, Srivastava S, Criado F, Green R (2000) Endovascular grafting in patients with short proximal necks: an analysis of short-term results. Cardiovasc Surg 8:350–354PubMedCrossRefGoogle Scholar
  7. 7.
    Green RM (2002) Patient selection for endovascular abdominal aortic aneurysm repair. J Am Coll Surg 194:S67–S73PubMedCrossRefGoogle Scholar
  8. 8.
    Verhoeven EL, Tielliu IF, Bos WT, Zeebregts CJ (2009) Present and future of branched stent grafts in thoraco-abdominal aortic aneurysm repair: a single-centre experience. Eur J Vasc Endovasc Surg 38:155–161PubMedCrossRefGoogle Scholar
  9. 9.
    Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Stelter WJ (2007) Fenestrated endografting for aortic aneurysm repair: a 7-year experience. J Endovasc Ther 14:609–618PubMedCrossRefGoogle Scholar
  10. 10.
    Mohabbat W, Greenberg RK, Mastracci TM, Cury M, Morales JP, Hernandez AV (2009) Revised duplex criteria and outcomes for renal stents and stent grafts following endovascular repair of juxtarenal and thoracoabdominal aneurysms. J Vasc Surg 49:827–837PubMedCrossRefGoogle Scholar
  11. 11.
    Bicknell CD, Cheshire NJ, Riga CV, Bourke P, Wolfe JH, Gibbs RG, Jenkins MP, Hamady M (2009) Treatment of complex aneurysmal disease with fenestrated and branched stent grafts. Eur J Vasc Endovasc Surg 37:175–181PubMedCrossRefGoogle Scholar
  12. 12.
    Kristmundsson T, Sonesson B, Malina M, Björses K, Dias N, Resch T (2009) Fenestrated endovascular repair for juxtarenal aortic pathology. J Vasc Surg 49:568–574PubMedCrossRefGoogle Scholar
  13. 13.
    Ohrlander T, Sonesson B, Ivancev K, Resch T, Dias N, Malina M (2008) The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 15:427–432PubMedCrossRefGoogle Scholar
  14. 14.
    Donas KP, Torsello G, Austermann M, Schwindt A, Troisi N, Pitoulias GA (2010) Use of abdominal chimney grafts is feasible and safe: short-term results. J Endovasc Ther 17:589–593PubMedCrossRefGoogle Scholar
  15. 15.
    Rancic Z, Pfammatter T, Lachat M, Hechelhammer L, Frauenfelder T, Veith FJ, Criado FJ, Mayer D (2010) Periscope graft to extend distal landing zone in ruptured thoracoabdominal aneurysms with short distal necks. J Vasc Surg 51:1293–1296, Epub 2010 Mar 29PubMedCrossRefGoogle Scholar
  16. 16.
    Hobo R, Sybrandy JE, Harris PL, Buth J, EUROSTAR Collaborators (2008) Endovascular repair of abdominal aortic aneurysms with concomitant iliac artery aneurysm: outcome analysis of the EUROSTAR experience. J Endovasc Ther 15:12–22PubMedCrossRefGoogle Scholar
  17. 17.
    Heyer K, Tang GL, Resnick SA, Eskandari MK (2010) Hybrid thoracoabdominal aortic aneurysm repair: visceral revascularization combined with endovascular abdominal and thoracic aneurysm repair. J Vasc Interv Radiol 21:735–737PubMedCrossRefGoogle Scholar
  18. 18.
    Pua U, Tan K, Rubin BB, Sniderman KW, Rajan DK, Oreopoulos GD, Lindsey TF (2011) Iliac branch graft in the treatment of complex aortoiliac aneurysms: early results from a North American institution. J Vasc Interv Radiol 22:542–9PubMedCrossRefGoogle Scholar
  19. 19.
    Lobato AC (2011) Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther 18:106–11PubMedCrossRefGoogle Scholar
  20. 20.
    Kolvenbach RR, Yoshida R, Pinter L, Zhu Y, Lin F (2011) Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney grafts–a technical description. Eur J Vasc Endovasc Surg 41:54–60PubMedCrossRefGoogle Scholar
  21. 21.
    Stavropoulos SW, Charagundla SR (2007) Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair. Radiology 243:641–655PubMedCrossRefGoogle Scholar
  22. 22.
    Veith FJ, Baum RA, Ohki T et al (2002) Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 35:1029–35PubMedCrossRefGoogle Scholar
  23. 23.
    Bent CL, Jaskolka JD, Lindsay TF, Tan K (2010) The use of dynamic volumetric CT angiography (DV-CTA) for the characterization of endoleaks following fenestrated endovascular aortic aneurysm repair (f-EVAR). J Vasc Surg 51:203–206PubMedCrossRefGoogle Scholar
  24. 24.
    Sun Z, Mwipatayi BP, Allen YB, Hartley DE, Lawrence-Brown MM (2009) Computed tomography virtual intravascular endoscopy in the evaluation of fenestrated stent graft repair of abdominal aortic aneurysms. ANZ J Surg 79:836–840PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2011

Authors and Affiliations

  1. 1.Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General HospitalUniversity Health NetworkTorontoCanada
  2. 2.Department of Diagnostic RadiologyTan Tock Seng HospitalSingaporeSingapore

Personalised recommendations