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PREOPERATIVE DIAGNOSIS: Increasing abdominal aortic aneurysm,
high-grade left renal artery stenosis.
POSTOPERATIVE DIAGNOSIS: Increasing abdominal aortic aneurysm,
high-grade left renal artery stenosis.
NAME OF PROCEDURE: Left subclavian vein triple lumen catheter
placement, bilateral femoral artery exposure and repair, abdominal
aortogram, pelvic arteriogram, intravascular ultrasound scan abdominal
aorta, intravascular ultrasound scan, left iliac artery, intravascular
ultrasound scan, right common iliac artery, left renal artery balloon
angioplasty, left renal artery stent angioplasty, left iliac limb
stent angioplasty, endovascular aneurysm repair with three pieces.
INDICATION FOR SURGERY: The patient is a 70-year-old male with
coronary artery disease and an increasing intrarenal abdominal aortic
aneurysm. It is approaching 5 cm in diameter and has increased over
the observation period over the last 12-18 months. The patient on CT
angiogram has adequate anatomy for an endovascular aneurysm repair.
The patient also has a baseline creatinine of 1.5. Patient has a
high-grade left renal artery stenosis. We have had a detailed
counseling session concerning indications, technique, expected outcome
and potential complications to include but not limited to bleeding,
infection, myocardial infarction, stroke, death and need for an open
procedure. The patient and family fully understand and agree to
proceed with surgery without reservations.
FINDINGS AT SURGERY: Left subclavian vein was successfully cannulated
and a triple-lumen catheter placed uneventfully. A 3-piece Medtronic
Endurant II stent graft system was implanted 28 mm in diameter
delivered from the right common femoral artery with anatomic limb
orientation. The device, reference # ETBF2816C145E, serial #
V05908914. The left limb was a 20 mm flared limb, reference
#ETLW1620C124E, serial # V05964577. The right iliac system was
treated with a 20 mm flared limb, reference # ETLW1620C82E, serial
#V04205449. In the left limb of the device a 10 mm x30 mm Medtronic
Bridge Assurant stent was placed, reference # ASC1030SV, lot #
0007280855. Left renal artery had a 5 mm x 12 mm Medtronic
Racer stent placed, reference #XD512YF, lot # 0006708674. A Volcano
Visions catheter was used, reference #88901, serial #023250029710091.
An 8 x 20 mm balloon was used for the left common iliac artery balloon
angioplasty, catalog number REE080020082, lot #1E027925. Reliant stent
graft balloon model # REL46, lot 000-718-8855 was used to model the
stent graft system. A 12 x 20 mm balloon was used on the left limb of
the device, catalog #ADM120020080, , lot #1D003642. Total radiation
dose was 745 mGy with 39 minutes of fluoro time. Total contrast was
approximately 150 mL of Visipaque. There was a 10% residual stenosis
at the highly calcified left renal artery lesion. The left limb of
the stent graft had moderate narrowing at the proximal left common
iliac artery area and I treated this with a 10 mm stent. After the
intravascular ultrasound scan showed approximately a 7.5 mm lumen and
I wanted to improve upon that. There were palpable pedal pulses at
the completion. All wire manipulation was done under continuous
fluoroscopic guidance. No endoleaks were noted.
DESCRIPTION OF OPERATION: The patient was taken to the operating room
and placed in a supine position. General endotracheal anesthesia was
administered. Left subclavian area was prepped and draped in the
usual sterile manner with the patient in Trendelenburg position access
was gained to the left subclavian vein with a micropuncture needle,
wire and sheath. J-tipped wire was placed and the tract was gently
dilated. A triple lumen catheter was placed and secured to the skin
with 3-0 silk sutures. It flowed well connected to a gravity fed IV
and each port aspirated and flushed easily. The abdomen, groins and
legs were prepped and draped in the usual sterile manner and through
transverse skin incisions and vertical fascial incisions, each common
femoral artery, profunda femorus and superficial femoral artery were
exposed and encircled with Vesseloops. The patient was systemically
heparinized with 20,000 units of intravenous heparin and after
adequate circulation time was allowed, the left femoral artery was
cannulated with an 11 French sheath and a Glidewire was advanced into
the thoracic aorta. Intravascular ultrasound scan was performed and
the left common iliac artery was balloon angioplastied with an 8 mm
balloon to 9 atmospheres for moderate stenosis. A Berenstein catheter
was used to exchange the wire for a Lunderquist and a 16 French sheath
was placed through the iliac system and with the tip in the abdominal
aorta. A pigtail catheter was then positioned at the lumbar vertebral
body #1. The right femoral artery was cannulated with an 11 French
sheath and Glidewire was advanced into the thoracic aorta and then
exchanged for a Lunderquist wire. Intravascular ultrasound scanning
was done of the iliac system for measurement purposes. With the image
intensifier and the table locked flush aortography was performed and
the high-grade renal artery was identified on the left side. A RDC
catheter was placed after the Glidewire was reintroduced on the right
side and the left renal artery was selectively cannulated. A 0.014
floppy tipped PT wire was placed through the lesion and into the renal
vasculature with care being taken to always keep its tip visualized.
There was a very high-grade lesion and we did predilatation with a 3
mm x 20 mm balloon to 10 atmospheres. I then placed the 5 mm stent to
nominal inflation and did completion angiography which showed
approximately a 10% residual but excellent flow and no vessel
problems. We placed a Glidewire then back through the RDC catheter
into the thoracic aorta and removed the RDC catheter. Subsequently
then exchanging that wire for a Lunderquist wire and placed the main
body device with the limbs oriented anatomically starting just at the
left renal stent, which is the lowest renal artery. We opened the
stent graft using the left renal artery stent for guidance and the
gate was opened. It was successfully cannulated from the left side
and a pigtail catheter was twirled in the main body. Hand injection
contrast was done and the flow divider was deflected with the pigtail
catheter confirming proper location. It measured a measurement was
made to the left chronically occluded internal iliac artery takeoff
and we chose the 20 mm flared limb and deployed it. We then deployed
the rest of the main body device and after having deployed the
suprarenal portion. We removed the deep apparatuses and placed a 16
French sheath in the right common femoral artery and made a
measurement to the right hypogastric artery with the image intensifier
in an oblique LAO position. A 20 mm flared limb was chosen and
deployed. Using the Reliant stent graft balloon, we gently inflated
the balloon throughout the stent graft, assuring proper expansion and
then did an intervascular ultrasound scan through both wires. There
was approximately a 7.5 mm lumen in the left common iliac limb area at
the site of the previous balloon angioplasty. I elected to place a 10
mm stent in this area and then did post-stent placement ballooning
proximally and distally with a 12 mm balloon to flare out the stent.
Repeat intravascular ultrasound scanning showed an excellent 10 mm
symmetrical lumen. Flush aortography was performed with gentle
aspiration on each sheath and no type 1 endoleaks were noted. The
renal arteries were well perfused. There was good runoff. Retrograde
angiography was also done through each sheath and no endoleaks noted.
Pressures were measured at each femoral artery and were symmetrical
and appropriate in comparison to the radial artery. Each sheath was
then removed and the artery repaired with interrupted 6-0 Pronova
suture carefully reperfusing each leg in coordination with the
anesthesia service. There were palpable pedal pulses. Protamine was
administered and hemostasis was obtained. The wounds were irrigated
with antibiotic containing solution, suctioned dry and closed in
layers with absorbable suture. Sterile dressings were applied and the
patient was transported to the intensive care unit in stable
condition, having tolerated the procedure well. All needles and
wires, sharps and sponge count were correct x2.
high-grade left renal artery stenosis.
POSTOPERATIVE DIAGNOSIS: Increasing abdominal aortic aneurysm,
high-grade left renal artery stenosis.
NAME OF PROCEDURE: Left subclavian vein triple lumen catheter
placement, bilateral femoral artery exposure and repair, abdominal
aortogram, pelvic arteriogram, intravascular ultrasound scan abdominal
aorta, intravascular ultrasound scan, left iliac artery, intravascular
ultrasound scan, right common iliac artery, left renal artery balloon
angioplasty, left renal artery stent angioplasty, left iliac limb
stent angioplasty, endovascular aneurysm repair with three pieces.
INDICATION FOR SURGERY: The patient is a 70-year-old male with
coronary artery disease and an increasing intrarenal abdominal aortic
aneurysm. It is approaching 5 cm in diameter and has increased over
the observation period over the last 12-18 months. The patient on CT
angiogram has adequate anatomy for an endovascular aneurysm repair.
The patient also has a baseline creatinine of 1.5. Patient has a
high-grade left renal artery stenosis. We have had a detailed
counseling session concerning indications, technique, expected outcome
and potential complications to include but not limited to bleeding,
infection, myocardial infarction, stroke, death and need for an open
procedure. The patient and family fully understand and agree to
proceed with surgery without reservations.
FINDINGS AT SURGERY: Left subclavian vein was successfully cannulated
and a triple-lumen catheter placed uneventfully. A 3-piece Medtronic
Endurant II stent graft system was implanted 28 mm in diameter
delivered from the right common femoral artery with anatomic limb
orientation. The device, reference # ETBF2816C145E, serial #
V05908914. The left limb was a 20 mm flared limb, reference
#ETLW1620C124E, serial # V05964577. The right iliac system was
treated with a 20 mm flared limb, reference # ETLW1620C82E, serial
#V04205449. In the left limb of the device a 10 mm x30 mm Medtronic
Bridge Assurant stent was placed, reference # ASC1030SV, lot #
0007280855. Left renal artery had a 5 mm x 12 mm Medtronic
Racer stent placed, reference #XD512YF, lot # 0006708674. A Volcano
Visions catheter was used, reference #88901, serial #023250029710091.
An 8 x 20 mm balloon was used for the left common iliac artery balloon
angioplasty, catalog number REE080020082, lot #1E027925. Reliant stent
graft balloon model # REL46, lot 000-718-8855 was used to model the
stent graft system. A 12 x 20 mm balloon was used on the left limb of
the device, catalog #ADM120020080, , lot #1D003642. Total radiation
dose was 745 mGy with 39 minutes of fluoro time. Total contrast was
approximately 150 mL of Visipaque. There was a 10% residual stenosis
at the highly calcified left renal artery lesion. The left limb of
the stent graft had moderate narrowing at the proximal left common
iliac artery area and I treated this with a 10 mm stent. After the
intravascular ultrasound scan showed approximately a 7.5 mm lumen and
I wanted to improve upon that. There were palpable pedal pulses at
the completion. All wire manipulation was done under continuous
fluoroscopic guidance. No endoleaks were noted.
DESCRIPTION OF OPERATION: The patient was taken to the operating room
and placed in a supine position. General endotracheal anesthesia was
administered. Left subclavian area was prepped and draped in the
usual sterile manner with the patient in Trendelenburg position access
was gained to the left subclavian vein with a micropuncture needle,
wire and sheath. J-tipped wire was placed and the tract was gently
dilated. A triple lumen catheter was placed and secured to the skin
with 3-0 silk sutures. It flowed well connected to a gravity fed IV
and each port aspirated and flushed easily. The abdomen, groins and
legs were prepped and draped in the usual sterile manner and through
transverse skin incisions and vertical fascial incisions, each common
femoral artery, profunda femorus and superficial femoral artery were
exposed and encircled with Vesseloops. The patient was systemically
heparinized with 20,000 units of intravenous heparin and after
adequate circulation time was allowed, the left femoral artery was
cannulated with an 11 French sheath and a Glidewire was advanced into
the thoracic aorta. Intravascular ultrasound scan was performed and
the left common iliac artery was balloon angioplastied with an 8 mm
balloon to 9 atmospheres for moderate stenosis. A Berenstein catheter
was used to exchange the wire for a Lunderquist and a 16 French sheath
was placed through the iliac system and with the tip in the abdominal
aorta. A pigtail catheter was then positioned at the lumbar vertebral
body #1. The right femoral artery was cannulated with an 11 French
sheath and Glidewire was advanced into the thoracic aorta and then
exchanged for a Lunderquist wire. Intravascular ultrasound scanning
was done of the iliac system for measurement purposes. With the image
intensifier and the table locked flush aortography was performed and
the high-grade renal artery was identified on the left side. A RDC
catheter was placed after the Glidewire was reintroduced on the right
side and the left renal artery was selectively cannulated. A 0.014
floppy tipped PT wire was placed through the lesion and into the renal
vasculature with care being taken to always keep its tip visualized.
There was a very high-grade lesion and we did predilatation with a 3
mm x 20 mm balloon to 10 atmospheres. I then placed the 5 mm stent to
nominal inflation and did completion angiography which showed
approximately a 10% residual but excellent flow and no vessel
problems. We placed a Glidewire then back through the RDC catheter
into the thoracic aorta and removed the RDC catheter. Subsequently
then exchanging that wire for a Lunderquist wire and placed the main
body device with the limbs oriented anatomically starting just at the
left renal stent, which is the lowest renal artery. We opened the
stent graft using the left renal artery stent for guidance and the
gate was opened. It was successfully cannulated from the left side
and a pigtail catheter was twirled in the main body. Hand injection
contrast was done and the flow divider was deflected with the pigtail
catheter confirming proper location. It measured a measurement was
made to the left chronically occluded internal iliac artery takeoff
and we chose the 20 mm flared limb and deployed it. We then deployed
the rest of the main body device and after having deployed the
suprarenal portion. We removed the deep apparatuses and placed a 16
French sheath in the right common femoral artery and made a
measurement to the right hypogastric artery with the image intensifier
in an oblique LAO position. A 20 mm flared limb was chosen and
deployed. Using the Reliant stent graft balloon, we gently inflated
the balloon throughout the stent graft, assuring proper expansion and
then did an intervascular ultrasound scan through both wires. There
was approximately a 7.5 mm lumen in the left common iliac limb area at
the site of the previous balloon angioplasty. I elected to place a 10
mm stent in this area and then did post-stent placement ballooning
proximally and distally with a 12 mm balloon to flare out the stent.
Repeat intravascular ultrasound scanning showed an excellent 10 mm
symmetrical lumen. Flush aortography was performed with gentle
aspiration on each sheath and no type 1 endoleaks were noted. The
renal arteries were well perfused. There was good runoff. Retrograde
angiography was also done through each sheath and no endoleaks noted.
Pressures were measured at each femoral artery and were symmetrical
and appropriate in comparison to the radial artery. Each sheath was
then removed and the artery repaired with interrupted 6-0 Pronova
suture carefully reperfusing each leg in coordination with the
anesthesia service. There were palpable pedal pulses. Protamine was
administered and hemostasis was obtained. The wounds were irrigated
with antibiotic containing solution, suctioned dry and closed in
layers with absorbable suture. Sterile dressings were applied and the
patient was transported to the intensive care unit in stable
condition, having tolerated the procedure well. All needles and
wires, sharps and sponge count were correct x2.