• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Please help with abd aortic aneurysm endovascular/rt.side a-line

Messages
120
Best answers
0
Procedure(s):
ABD AORTIC ANEURYSM ENDOVASCULAR/RT.SIDE A-LINE
*
Procedure list in detail:
1. Placement of left axillary conduit graft 10 mm Hemashield for delivery of multiple covered stents to the bilateral renal arteries and superior mesenteric artery
2. Complex endovascular repair of juxtarenal abdominal aortic aneurysm with bifurcated endograft 2 docking limbs with suprarenal fixation and snorkel technique
3. Right renal artery covered stent angioplasty, 7 x 59 atrium Icast
4. Left renal artery covered stent angioplasty, 6 x 59 Atrium Icast
5. Superior mesenteric artery covered stent angioplasty, 7 x 59 Atrium Icast
6. Placement right iliac artery endograft extension limb for treatment of complex abdominal aortic aneurysm
7. Placement of left iliac artery endograft extension limb for treatment of complex abdominal aortic aneurysm
8. Percutaneous large vessel access of the bilateral femoral arteries with 16 French right sheath and 12 French left sheath closed with large vessel closure devices, pro-glide ×4
9. Ultrasound-guided puncture of the bilateral femoral arteries
10. Radiologic supervision and interpretation of above
*
Post-operative Diagnosis: Post-op Diagnosis
* Abdominal aortic aneurysm (AAA) greater than 5.5 cm in diameter in male (CMS/HCC) [I71.4]
*
Indications: Symptomatic juxtarenal abdominal aortic aneurysm with contained rupture

Anesthesia Type: General
*
Estimated Blood Loss: 300 mL

Specimens: * No specimens in log *

Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used
HEMASHIELD PLATINUM * * * * 18E30 * 1
CAST COVERED STENT * * 417492009 ATRIUM MEDICAL CORP * * 1
CAST COVERED STENT * * 417492028 ATRIUM MEDICAL CORP * * 1
CAST COVERED STENT * * 415627108 ATRIUM MEDICAL CORP * * 1
116870_STENT BIFURCATED ESBF3214C103E - SV08192507 - LOG169370 Implant 116870_STENT BIFURCATED ESBF3214C103E V08192507 MEDTRONIC USA * * 1
108757_GRAFT STENT 156MM 16-16MM 16FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA - SV07876249 - LOG169370 Implant 108757_GRAFT STENT 156MM 16-16MM 16FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA V07876249 MEDTRONIC USA * * 1
108756_GRAFT STENT 124MM 16-16MM 14FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA - SV07824799 - LOG169370 Implant 108756_GRAFT STENT 124MM 16-16MM 14FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA V07824799 MEDTRONIC USA * * 1
108755_GRAFT STENT ENDURANT II STRAIGHT L93 MM OD16 MM ODSEC14 FR CONTRALATERAL ILIAC LIMB - SV07617551 - LOG169370 Implant 108755_GRAFT STENT ENDURANT II STRAIGHT L93 MM OD16 MM ODSEC14 FR CONTRALATERAL ILIAC LIMB V07617551 MEDTRONIC USA * * 1
108754_GRAFT STENT 82MM 16-16MM 14FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA - SV08094043 - LOG169370 Implant 108754_GRAFT STENT 82MM 16-16MM 14FR ENDURANT II ENDOVASCULAR ABDOMEN AORTA ILIUM INFRARENAL POLYESTER NITINOL SYSTEM CONTRALATERAL LIMB C DESIGN AAA V08094043 MEDTRONIC USA * * 1
*
*
Antibiotics: Ancef
*
VTE Prophylaxis: Heparinized during the procedure

Complications: None; patient tolerated the procedure well.

Disposition: ICU - intubated and hemodynamically stable.
*
Procedure in detail:
This is a patient who presented with back pain and possible contained rupture of a complex juxtarenal abdominal aortic aneurysm. Patient was felt to be a poor candidate for open surgery due 2 morbid obesity and congestive heart failure. She was not a candidate for conventional endovascular repair due to the juxtarenal nature of his aneurysm. Endovascular repair was felt to be his best option in light of his core morbidities and anatomy.
*
Patient was taken to the endovascular suite and placed in supine position. Timeouts were was performed. Patient received preoperative Ancef.
*
The bilateral femoral areas and abdomen were prepped and draped with ChloraPrep Ioban was applied. The bilateral femoral arteries were then accessed using ultrasound guidance. Perclose Proglide devices were then positioned at the 1 and 11 o'clock position under fluoroscopy for a pre-close technique.11 French sheaths were placed. The right femoral sheath was upsized to a 16 French sheath following deployment of the main body and retrieval of the delivery system.
*
In order to address the patient's juxtarenal aneurysm creation of a neo-neck was planned seen a snorkel technique to both renal arteries and the superior mesenteric artery. In order to delivery multiple covered stent graft simultaneously a axillary conduit was required. A left infraclavicular incision was made and the pectoral fascia opened. The pectoralis major fibers opened in the direction of their travel and the pectoralis minor muscle was exposed. The pectoralis minor fibers were divided and the axillary artery exposed for approximately 10 cm. The vessel was sufficiently mobilized for proximal and distal control. The patient was systemically heparinized. The axillary artery was clamped and a longitudinal arteriotomy performed. A 10 mm Hemashield dacryon graft was then sewn in with 5-0 Prolene suture. A Gore dry seal sheath was then modified to place into the dacryon conduit into in. A 24 French Gore dry seal sheath was utilized.
*
Under fluoroscopy wires were then advanced into the descending thoracic aorta followed by placement of three90 cm 7 French Pinnacle destination sheaths. The right renal artery was selected first with a Glidewire and modified Simmons catheter. The Glidewire was exchanged to a Rosen wire which was left in the distal right renal artery. The left renal artery was then selected with a angled vertebral catheter and likewise a Rosen wire positioned in the distal left renal artery. The superior mesenteric artery was then selected with a IMA catheter and a Storq were positioned into the superior mesenteric artery. This 3 Icast balloon mounted covered stents were advanced into the bilateral renal arteries and superior mesenteric artery. 6 and 7 mm x 59 mm stents were placed in the renal arteries and a 7 mm x 59 mm stent was placed in the superior mesenteric artery.
*
Placement of the selective catheters and subsequent covered stents was performed after several angiograms were obtained in his different projections to optimize placement.
*
Attention was then returned to the groin access sites. A 32 mm main body bifurcated Endurant endograft was then introduced over the right femoral access wire. The device was positioned in a suprarenal position as planned. This point the covered stent grafts in the renal arteries and superior mesenteric artery were optimally positioned. Placement of the main endograft was then performed simultaneously with deployment of the covered stents in the SMA and renal arteries. All of the covered stents deployed on target as did the endograft at the distal margin of our intended target at the bottom of the celiac trunk. The stent graft deployment balloons were then pulled back to allow flow within the stent grafts but left in position for now. Attention then returned to the main body endograft which was deployed further by releasing the top cap and further deploying the graft until the contralateral limb was free. Capture of the contralateral limb was then accomplished with a Glidewire with some difficulty due to the patient's mid body aneurysm anatomy. Eventually we used a steerable sheath to optimally positioned a selective catheter near the limb origin. Intragraft position was confirmed by spinning a pigtail the main body of the graft after advancing it through the captured limb. Due to the patient's long infrarenal aorta and set for the deploying suprarenal iliac extensions be required in both limbs. Measurements were taken and the first left long limb which was a 16 x 16 x 156 was deployed. 4 optimal purchase into the left iliac above the left iliac bifurcation and additional 16 x 16 x 82) graft limb was deployed. The main body of the graft was then completely deployed and the main body delivery system captured and removed. The delivery system was replaced with a 16 French sheath. The right main ipsilateral limb which was a 16 x 16 x 124 was then deployed with a additional extension of a I 16 x 93 extension limb to extend down to near the right iliac origin.
*
Reliant balloon was then introduced over the wire and the aortic main body portion of the endograft angioplasty with simultaneous inflation of the bilateral renal and SMA covered stents. The remainder of graft to graft and graft artery attachments were then ballooned with the Reliant balloon by introducing and from both sides. The balloons were removed from the covered stents within the renals and SMA. A completion arteriogram was then performed in 2 stages proximally and distally. The arteriogram demonstrated patency of the celiac artery as well as the covered stents into the SMA and bilateral renal arteries. There was no evidence of any type I endoleak. An no obvious type II endoleak was visualized as well. Additional views showed both iliac limbs patent with patency of the external and internal iliac arteries bilaterally.
*
Wires within the covered stent grafts within the renals and sprue mesenteric artery with then removed along with the balloons. The long Pinnacle destination sheaths were removed. The left axillary conduit was clamped and divided near the axillary artery creating a small cuff remnant of graft. This was oversewn with 5-0 Prolene and also secured with 2 large hemoclips. The axillary wound was closed with 3-0 PDS and 4 Monocryl. A 10 flat Jackson-Pratt drain was left in the wound site.
*
The femoral sheaths were then pulled and the probe line devices pre-positioned used to affect large vessel sheath closure. All of the puncture sites appeared to be hemostatic after appropriate pressure for a few minutes. The puncture sites were closed with Monocryl.
*
This was an extremely complex endovascular procedure which was made difficult by the patient's vascular anatomy as well as his morbid obesity which was a challenge to view optimally under fluoroscopy. Multiple difficult renal and visceral cannulations were required and the patient's gait limb capture was also difficult which prolonged fluoroscopy time. Oblique views of the patient's large body mass and need to use digital subtraction also greatly increased the patient's DAP exposure.
*
DAP 1873
fluoroscopy time 87 minutes
*
*
cedure. Patient tolerated well.
*
Summary of radiographic findings:
Complex juxtarenal bilobed, probable contained ruptured abdominal aortic aneurysm successfully treated with advanced endovascular procedure utilizing snorkel technique
 
Top