Help - Abdominal Aortic Pseudoaneurysm

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.

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Help - Abdominal Aortic Pseudoaneurysm