# Thoracic Abdominal Aneurysm--please help



## froggie11 (Nov 6, 2008)

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.


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## BRENDAPERRITANO (Jul 21, 2009)

*Star close closure*

Noticed star close closure in note  can anyone tell me
who manufactures this and if there is a procedure code
for this closure?

Thanks for any info on this item  brenda


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