Revision Of AAA Rupture post EVAR

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34812 x 2
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ORDERING MD: OP LOCATION:
SP AAA ENDOVASCULAR REPAIR ACCESSION NO:

PREOPERATIVE DIAGNOSIS:
Rupture of aortic aneurysm status post EVAR

POSTOPERATIVE DIAGNOSIS:
Rupture of abdominal aortic aneurysm sac status post EVAR and type III endoleak related to graft fatigue break,

PROCEDURES PERFORMED:
1, Revision aortoiliac stent graft placement.
2. Right-to-left femoral-femoral bypass

CONTRAST:
270 mL Omnipaque 300

FLUORO TIME:
20.4 minutes

CLINICAL INDICATIONS:
Mr. with a history of EVAR performed 7 years ago who presented with rupture of his residual aortic aneurysm sac. He can't remember the specific details surrounding the placement of his aortic graft, He is currently taking for reasons that he believes is related to a recent pacemaker placement. Examination of the CT scan performed at is suspicious for a type III endoleak leading to his rupture. As such, an initial endovascular approach was elected. Given his anticoagulation, we elected to proceed with a femoral cut down.


PROCEDURE:
The patient was brought to the operating room. The patient was placed in the supine position with the arms tucked. Intravenous sedation was administered. SCD';s were applied. Antibiotics were administered. The abdomen and groins were prepped and draped in the usual sterile fashion. Timeout was performed and the patient, procedure, and side were verified correct. Local anesthetic was infiltrated into the skin and subcutaneous tissues over the right groin. A longitudinal incision was made over the right common femoral artery and extended down through the femoral sheath. The common femoral artery was dissected from the surrounding tissues and isolated proximally and distally with vessel loops. The right common femoral artery was accessed with an 18 gauge Cook needle An 0.035 Versacore guidewire was advanced through the pre-existing graft under fluoroscopic guidance. During this process we identified what appeared to be a modular break between the right iliac limb and the main body of
the endograft. Despite this the guidewire was easily passed in the main body and into the descending thoracic aorta. 11-French sheath was then advanced over the wire in the right external iliac artery. A 5-French pigtail catheter was advanced over the wire into the suprarenal aorta. Power injection imaging was then performed. This confirmed the type III leak related to the modular break between the right iliac limb and the main body. Based on this imaging we suspected the top of the graft flow divider to be approximately 2 to 3 cm proximal to the distal end of the left limb of the main body. As such, it is seen that simple realigning of the right iliac limb would fix the problem. However, given the angulation, we were worried that this would encroach on the flow into the left iliac limb. As such, we elected to realign both limbs in kissing fashion. Based preoperative CT and this intraoperative imaging, a Gore contralateral limb stent graft measuring 16 x 14 x 12 mm as well as a 16 x
20 x 13 mm graft were selected for the right iliac limb and left iliac limb respectively. Left femoral cut down was performed over the left common femoral artery. The left common femoral artery was isolated with vessel loops in the same fashion as described previously. The left common femoral artery was accessed with an 18 gauge Cook needle and an 0.035 Versacore guidewire was then advanced through the graft into the descending thoracic aorta under fluoroscopic guidance. The patient was then systemically heparinized. The bilateral common femoral arteries then underwent exchange for 12-French sheaths. The selected stent grafts were then advanced over the wires and positioned appropriately in the plug and kissing fashion under fluoroscopic guidance. The grafts were then post dilated using a CODA balloon. Repeat power injection imaging revealed a persistent endoleak. Examination of the images revealed the leak was most likely due to poor fixation of the left iliac limb. It seems as
though the flow divider did not actually extend proximally for more than 1 cm from beyond the break. Furthermore, it appeared that the graft did not suffer modular disconnect but rather fatigue of the graft and break through an area of main body and limb overlap. As such, there is really only 1 cm of true overlap of the newly placed limb and the right limb of the pre-existing main body. After considering all options, we determined the best route was to exclude the left iliac limb and deploy a Gore extruder 28 x 14 x 12 mm main body to the level of the renals from within the right iliac limb with subsequent placement of a left iliac limb plug and right-to-left fem-fem bypass. We felt strongly that this would give us a 2 cm overlap of the main body within the old main body below the renals. The 12-French sheath in the right groin was then exchanged for an 18-French sheath. The 28 mm main body was then advanced and positioned. Repeat power injection imaging was performed from the
contralateral groin to the position of the renal arteries. Main body was deployed and post dilatation was performed with a CODA balloon. Repeat power injection imaging revealed than ongoing type I endoleak with antegrade filling of the left iliac limb but no further filling of the aneurysm sac. The main body was again treated with CODA balloon. Repeat injection imaging revealed no further endoleak with exclusion of the left iliac limb and the aneurysm sac, At this point a 22 mm Amplatzer plug was then deployed within the proximal left iliac limb. A 6 mm ring PTFE graft was then tunnelled subcutaneously in the suprapubic region from groin to groin. Proximal and distal control of the right common femoral artery was achieved with vessel loops. The sheath was removed. The graft was then cut to size and shape and anastomosed to the common femoral artery using a 5-0 Prolene running suture. Vascular control was then moved to the graft and arterial control was released with adequate
hemostasis. The left groin graft was cut to size and shape. Vascular control was achieved. The anastomosis was then created in the same fashion using a 5-0 Prolene running suture. The anastomosis was flushed prior to completion and found to be hemostatic after securing the suture. Examination of the extremities revealed a faint left DP pulse and an easily palpable right DP pulse. Further inspection of the left foot revealed a strong left DP signal. Hemostasis was achieved in the groins with the combination of cautery, Evicel, and Surgicel snow. The groins were closed in multiple layers using running Vicryl sutures. The skin was closed with staples. Sterile dressing were applied. The patient was extubated in the operating room and transferred to the ICU. Dr. was scrubbed and present throughout the entire procedure.
 
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