GORE excluder modular with iliac branch endoporsthesis

mlsnow

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Marquette Heights, IL
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Curious how others are coding these modular bifurcated endografts:


PROCEDURE:
1. Abdominal aortogram.
2. Endovascular repair of the right common iliac and distal aortic
aneurysms while conserving the single remaining internal iliac artery,
using dual modular bifurcated endografts (GORE Excluder with an Iliac
Branch Endoprosthesis and an ipsilateral extender).
3. Preclose and AngioSeal closure of bilateral arteriotomies.
DATE: 8/22/2016
Physicians:
James Swischuk, MD, VIR attending
Dale Mueller, MD, Cardiovascular surgery attending
Greg Shaw, MD, VIR fellow
COMPARISON: CTA abdominal aorta with bilateral runoff 3/11/2016; aortic
ultrasound 3/4/2016
MEDICATIONS: General anesthesia.
DOSE: Fluoroscopy time 31.5 minutes; DAP 824.
CONTRAST: 120 mL of Isovue-300 intra-arterially.
CLINICAL HISTORY: 65-year-old male with history of hypercholesterolemia,
COPD, coronary artery disease, former smoker, diabetes, recently found to
have a right iliac aneurysm on ultrasound which was further characterize
on CTA.
TECHNIQUE/FINDINGS: Written informed consent was obtained from the patient
after thorough discussion of the risks, benefits, and alternatives to the
procedure. All questions from the patient himself and his family were
answered appropriately and thoroughly. The patient was then brought back
to the operating room and placed supine on the OR table. A "timeout" was
performed prior to the procedure to verify the patient's name, birthdate,
and site and type of procedure to be performed. The patient's bilateral
groins and midabdomen were prepped and draped in routine sterile fashion
utilizing maximum sterile barrier technique.
Access was achieved in bilateral common femoral arteries with 21-gauge
micropuncture kits, using manual palpation. Left-sided access angiography
was performed with the inner cannula, demonstrating appropriate position
of the left arteriotomy. Using standard Seldinger technique, a 7 French,
11 cm vascular sheath was placed over 0.035 Bentson wires on the left
side. On each side, two separate Perclose closure devices were advanced
over the wires and deployed alternating 20 degrees from midline for
attempted percutaneous preclose of the arteriotomy. The sutures of the
devices were clamped and set aside for the remainder of the procedure.
At this point, a large sheath was placed in the right access site and a
Hydrosteer wire placed through the sheath. A 18/30mm Ensnare was advanced
through the left side, and used to snare the Hydrosteer wire. The
Hydrosteer was then pulled through the left sided sheath. A Meyer wire was
then advanced from the right-sided sheath, adjacent to the Hydrosteer
wire. The Meier wire was then advanced into the abdominal aorta. Digital
subtraction angiography was performed from the right sided sheath to
delineate the right common iliac aneurysm. Over the Meier wire and
Hydrosteer wire, the Iliac Bifurcation Endoprosthesis (IBE) stent graft
measuring 23 mm (proximal diameter) x 14 mm (distal diameter) x 100 mm
(length) was advanced to the level of the right common iliac aneurysm. The
stent graft was then partially deployed within the right common iliac
aneurysm. An MPA catheter was advanced over the Hydrosteer wire from the
left side through the stent graft into the origin of the right internal
iliac artery. Using multiple obliquities and angiographies of the right
hemipelvis, we were able to cannulate the right internal iliac artery with
an MPA catheter and a Glidewire. A large sheath was advanced from the
patient's left side over the bifurcation, and through the right common
iliac graft. Through this large sheath the internal iliac graft limb
(measuring 10 mm in diameter x 70 mm in length) was advanced to the level
of the proximal right internal iliac. The internal iliac graft limb was
carefully deployed under fluoroscopic guidance. The external iliac limb
was then fully deployed. A compliant balloon was then used to dilate the
external and internal limbs, the overlaps, and the proximal portion of the
common iliac graft. A pigtail catheter was then advanced from the right
femoral access site to the suprarenal aorta, and used to perform an
abdominal aortogram. This demonstrated an unexcluded distal fusiform
aortic aneurysm and an excluded right common iliac aneurysm. No endoleak
was identified.
The main body of the EVAR device [measuring 38 mm (proximal diameter) x 12
mm (ipsilateral limb diameter) x 180 mm (length)] was then advanced from
the left side and deployed under fluoroscopic guidance to assure proper
alignment of the leading-edge radiopaque markers just below the lowest
renal artery. Using a combination of Glidewire and MPA catheter, the
right-sided gate was then selected and wire advanced into the thoracic
aorta. MPA catheter was advanced into the cephalad aspect of the stent
graft and 360 degree turn performed demonstrating free movement of the
catheter within the stent graft, thus ensuring adequate cannulation of the
gate. The Glidewire was exchanged for a 0.035 stiff wire and the
right-sided limb [measuring 23 mm (proximal diameter) x 14 mm (distal
diameter) x 100 mm (length)] was advanced to appropriate position to
bridge the gap between the main EVAR graft and the IBE graft. Angiography
through the pigtail advanced from the right side demonstrated good
position. Angiography through the left-sided sheath demonstrated a type I
endoleak, indicating that we needed more length on the left side limb. An
extension limb measuring 12 mm (diameter) x 120 mm (length) was then
placed to extend the left-sided limb to an appropriate position to provide
a better seal. A compliant balloon was again used to fully expand the
proximal and distal aspects of the respective modules.
 
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