INDICATION: HISTORY: 83-year-old female with large descending thoracic aortic aneurysm for possible endograft repair.

PELVIC ARTERIOGRAM, DESCENDING THORACIC AORTOGRAM, ENDOGRAFT REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM, RIGHT COMMON ILIAC AND EXTERNAL ILIAC ARTERY STENT GRAFT PLACEMENT AND ANGIOPLASTY, RIGHT COMMON FEMORAL ARTERY STENT PLACEMENT AND ANGIOPLASTY, RIGHT EXTERNAL ILIAC TO COMMON FEMORAL ARTERY BYPASS GRAFT, OCCLUSION BALLOON ANGIOPLASTY AND THORACIC AORTA STENT GRAFT

HISTORY: 83-year-old female with large descending thoracic aortic
aneurysm for possible endograft repair.
PROCEDURE: After consent was obtained, spinal anesthetic catheter,
central line and arterial line were placed by the anesthesiologist in
attendance. Patient placed supine on the angiography table and
prepped and draped in the usual sterile manner from the nipples to
the toes for open aneurysm repair. Transverse incision was made over
the right lower quadrant and in sharp and blunt dissection carried
down to the distal right external iliac artery. Loops were placed
proximally and distally along for vascular control. Patient was
heparinized. 18 gauge needle was used to puncture the right external
iliac artery under direct visualization. Wire was advanced to the
descending thoracic aorta. 5 French catheter was placed and stiff
wire was manipulated to the aortic arch through the abdominal aortic
as well as thoracic aneurysms. A Gore introducer sheath was prepped
in the usual fashion and this was brought over the wire in the right
external iliac artery and manipulated into the distal right external
iliac artery. A 28 mm x 15 cm Gore thoracic endoprosthesis was
prepped in the usual fashion and this was brought the right external
iliac artery sheath and attempt was made to place it in the iliac
vessels which failed. This was removed. 8 mm x 4 cm balloon was
placed and 8 mm angioplasty performed throughout the right external
iliac artery and right common femoral artery. Balloon was removed
and again attempt was made to place the tag device which again
failed. The device was removed.
A 10 mm x 10 cm Viabon covered endoprosthesis was prepped in the
usual fashion and brought through the right external iliac artery
sheath. This was deployed from the right common iliac artery origin
into the right external iliac artery. Delivery catheter was removed.
8 mm x 4 cm balloon was placed and 8 mm angioplasty performed
throughout the stented segment. Balloon was removed and followup
angiogram was obtained. A 10 mm x 5 cm Gore Viabon endoprosthesis
was prepped in the usual fashion and brought through the right
external iliac artery sheath and after position angiography was
deployed in the distal right external iliac artery. Delivery
catheter was removed. 8 mm x 4 cm balloon was placed and 8 mm
angioplasty performed throughout the right common and external iliac
artery. Balloon was removed and followup angiogram was obtained.
Attempt was again made to place the protective device which failed.
18 gauge needle was used to puncture the left common femoral artery.
Wire was advanced to the abdominal aorta. Long 6-French sheath was
placed. Sos catheter was placed and manipulated into the right
external iliac artery. Catheter was removed. 10 mm x 4 cm balloon
was placed and 10 mm angioplasty performed throughout the right
common iliac and external iliac artery at the stented segment.
Followup angiogram was obtained showing active extravasation. A
balloon was inflated for a tamponade at the area of rupture below the
previously placed iliac stent graft. A 12 mm x 14 cm Gore excluder
iliac limb was prepped in the usual fashion and this was brought over
the wire in the right external iliac artery and balloon was deflated.
Excluder endograft was deployed from the right common iliac limb to
the distal most right external iliac artery. Delivery catheter was
removed. 10 mm balloon was placed and 10 mm balloon angioplasty was
performed throughout the upper portion of the excluder limb. 8 mm
balloon was placed and 8 mm angioplasty performed throughout the
lower porion of the excluder limb. Balloon was removed and followup
angiogram was obtained. A second 28 mm x 15 cm Gore thoracic
endoprosthesis was prepped in the usual fashion and this was brought
through the sheath in the right external iliac artery and again
attempt was made to place the endograft which failed. This was
removed. Sheath was removed.
10 mm Gore-Tex graft was sutured onto the Gore excluder iliac limb
and brought out through the right groin incision. Gore introducer
sheath was placed through this Gore limb and manipulated to the level
of the external iliac artery. 10 mm balloon was placed and 10 mm
angioplasty again performed throughout the right common and external
iliac artery. Balloon was removed. 28 mm x 15 cm Gore-Tex device
was again placed through the right groin sheath and manipulated to
the level of the thoracic aorta. Marker pigtail catheter was placed
through the left common femoral sheath. Biplane thoracic aortogram
was obtained. Gore tag device was deployed from the celiac axis up
to the upper portion of the thoracic aneurysm. Delivery catheter was
removed. a second 28 mm x 15 cm Gore endoprosthesis was prepped in
the usual fashion and brought through the right groin sheath and
manipulated to the descending thoracic aorta. This was deployed from
the descending thoracic aorta into the previously placed tag device.
Delivery catheter was removed. Trilobed balloon catheter was placed
and trilobed balloon angioplasty performed throughout the descending
thoracic aortic stent graft. Balloon was removed. Pigtail catheter
was placed and biplane aortogram was obtained. Selective pelvic
arteriogram was obtained. Sos catheter was placed in the right iliac
limb. Balloon was placed from the left common femoral artery sheath
into the right iliac limb and inflated and for vascular control. The
right common femoral artery was resected and bypass was performed
from the right external iliac limb to the right common femoral
artery. Occlusion balloon was removed. Soft tissues were closed in
the usual fashion. The left external iliac artery sheath was removed
and arteriotomy closed with Star Close closure device. Patient
tolerated the procedure well with no apparent complications.

FINDINGS: Initial pelvic arteriogram demonstrates diffusely small
calcified vessels throughout with significant right external iliac
artery stenosis. 8 mm angioplasty throughout the right common and
external iliac artery with followup angiogram demonstrates improved
luminal diameter however inability to place the thoracic graft. A
stent graft was placed from the common iliac to the distal external
iliac artery as described above with 8 mm and 10 mm angioplasty.
Followup angiogram demonstrates area of hemorrhage within the
external iliac artery below the level of the grafted segment.
Placement of Gore excluder endograft as described above from the
right common femoral to the distal most right external iliac artery
with 8 and 10 mm angioplasty as described above. Followup angiogram
demonstrates widely patent limb. Dual limb anastomosis to the right
external iliac artery as described above to allow for access with the
tag device. Placement of two 28 mm x 15 cm Gore thoracic
endoprosthesis as described above with occlusion angioplasty
throughout the stented segment. Followup angiogram demonstrates
complete exclusion of the very large descending thoracic aortic
aneurysm. Patent celiac axis and superior mesenteric arteries.
Followup angiogram demonstrates small infrarenal abdominal aortic
aneurysm with widely patent right common and external iliac limb.
Widely patent right common femoral artery bypass graft.

IMPRESSION:
1. Large descending thoracic aortic aneurysm.
2. Diffusely small calcified common and external iliac artery.
3. Stent graft placement right common and external iliac artery with
angioplasty as described above.
4. Placement of Gore thoracic endoprosthesis through the right iliac
endograft with complete exclusion of the large descending thoracic
aortic aneurysm.
5. Right external iliac and common femoral artery bypass graft
widely patent.
6. Good distal flow with intact pedal pulses bilaterally after
intervention