conleyclan
Guru
Hi there. I am hoping someone can help me with this report. Some of these aneurysm reports have been hard to decypher lately. Maybe I am looking too hard into it. This patient did have an EVAR two weeks prior. Thanks!!
PREOPERATIVE DIAGNOSIS: Abdominal aortic pseudoaneurysm, type 1 endoleak.
POSTOPERATIVE DIAGNOSIS: Abdominal aortic pseudoaneurysm, type 1 endoleak.
PROCEDURE PERFORMED: Abdominal aortic, left common iliac arterial, right
external iliac arterial and left hypogastric arterial replacement (28 mm
Vascutek graft 14 x 8 x 8 mm trifurcated graft), lumbar arterial grafting (6 mm
Vascutek graft), removal previous endovascular aortic stent graft, left
subclavian arterial cutdown and creation of a silo graft for arterial inflow
(10 mm Vascutek graft), intravascular ultrasound with radiologic supervision
and interpretation.
BRIEF HISTORY: The patient is a 53-year-old male who presented in early
November with an acute complicated type B aortic dissection with both
mesenteric, renal and lower extremity malperfusion. He had had a history
of a prior infrarenal abdominal aortic aneurysm that was repaired
endovascularly with a Cook EVAR stent graft. That stent graft had
completely collapsed at its proximal aspect secondary to the acute type B
aortic dissection with complete compression of the true lumen. This
constellation of malperfusion and collapse of the previously placed EVAR stent
graft was managed by deploying the Cook dissection endovascular system
which was made available through the national clinical trial as a protocol
deviation given the fact that there were no other devices available to address
the unusual set of problems that included the abdominal stent graft collapse
and it was felt that this system would optimally facilitate reexpansion of the
collapsed stent graft. That procedure went uneventfully. We were able to pave
the thoracic aorta with a covered stent graft using the Cook dissection system
and then the abdominal aspect was stented with the bare-metal Cook stent with
complete expansion of the collapsed EVAR stent graft. The patient was then
hemodynamically stable and asymptomatic. He was followed with serial CT
angiography, and we with these images we noted development of either a
periaortic pseudoaneurysm versus reexpansion of the old infrarenal abdominal
aortic aneurysm sac with a demonstrable type 1a endoleak just below the renal
arteries at a level where the previous EVAR graft's most proximal aspect
touched down. There was an additional type 1b endoleak of the right iliac limb
feeding the false lumen also feeding either what was either the pseudoaneurysm
or rapidly expanding old AAA sac. In order to temporize this expanding
pseudoaneurysm we placed coils transcutaneously into the pseudoanuerysm at the location of the proximal type 1 endoleak and achieved thrombosis of the
majority of the pseudoanuerysm. Despite thrombosis of that proximal type 1
endoleak, over the last few weeks with serial imaging, we have noted
progressive enlargement of the pseudoaneurysm, now measuring nearly 9 cm in the
maximal orthogonal dimension. Because of this, the patient was brought to the
operating suite today for definitive removal of the previous EVAR graft with
plans to replace the entire abdominal aorta and replaced both common iliac
arteries, given their aneurysmal dilatation and their dissection. The patient
was brought to the operating suite for definitive management with a strategy
planned for placement on cardiopulmonary bypass to allow for an endovascular
occlusion of the abdominal aorta above the renal arteries with continued
perfusion of the lower extremities to minimize the risk of paraplegia.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia after a lumbar
drain was placed by the Anesthesia team for CSF drainage. Central access
in both radial and femoral arterial lines were placed by the Anesthesia
team for intraoperative monitoring. The patient was then prepped and
draped in usual sterile fashion from the chin to the toes, we first made a
3 cm transverse incision below and just lateral to the angle of the right
clavicle. The pectoralis fascia was incised transversely. The pectoralis
muscles were retracted without diving them and then we circumferentially
controlled the right subclavian artery. We then made a midline laparotomy
from the xiphoid to pubis. We then dissected out the right external iliac
artery, right hypogastric artery, right common iliac artery, left
hypogastric, left external iliac and left common iliac artery
circumferentially. We dissected out the abdominal aorta up to and above
the level of the left renal vein. We identified the right renal artery
takeoff and the left renal artery takeoff. We obtained a control of the
aorta at this level. After dissecting out all of the segments, we
carefully also dissected the duodenum completely off the large aortic
pseudoaneurysm and after adequate exposure of all these structures, we then
heparinized the patient to an ACT over 400 seconds. We then placed
proximal and distal clamps on the right subclavian artery, made an
elliptical arteriotomy and then sewed a 12 mm Vascutek graft in a beveled
fashion to the right subclavian artery using running 6-0 Prolene suture and
then connected that to the arterial inflow circuit about cardiopulmonary
bypass circuit, deaired the system. We then placed a pursestring suture of
5-0 on the anterior aspect of the inferior vena cava just proximal to its
bifurcation into the iliac vein. Through that pursestring, we then
introduced an 18-gauge needle into the IVC and advanced the guidewire under
TEE guidance up into the right atrium. A pigtail catheter was placed over
that and the guidewire was exchanged for a Super Stiff guidewire over which
we then advanced a 20 French femoral venous cannula, positioning it in the
right atrium for venous drainage. We then dissected out the right common
iliac artery circumferentially and then fired an Endo-GIA stapler across
that and then placed a distal occlusive clamp on the right hypogastric and
the right external iliac arteries and then transected these vessels. We
then chose a 14 x 8 x 8 mm trifurcated Spielvogel graft. We trimmed the first
8 mm limb of that trifurcated graft to an appropriate length and
anastomosed it in an end-to-end fashion to the right external iliac artery.
We then took the second 8 mm limb of that trifurcated graft, cut it to an
appropriate length and then anastomosed it in an end-to-end fashion to the
right hypogastric artery, which was a large caliber vessel with a diameter
of 8 mm. That anastomosis was completed with running 5-0 Prolene suture as
well.
Next, we took a 28 mm Vascutek graft, cut it in a beveled fashion distally
and then cut the proximal aspect of the 14 mm trifurcated inflow portion of
that graft, cutting in a steep beveled fashion and anastomosed that in an
end-to-end fashion to the beveled cut of the 28 mm graft to create a single
longitudinal graft trifurcating to the 14 x 8 x 8 mm graft. On the left
lateral aspect of the 28 mm Vascutek graft, we then cannulated it with #6 Sarns
soft tip cannula widened into the arterial inflow of the cardiopulmonary
bypass circuit to establish a dual arterial inflow. The graft was completely
de-aired and then we began arterial inflow through the graft into the right
hypogastric right external iliac arteries and began arterial inflow through
the right subclavian artery as well establishing cardiopulmonary bypass. We
then systemically cooled the patient to approximately 28 degrees centigrade.
During systemic cooling, we then circumferentially dissected out the left
common iliac artery and fired an Endo-GIA stapler across it and then placed
distal clamps on the left hypogastric and left external iliac arteries. We
then transected the left common iliac artery right at its bifurcation. We
then trimmed the distal aspect of the 14 mm trifurcated graft cut to an
appropriate length and anastomosed it in an end-to-end fashion to the very
distal left common iliac artery at the bifurcation point using running 5-0
Prolene suture. We then reestablished inflow to the left lower extremity
through the cannulated 28 mm Vascutek graft. We then draw our attention toward
the placement of an endoaortic balloon to facilitate the endoaortic
crossclamping safely (given the inability to safely clamp the mesenteric aorta
with the indwelling stents.) This was achieved by introducing an 18-gauge
needle into the stapled stump of the right common iliac artery. The needle was
introduced into the iliac limb of the previous EVAR bifurcated stent graft
system and then a guidewire advanced up into that stent graft (which
represented the true lumen) and up into the descending thoracic aorta. One we
confirmed position of the guidewire in the thoracic aortic stent graft by TEE
guidance, we then placed an 11-French sheath over that guidewire and then over
the guidewire advanced a pigtail catheter and exchanged the soft wire for a
Super Stiff guidewire. Over that Super Stiff guidewire, we then advanced an
intravascular ultrasound probe and confirmed that we were in fact in the true
lumen and within the stent graft system all the way from the right iliac all
the way through the abdominal and thoracic aorta. Once we are confirmed with
the true lumen cannulation, we then advanced a 46 mm Reliant balloon up into
the abdominal aorta. After having confirmed the exact location of the celiac
artery by IVUS, we noted where the position of the balloon would need to be for
a suprarenal control and we marked the exact length of the Reliant balloon
entry needed from the level of the 11- French sheath through which it was
going to the infraceliac aorta. We then exchanged the 11- French sheath for a
14- French sheath to allow for easier passage of the Reliant balloon to and
fro. Reliant balloon was then positioned just on the inferior aspect of the
celiac artery takeoff to ensure ongoing perfusion of the celiac system. The
SMA and both renal artery would be occluded by balloon. We then inflated the balloon to aortic occlusion confirmed by
loss of the pressure in the infrarenal abdominal aorta. We maintained our
arterial inflow through the right subclavian arterial silo graft, and through
the reconstructed iliac system for dual inflow. We then opened the abdominal
aorta longitudinally and carefully removed the previously placed EVAR stent
graft system. We could easily see the proximal aspect of that stent graft and
we could easily see the endoaortic balloon, which was sitting just above the
level of the renal artery takeoffs. We identified the previously placed bare
metal stents(Cook dissection endovascular system) at the level of the renal
arteries. We then transected the abdominal aorta just intrarenally, which was
cephalad to the take off of the pseudoaneurysm such that we could now
completely exclude the pseudoaneurysms inflow. We then trimmed the proximal
aspect of the 28 mm abdominal graft to an appropriate length and anastomosed it
to the transected abdominal aorta at the level of the renal arteries, taking
care to sew the 28 mm graft to the native true lumen and adventitia with
running 4-0 Prolene suture, taking care to place the bare-metal stent
endoluminally in the abdominal segment inside the Vascutek graft that we were
now sewing so that the stent sat within both the native true lumen and within
the Vascutek graft at its distal most aspect. Approximately 3/4 away through
that aortic anastomosis, the endoaortic balloon actually popped causing
immediate egress of blood. This was controlled manually and all sumped blood
was circulated back into the CPB circuit with no significant loss of blood
pressure. We had excellent inflow with our dual inflow cardiopulmonary bypass
circuit. In fact, the reason we had set up the dual inflow circuit was in
anticipation of this risk. We then removed the indwelling Reliant
balloon and advanced a new 46 mm Reliant balloon over the indwelling guidewire
up into the suprarenal abdominal aorta and inflated that new balloon to get
hemostasis and then completed the remaining 25% of that aortic anastomosis.
Upon completion, we then tightened the suture and then deflated the endoaortic
balloon creating a reconstituted aortic flow. The patient was now systemically
rewarmed and then once achieving normothermia, was weaned from cardiopulmonary
bypass. Following weaning from bypass, he was decannulated. The heparin
reversed with IV protamine, and meticulous hemostasis confirmed the entire
operative field. We then meticulously covered the entire grafted aorta and
iliac system with aneurysm wall and peritoneum to ensure no apposition of the
duodenum to any graft material. The right subclavian was repaired by
transecting the silo graft with an Endo-GIA stapler creating a hood of graft
material for the subclavian to ensure no narrowing of that vessel. The right
subclavian axis incision was then cleared, closed in layers with running
absorbable suture and the abdomen was closed in layers. The abdominal fascia was approximated with a looped #1 Maxon suture. Subcutaneous tissues and skin were all approximated with running absorbable sutures. The patient tolerated the procedure well. All the while, we had monitored SCP, MET, then EEG for the patient and the patient never lost signals of his legs due to the motor or somatosensory evoked potentials. He was transferred to the CTICU in stable
condition.
______________________________
PREOPERATIVE DIAGNOSIS: Abdominal aortic pseudoaneurysm, type 1 endoleak.
POSTOPERATIVE DIAGNOSIS: Abdominal aortic pseudoaneurysm, type 1 endoleak.
PROCEDURE PERFORMED: Abdominal aortic, left common iliac arterial, right
external iliac arterial and left hypogastric arterial replacement (28 mm
Vascutek graft 14 x 8 x 8 mm trifurcated graft), lumbar arterial grafting (6 mm
Vascutek graft), removal previous endovascular aortic stent graft, left
subclavian arterial cutdown and creation of a silo graft for arterial inflow
(10 mm Vascutek graft), intravascular ultrasound with radiologic supervision
and interpretation.
BRIEF HISTORY: The patient is a 53-year-old male who presented in early
November with an acute complicated type B aortic dissection with both
mesenteric, renal and lower extremity malperfusion. He had had a history
of a prior infrarenal abdominal aortic aneurysm that was repaired
endovascularly with a Cook EVAR stent graft. That stent graft had
completely collapsed at its proximal aspect secondary to the acute type B
aortic dissection with complete compression of the true lumen. This
constellation of malperfusion and collapse of the previously placed EVAR stent
graft was managed by deploying the Cook dissection endovascular system
which was made available through the national clinical trial as a protocol
deviation given the fact that there were no other devices available to address
the unusual set of problems that included the abdominal stent graft collapse
and it was felt that this system would optimally facilitate reexpansion of the
collapsed stent graft. That procedure went uneventfully. We were able to pave
the thoracic aorta with a covered stent graft using the Cook dissection system
and then the abdominal aspect was stented with the bare-metal Cook stent with
complete expansion of the collapsed EVAR stent graft. The patient was then
hemodynamically stable and asymptomatic. He was followed with serial CT
angiography, and we with these images we noted development of either a
periaortic pseudoaneurysm versus reexpansion of the old infrarenal abdominal
aortic aneurysm sac with a demonstrable type 1a endoleak just below the renal
arteries at a level where the previous EVAR graft's most proximal aspect
touched down. There was an additional type 1b endoleak of the right iliac limb
feeding the false lumen also feeding either what was either the pseudoaneurysm
or rapidly expanding old AAA sac. In order to temporize this expanding
pseudoaneurysm we placed coils transcutaneously into the pseudoanuerysm at the location of the proximal type 1 endoleak and achieved thrombosis of the
majority of the pseudoanuerysm. Despite thrombosis of that proximal type 1
endoleak, over the last few weeks with serial imaging, we have noted
progressive enlargement of the pseudoaneurysm, now measuring nearly 9 cm in the
maximal orthogonal dimension. Because of this, the patient was brought to the
operating suite today for definitive removal of the previous EVAR graft with
plans to replace the entire abdominal aorta and replaced both common iliac
arteries, given their aneurysmal dilatation and their dissection. The patient
was brought to the operating suite for definitive management with a strategy
planned for placement on cardiopulmonary bypass to allow for an endovascular
occlusion of the abdominal aorta above the renal arteries with continued
perfusion of the lower extremities to minimize the risk of paraplegia.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia after a lumbar
drain was placed by the Anesthesia team for CSF drainage. Central access
in both radial and femoral arterial lines were placed by the Anesthesia
team for intraoperative monitoring. The patient was then prepped and
draped in usual sterile fashion from the chin to the toes, we first made a
3 cm transverse incision below and just lateral to the angle of the right
clavicle. The pectoralis fascia was incised transversely. The pectoralis
muscles were retracted without diving them and then we circumferentially
controlled the right subclavian artery. We then made a midline laparotomy
from the xiphoid to pubis. We then dissected out the right external iliac
artery, right hypogastric artery, right common iliac artery, left
hypogastric, left external iliac and left common iliac artery
circumferentially. We dissected out the abdominal aorta up to and above
the level of the left renal vein. We identified the right renal artery
takeoff and the left renal artery takeoff. We obtained a control of the
aorta at this level. After dissecting out all of the segments, we
carefully also dissected the duodenum completely off the large aortic
pseudoaneurysm and after adequate exposure of all these structures, we then
heparinized the patient to an ACT over 400 seconds. We then placed
proximal and distal clamps on the right subclavian artery, made an
elliptical arteriotomy and then sewed a 12 mm Vascutek graft in a beveled
fashion to the right subclavian artery using running 6-0 Prolene suture and
then connected that to the arterial inflow circuit about cardiopulmonary
bypass circuit, deaired the system. We then placed a pursestring suture of
5-0 on the anterior aspect of the inferior vena cava just proximal to its
bifurcation into the iliac vein. Through that pursestring, we then
introduced an 18-gauge needle into the IVC and advanced the guidewire under
TEE guidance up into the right atrium. A pigtail catheter was placed over
that and the guidewire was exchanged for a Super Stiff guidewire over which
we then advanced a 20 French femoral venous cannula, positioning it in the
right atrium for venous drainage. We then dissected out the right common
iliac artery circumferentially and then fired an Endo-GIA stapler across
that and then placed a distal occlusive clamp on the right hypogastric and
the right external iliac arteries and then transected these vessels. We
then chose a 14 x 8 x 8 mm trifurcated Spielvogel graft. We trimmed the first
8 mm limb of that trifurcated graft to an appropriate length and
anastomosed it in an end-to-end fashion to the right external iliac artery.
We then took the second 8 mm limb of that trifurcated graft, cut it to an
appropriate length and then anastomosed it in an end-to-end fashion to the
right hypogastric artery, which was a large caliber vessel with a diameter
of 8 mm. That anastomosis was completed with running 5-0 Prolene suture as
well.
Next, we took a 28 mm Vascutek graft, cut it in a beveled fashion distally
and then cut the proximal aspect of the 14 mm trifurcated inflow portion of
that graft, cutting in a steep beveled fashion and anastomosed that in an
end-to-end fashion to the beveled cut of the 28 mm graft to create a single
longitudinal graft trifurcating to the 14 x 8 x 8 mm graft. On the left
lateral aspect of the 28 mm Vascutek graft, we then cannulated it with #6 Sarns
soft tip cannula widened into the arterial inflow of the cardiopulmonary
bypass circuit to establish a dual arterial inflow. The graft was completely
de-aired and then we began arterial inflow through the graft into the right
hypogastric right external iliac arteries and began arterial inflow through
the right subclavian artery as well establishing cardiopulmonary bypass. We
then systemically cooled the patient to approximately 28 degrees centigrade.
During systemic cooling, we then circumferentially dissected out the left
common iliac artery and fired an Endo-GIA stapler across it and then placed
distal clamps on the left hypogastric and left external iliac arteries. We
then transected the left common iliac artery right at its bifurcation. We
then trimmed the distal aspect of the 14 mm trifurcated graft cut to an
appropriate length and anastomosed it in an end-to-end fashion to the very
distal left common iliac artery at the bifurcation point using running 5-0
Prolene suture. We then reestablished inflow to the left lower extremity
through the cannulated 28 mm Vascutek graft. We then draw our attention toward
the placement of an endoaortic balloon to facilitate the endoaortic
crossclamping safely (given the inability to safely clamp the mesenteric aorta
with the indwelling stents.) This was achieved by introducing an 18-gauge
needle into the stapled stump of the right common iliac artery. The needle was
introduced into the iliac limb of the previous EVAR bifurcated stent graft
system and then a guidewire advanced up into that stent graft (which
represented the true lumen) and up into the descending thoracic aorta. One we
confirmed position of the guidewire in the thoracic aortic stent graft by TEE
guidance, we then placed an 11-French sheath over that guidewire and then over
the guidewire advanced a pigtail catheter and exchanged the soft wire for a
Super Stiff guidewire. Over that Super Stiff guidewire, we then advanced an
intravascular ultrasound probe and confirmed that we were in fact in the true
lumen and within the stent graft system all the way from the right iliac all
the way through the abdominal and thoracic aorta. Once we are confirmed with
the true lumen cannulation, we then advanced a 46 mm Reliant balloon up into
the abdominal aorta. After having confirmed the exact location of the celiac
artery by IVUS, we noted where the position of the balloon would need to be for
a suprarenal control and we marked the exact length of the Reliant balloon
entry needed from the level of the 11- French sheath through which it was
going to the infraceliac aorta. We then exchanged the 11- French sheath for a
14- French sheath to allow for easier passage of the Reliant balloon to and
fro. Reliant balloon was then positioned just on the inferior aspect of the
celiac artery takeoff to ensure ongoing perfusion of the celiac system. The
SMA and both renal artery would be occluded by balloon. We then inflated the balloon to aortic occlusion confirmed by
loss of the pressure in the infrarenal abdominal aorta. We maintained our
arterial inflow through the right subclavian arterial silo graft, and through
the reconstructed iliac system for dual inflow. We then opened the abdominal
aorta longitudinally and carefully removed the previously placed EVAR stent
graft system. We could easily see the proximal aspect of that stent graft and
we could easily see the endoaortic balloon, which was sitting just above the
level of the renal artery takeoffs. We identified the previously placed bare
metal stents(Cook dissection endovascular system) at the level of the renal
arteries. We then transected the abdominal aorta just intrarenally, which was
cephalad to the take off of the pseudoaneurysm such that we could now
completely exclude the pseudoaneurysms inflow. We then trimmed the proximal
aspect of the 28 mm abdominal graft to an appropriate length and anastomosed it
to the transected abdominal aorta at the level of the renal arteries, taking
care to sew the 28 mm graft to the native true lumen and adventitia with
running 4-0 Prolene suture, taking care to place the bare-metal stent
endoluminally in the abdominal segment inside the Vascutek graft that we were
now sewing so that the stent sat within both the native true lumen and within
the Vascutek graft at its distal most aspect. Approximately 3/4 away through
that aortic anastomosis, the endoaortic balloon actually popped causing
immediate egress of blood. This was controlled manually and all sumped blood
was circulated back into the CPB circuit with no significant loss of blood
pressure. We had excellent inflow with our dual inflow cardiopulmonary bypass
circuit. In fact, the reason we had set up the dual inflow circuit was in
anticipation of this risk. We then removed the indwelling Reliant
balloon and advanced a new 46 mm Reliant balloon over the indwelling guidewire
up into the suprarenal abdominal aorta and inflated that new balloon to get
hemostasis and then completed the remaining 25% of that aortic anastomosis.
Upon completion, we then tightened the suture and then deflated the endoaortic
balloon creating a reconstituted aortic flow. The patient was now systemically
rewarmed and then once achieving normothermia, was weaned from cardiopulmonary
bypass. Following weaning from bypass, he was decannulated. The heparin
reversed with IV protamine, and meticulous hemostasis confirmed the entire
operative field. We then meticulously covered the entire grafted aorta and
iliac system with aneurysm wall and peritoneum to ensure no apposition of the
duodenum to any graft material. The right subclavian was repaired by
transecting the silo graft with an Endo-GIA stapler creating a hood of graft
material for the subclavian to ensure no narrowing of that vessel. The right
subclavian axis incision was then cleared, closed in layers with running
absorbable suture and the abdomen was closed in layers. The abdominal fascia was approximated with a looped #1 Maxon suture. Subcutaneous tissues and skin were all approximated with running absorbable sutures. The patient tolerated the procedure well. All the while, we had monitored SCP, MET, then EEG for the patient and the patient never lost signals of his legs due to the motor or somatosensory evoked potentials. He was transferred to the CTICU in stable
condition.
______________________________