PREOPERATIVE DIAGNOSES: Occluded aortoiliac system with limb threatening ischemia, severe claudication, hypertension, dyslipidemia, obesity, smoking abuse, typical Buerger disease aorta with 100% occlusion just below the inferior mesenteric artery with a string sign to the right common iliac and a totally occluded left common and external iliac with poor visualization of the femoral vessels, collateralized from lumbar collaterals.
POSTOPERATIVE DIAGNOSES: Totally occluded aortoiliac bilateral subsequent endovascular procedure with excellent result, good profile, no evidence of any rupture. Postprocedure, the inferior mesenteric collateral arteries remained intact as well as 2 prominent lumbar vessels. There was no actual residual stenosis. The aorta overall was small and tapering and dilatation with a two 8-mm Mustang balloons resulted in full expansion of the stent with resolution of what appeared to be the culprit lesion in the proximal common iliacs bilaterally noting a waist that popped open from total occlusion to no significant stenosis. She had much grumous and debris that was thrombectomized with a Fogarty prior to deployment of the stent. Complex plaque involving the distal aorta with extended time needed for reentry of the true lumen.
1. Bilateral femoral artery exploration, bilateral retrograde iliac arteriogram, bilateral primary Fogarty thromboembolectomy using a #6 over the wire Fogarty balloon, subsequent bilateral primary iliac angioplasties using an 8 x 80 Powerflex balloon to low pressure at 3 atmospheres.
2. Kissing balloon aorto-bilateral iliac angioplasty using an 8 x 80 Mustang balloons to 4 atmospheres to allow passage of the 16-French sheath to the right iliac system and a 12-French sheath through the left iliac system, antegrade aorto-bilateral iliac arteriogram with pigtail marker catheter with appropriate measurements from inferior mesenteric artery to the internal iliac arteries for proper graft selection.
3. Placement of a Gore Excluder 23 mm aortic cuff just at the inferior mesenteric collateral orifice and subsequent placement of bilateral aortoiliac 8 x 80 Viabahn stents with a long high-pressure inflations to 6 atmospheres of the aorto-bilateral iliac system and cuff.
4. Selective inferior mesenteric artery angiogram.
5. Completion antegrade aorto-bilateral iliofemoral arteriogram.
ESTIMATED BLOOD LOSS: 150 mL from flushing and thrombectomy.
TOTAL DYE: Omnipaque 300 260 mL.
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room, placed supine upon the carbon light radio op table, was given general anesthesia, peripheral IV access, pulse oximetry and arterial line and Foley catheter were placed for physiological monitoring. The patient was positioned, shaved, prepped with alcohol, ChloraPrep, Ioban and sterile drapes. Bilateral common femoral arteries were explored through longitudinal groin incisions. Vessel loops were passed. Seldinger technique was used to gain access. J-wire was passed. A 7-French introducer placed. Retrograde angiograms were performed, showed total occlusion with a string sign on the right, totally occluded left external and common iliac on the left. I was able to wiggle 0.035 Glidewire and a glide catheter through the right iliac system to the suprarenal position. I then placed a pigtail marker catheter up the suprarenal position and antegrade arteriogram was performed, showed the totally occluded left iliac system, but I used this catheter as my guide for opening the chronic total occlusion on the left iliac system. It was a long occlusion from the external iliac to the aorta. I was able to manipulate first Glidewire and straight angiographic catheter that was changed out for an angled tip special catheter. I was able to manipulate it to the base of the aortic bifurcation, took the butt end of an Amplatz wire, was able to work it in using a pigtail marker catheter as my guide and spiraling the C-arm so that I could get a better dimensional view for entry into the true lumen at the pigtail marker catheter. Eventual entry was accomplished. The Amplatz wire was removed and I placed a 0.035 Glidewire and manipulated the special angled tip catheter into the true lumen and was able to feel my way through the thrombus and crap that was in the distal aorta into the true lumen in the suprarenal position. A 0.035 Glidewire was then removed for the Amplatz wire in the normal direction with a soft tip being cephalad. She was then given 7500 units of heparin and then given additional heparin as needed to keep her ACT over 200. I then performed a Fogarty over-the-wire thrombectomy with #6 Fogarty bilaterally dragging down grumous and debris from the aorta and doing what appeared to be more like a Rashkind procedure pulling the intimal down into the common femoral where I snared the distal superficial femoral and allowed the grumous to come to the entry sites while snaring the proximal sites avoiding any significant blood loss. The sheaths were then changed out for 16-French on the right and a 12-French on the left. I placed the 16-French sheath at the level of the inferior mesenteric that demonstrated a rather large vessel into the intestines and collateralized to the pelvic vessels that served to keep circulation patent to her lower extremities. I then positioned a Gore Excluder aortic cuff just at the takeoff of the inferior mesenteric artery, released that quickly. It was a 23-mm diameter cuff. I then accessed this cuff with the contralateral limb with the 0.035 Glidewire exchanged out for an Amplatz. I then placed a pigtail marker catheter again in the right-sided limb to retrograde injection marked by internal iliac vessel, then took 2 Gore Excluder iliac extender grafts at length of 7 cm, placed it within the cuff about 2 cm and extending down into the common iliacs bilaterally just before the internal iliac vessels. The cuff and bilateral iliac stents were then dilated to 16 atmospheres with kissing Mustang balloons. A selective angiogram of the inferior mesenteric artery was accomplished with the angled tip special catheter using hand injection, noting that it was still patent with the proximal markings of the cuff somewhat close with a scallop at the proximal attachment site. The cuff and bilateral iliacs were then again ballooned with Mustang balloons to high pressure of 16 atmospheres and a completion antegrade arteriogram was accomplished with a pigtail marker catheter placed above the endovascular repair site. It showed excellent flow. No evidence of obstruction through the graft and into the iliac vessels. At closure, upon removal of the sheaths, I placed the #6 Fogarty through the sheath about 10 cm up within the distal portion of the graft, did a gentle extraction of any other formed clots, which there were none bilaterally. I did the same with the #4 Fogarty distally to make sure that there was no distal trash and then closed the arteriotomies with interrupted 5-0 Prolene. The catheter, sheaths, wire, balloons were all removed, suture was secured and flow was restored. Hemostasis was deemed adequate. Heparin was not reversed and then the wounds were closed in layers with interrupted 2-0 Vicryl and 3-0 subcuticular Vicryl and Dermabond. Sterile dressing applied. Patient was taken to the recovery room in stable condition. Tape, needle, sponge and instruments reported correct x 2.