Greer, SC
Best answers
Procedure list in detail:
1. Endovascular repair of abdominal aortic aneurysm and bilateral common iliac artery aneurysms with aortobiiliac endograft, 34705
2. Transcatheter delivery of enhanced fixation devices x6 to the aortic main body of the graft for dilated reverse conical neck, 34712
3. Placement of left external iliac bare-metal stent for stenosis 37236 ? 37221 OR 34709
4. Percutaneous access and closure of large vessel access devices bilateral femoral arteries +34713-50
5. Intravascular ultrasound of the aorta, noncoronary initial vessel +37252
6. Intravascular ultrasound of the bilateral iliac arteries, noncoronary additional vessel, +37253
7. Ultrasound-guided puncture of the bilateral femoral arteries

Duplex ultrasound was performed the bilateral femoral arteries. Both arteries were patent. The left common femoral artery is mildly aneurysmal. Utilizing real-time ultrasound imaging micropuncture technique was performed and microwire's were placed followed by 5 French micro sheath. Wires were upsized to a 035 wires. 7 French sheaths were placed.

Preclose technique was then performed of the bilateral femoral arteries by placing Pro-glide devices at the 11 and 1 o'clock position. 2 devices were placed in each femoral artery. These were subsequently used to close the large vessel access, 18 French right and 14 French left. This was done at completion of the endovascular stent procedure.

Lunderquist wire was introduced to the right femoral approach and a Bentson wire was introduced in the left femoral approach. Pigtail catheter was placed up the left side into the suprarenal aorta. Intravascular ultrasound was then introduced to the right femoral approach. Intravascular ultrasound was then performed of the aorta and right common iliac artery for proper sizing and complete evaluation of complex aneurysmal change in the right common iliac artery with focal dissection. IVUS images are recorded and measurements made.

Intravascular ultrasound was performed the left common iliac artery. IVUS images are recorded and measurements made.

Based on preoperative measurements and IVUS images a 28 mm main body Endurant 2 device was selected. The device was introduced over the Lunderquist wire through the right femoral approach. Spot magnification views with parallax adjustment were made with contrast injection to locate the lowest right renal artery. Based on imaging the main body device was deployed without difficulty. The contralateral left limb was completely deployed. Pigtail catheter was recaptured with a Glidewire. Angled catheter was then used to capture the ipsilateral limb. Intragraft position was confirmed with span of a pigtail catheter. Retrograde injection was then performed through the left femoral sheath for measurements. Based on those measurements the left limb was selected. Left limb was extended into the external iliac artery to treat the left common iliac artery aneurysm. The left internal iliac artery had previously been embolized at a separate procedure. The limb was deployed on target approximately 2 cm into the left external iliac artery.

The main body and ipsilateral limb were then completely deployed. The delivery platform was recaptured and removed from the patient and replaced with a 16 French sheath. Pigtail catheter was reintroduced and measurements made for the ipsilateral limb. A flared 20 mm limb was selected to address right common iliac artery aneurysm. IVUS was again repeated for precise location and measurement and deployment of this limb to address a focal dissection within the right common iliac artery. The 20 mm flared limb was deployed on target.

Reliant balloon angioplasty was then introduced through both femoral sheaths and angioplasty of all attachment sites graft artery and graft graft performed. Initial completion angiogram was performed. This demonstrated no evidence of type I endoleak and no significant type II endoleak. Main by the graft and the bilateral limbs were deployed on target based on the angiogram. Intravascular ultrasound was repeated to evaluate the left limb. Based on IVUS images the left external iliac limb was not at recommended diameter at its termination. Therefore left external iliac stent angioplasty was performed with a bare-metal balloon mounted 8 mm stent. This was deployed at the termination of the stent graft and into the native external iliac artery. The stent expanded fully and intravascular ultrasound demonstrated desired result.

Due to patient's relatively young age as well as a reverse conical relatively short infrarenal neck enhanced fixation was indicated. The APTUS stapling device and sheath were introduced to the right femoral approach. A total of 6 Endo staples were deployed into the main body of the graft just below the renal arteries in a clockwise distribution around the graft. All of the enhanced fixation staples appear to be in excellent position. Completion arteriogram was performed of the main body which showed no evidence of endoleak or malposition of the Endo staples.

The femoral sheaths were subsequently removed and the Pro-glide devices free deployed used to close the large device access in the both femoral arteries. Hemostasis was excellent. A single Monocryl was placed at the puncture sites. Patient Toller procedure well.
“Based on IVUS images the left external iliac limb was not at recommended diameter at its termination. Therefore left external iliac stent angioplasty was performed with a bare-metal balloon mounted 8 mm stent.” — this is included within 34705. Stent was only deployed to open the endograft, per guidelines all stenting and angioplasty within the treatment zone are included in 34705. I hope this helps!