HERE IS THE NOTE:
The patient has a long history
of severe peripheral vascular occlusive disease with multiple stents
being placed on both sides in the past. At operation, retrograde
angiography was done first, showing the presence of severe right
external iliac origin stenosis along with rattiness of a previous
external iliac artery stent. This required a 6 x 5 followed by 7 x 5
Viabahn stent. Good apposition was present with the final
angiography of this showing no significant problem. Following this,
direction was carried inferiorly. There was a stent that was present
in this common femoral traversing the profunda. This was
re-cannulized and further stents placed beyond this, a 6 x 25 was
taken from the popliteal upwards and then a 6 x 15 coming there to
the open femoral artery site. Endarterectomy completed the
revascularization.
DESCRIPTION OF PROCEDURE: After adequate general endotracheal
anesthesia was obtained, the patient was positioned, prepped and
draped in sterile fashion consistent with the above procedure.
Incisions were made with right groin, dissection being carried down
to the common femoral artery at the inguinal ligament downwards past
the bifurcation onto the superficial femoral artery. All these were
looped with vascular loops. The patient was heparinized, retrograde
stick was then done of the common femoral artery following which the
angiography was done. This showed the presence of rattiness of her
external iliac artery with in-stent stenosis along with severe
stenosis of the origin of the external iliac artery of approximately
80%. Guidewire recanalization was done of this, stabilization wire
being placed through the femoral artery through the iliac, through
the abdominal aorta into the descending thoracic aorta for
stabilization. Following this, over this, a 6 x 5 followed by a 7 x
5 MARS stents were placed basically covering the entire external
iliac artery from its origin. The internal iliac artery was
stenosed, but preserved in this process. Once this was completed,
the dissection was then carried inferiorly, the superficial femoral
arteries opened up from the stick. This was then had obviously
traversed a stent then was placed in the common femoral, traversing
the profunda femoris origin. The Glidewire was then passed down the
old stent, this terminates in the distal SFA. This was able to be
re-cannulized down into the main superficial femoral artery. The
angiography was performed, showing the presence of severe disease
present just beyond the stent. The stents were then passed a 6 x 25
from the proximal popliteal, and then from there, a 6 x 15 brought it
up into the open site of the superficial femoral artery. Balloon
dilatation was done to size. Followup angiography was performed with
runoff, it was obvious the patient had approximately 1 vessel runoff
with the tibioperoneal trunk appearing to be occluded in this area.
Following this, femoral endarterectomy was performed. This included
the common profunda and superficial femoral arteries, going from
stent to stent. This was proximal and distal. Once the
endarterectomy was done, a bovine patch was then fashioned. This was
sewn in place utilizing running 5-0 Prolene suture. Thorough
flushing was done. Upon completion of this, the heparin was
reversed, utilizing protamine sulfate injected intravenously.
Platelet gel application was done intraoperatively with blood being
withdrawn and centrifuged to get platelet rich and platelet poor
solutions, they were administered on the anastomotic and closure
surface sites. The patient tolerated the procedure well. She was
taken to the recovery room in stable condition.