michellebrewer
Contributor
PROCEDURE PERFORMED:
1. Bilateral common femoral artery exposure and dissection
2. Abdominal aortogram
3. Placement of 26cm x 12cm x 18cm Gore Excluder aortic graft
4. Pelvic aortogram
6. Placement of 12cm x 12cm Gore contralateral limb graft
7. Ballooning of proximal and distal aortic graft
8. Completion angiogram
9. Primary repair of bilateral common femoral arteries
PROCEDURE IN DETAIL:
Informed consent was obtained from the patient prior
taking back to the operating room. All risks and benefits of the procedure were
explained at this time. The patient was taken back to the operating room, where
he was placed in supine position on the operating room table. General
anesthesia was induced. Once this was done, the abdomen, bilateral groins, and
legs were prepped and draped in the usual sterile fashion. Began with bilateral groin cutdown,
oblique incisions were made in the groin above the groin crease deep into the subcutaneous tissue
using electrocautery all the way down to the level of femoral sheath. Femoral sheath
was divided and the femoral artery was identified. The common femoral artery
was dissected out for a good distance both proximally and distally and a vessel
loop was placed around the artery. This was done bilaterally. Once both common
femoral arteries were dissected out, attention was turned to the right side
which would be ipsilateral side. A small counter incision was made just lower
than our incision and the needle was placed through here and into the middle of
the common femoral artery. A J-wire was passed easily up into the abdominal
aorta and a 5-French sheath was placed in the right common femoral artery. The
same was done on the left. Once our sheaths were in place, fluoro was brought
in and we placed our Glide catheter up into the thoracic aorta over the J-wire
and these J-wires were then exchanged out for a stiff Amplatz wires and these
were both placed up into the thoracic aorta and catheters were removed. Once
this was in place, we then up sized the sheath on the right. An 16-French
sheath was placed up passed the bifurcation, into the aorta from the right, a 12-French sheath
was put in to place on the left. Once our sheaths were in place, we then introduced our
Gore excluder aortic graft and this was placed above the level of the renal
arteries on the right. The pigtail catheter was put in position and abdominal aortogram was performed showing all the visceral vessels as well as in the renal
arteries. The renal arteries were marked on the screen and we deployed our Gore
excluder graft just below the renal arteries. Another aortogram was performed
showing perfusion of both renal arteries. At this time, we then chose to
balloon the proximal portion of the graft with a reliant balloon in order to
attempt to seat the graft as there was a slightly short neck at the proximal
aneurysm. At this point, the contralateral limb was already open. We then
cannulated the gate from the left side. A pigtail catheter was placed from the
left into the graft and was twisted to ensure that we were within the graft
which we were. The pelvic aortogram was then performed and mapped out and
measured out the length of the left common iliac artery. We marked the origin
of the internal iliac on the left and then placed the left leg contralateral
limb landing it just proximal to the external iliac. Once this was done, we
then completed out the graft on the right. We did have to extend the limb on
the right and an extension limb was placed landing it again just above the
internal iliac on the right. Once this was done, the devices were removed. The
pigtail catheter was placed back at the level of the renal arteries. Another
aortogram was performed. There was still some filling of the aneurysm so the proximal graft was ballooned again.
The final completion showed a good seal on the aneurysm and there was no type 1 endoleak.
There was patent flow into the bilateral internal iliacs and down each leg. At
this point, we then removed our wires and catheters and each common femoral
artery was clamped as the sheaths were removed. The common femoral arteries were repaired in a running fashion with 6-0 Prolene suture. Patient tolerated
procedure well without any complications. He had good palpable pulses in the
common femoral arteries bilaterally. Each groin was irrigated and then closed
in multiple layers of 2-0, 3-0, and Vicryl suture and then the skin was closed
with 4-0 Biosyn. The patient tolerated the procedure well without any complications.
1. Bilateral common femoral artery exposure and dissection
2. Abdominal aortogram
3. Placement of 26cm x 12cm x 18cm Gore Excluder aortic graft
4. Pelvic aortogram
6. Placement of 12cm x 12cm Gore contralateral limb graft
7. Ballooning of proximal and distal aortic graft
8. Completion angiogram
9. Primary repair of bilateral common femoral arteries
PROCEDURE IN DETAIL:
Informed consent was obtained from the patient prior
taking back to the operating room. All risks and benefits of the procedure were
explained at this time. The patient was taken back to the operating room, where
he was placed in supine position on the operating room table. General
anesthesia was induced. Once this was done, the abdomen, bilateral groins, and
legs were prepped and draped in the usual sterile fashion. Began with bilateral groin cutdown,
oblique incisions were made in the groin above the groin crease deep into the subcutaneous tissue
using electrocautery all the way down to the level of femoral sheath. Femoral sheath
was divided and the femoral artery was identified. The common femoral artery
was dissected out for a good distance both proximally and distally and a vessel
loop was placed around the artery. This was done bilaterally. Once both common
femoral arteries were dissected out, attention was turned to the right side
which would be ipsilateral side. A small counter incision was made just lower
than our incision and the needle was placed through here and into the middle of
the common femoral artery. A J-wire was passed easily up into the abdominal
aorta and a 5-French sheath was placed in the right common femoral artery. The
same was done on the left. Once our sheaths were in place, fluoro was brought
in and we placed our Glide catheter up into the thoracic aorta over the J-wire
and these J-wires were then exchanged out for a stiff Amplatz wires and these
were both placed up into the thoracic aorta and catheters were removed. Once
this was in place, we then up sized the sheath on the right. An 16-French
sheath was placed up passed the bifurcation, into the aorta from the right, a 12-French sheath
was put in to place on the left. Once our sheaths were in place, we then introduced our
Gore excluder aortic graft and this was placed above the level of the renal
arteries on the right. The pigtail catheter was put in position and abdominal aortogram was performed showing all the visceral vessels as well as in the renal
arteries. The renal arteries were marked on the screen and we deployed our Gore
excluder graft just below the renal arteries. Another aortogram was performed
showing perfusion of both renal arteries. At this time, we then chose to
balloon the proximal portion of the graft with a reliant balloon in order to
attempt to seat the graft as there was a slightly short neck at the proximal
aneurysm. At this point, the contralateral limb was already open. We then
cannulated the gate from the left side. A pigtail catheter was placed from the
left into the graft and was twisted to ensure that we were within the graft
which we were. The pelvic aortogram was then performed and mapped out and
measured out the length of the left common iliac artery. We marked the origin
of the internal iliac on the left and then placed the left leg contralateral
limb landing it just proximal to the external iliac. Once this was done, we
then completed out the graft on the right. We did have to extend the limb on
the right and an extension limb was placed landing it again just above the
internal iliac on the right. Once this was done, the devices were removed. The
pigtail catheter was placed back at the level of the renal arteries. Another
aortogram was performed. There was still some filling of the aneurysm so the proximal graft was ballooned again.
The final completion showed a good seal on the aneurysm and there was no type 1 endoleak.
There was patent flow into the bilateral internal iliacs and down each leg. At
this point, we then removed our wires and catheters and each common femoral
artery was clamped as the sheaths were removed. The common femoral arteries were repaired in a running fashion with 6-0 Prolene suture. Patient tolerated
procedure well without any complications. He had good palpable pulses in the
common femoral arteries bilaterally. Each groin was irrigated and then closed
in multiple layers of 2-0, 3-0, and Vicryl suture and then the skin was closed
with 4-0 Biosyn. The patient tolerated the procedure well without any complications.