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75953-26
PREOPERATIVE DIAGNOSIS: A 6.6-cm abdominal aortic aneurysm, 4.2-cm left
common iliac artery aneurysm.
POSTOPERATIVE DIAGNOSIS: A 6.6-cm abdominal aortic aneurysm, 4.2-cm left
common iliac artery aneurysm.
PROCEDURES:
1. Endovascular repair of abdominal aortic aneurysm using a Gore Excluder
bifurcated graft with 1 docking limb (left side - 26 x 12 x 18 main
body/ipsilateral limb graft, right side - 27 x 10 contralateral limb
graft).
2. Placement of 12 x 7 left external iliac artery extension graft.
3. Bilateral groin cutdowns.
4. Placement of catheter aorta.
5. Aortogram with bilateral iliac artery runoff.
6. Percutaneous transluminal angioplasty of the graft with a Gore balloon,
completion angiogram.
7. Endarterectomy of left common femoral artery.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 150.
INDICATIONS: The patient is a 67-year-old man who was referred to Vascular
Surgery Clinic with a large 6.6 cm abdominal aortic aneurysm and a 4.2 cm left
common iliac artery aneurysm. Left common iliac artery extended just proximal
to the bifurcation of the internal and external iliac arteries. Two days ago,
the patient underwent coil embolization of the left internal iliac artery with
8 interlock 0.35 coils. This completely sealed off the left internal iliac
artery. The patient now presents for endovascular repair of his abdominal and
left common iliac artery aneurysms. Benefits and risks of repair were
discussed with the patient. Risks reviewed included pain, bleeding,
infection, permanent leg weakness, numbness, pain, distal embolization which
could lead to amputation, rupture of the artery, bleeding at the catheter
insertion site, ischemic colon which can lead to colon resection and colostomy
formation, renal failure requiring contrast as well as risk of heart attack,
allergic reaction as well as 1% to 2% risk of perioperative death. The
patient was informed the risk of aneurysm rupture in the future is
approximately 1%, that the risk of type 1 endoleak is approximately 1% and
type 2 endoleak could be as high as 10% to 20%. The patient understood the
benefits and risks, and agreed to surgery.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was
brought to the operating room and placed in supine position. Adequate
anesthesia was obtained using general endotracheal intubation. The patient's
groins were prepped and draped in normal sterile fashion. Time-out was
performed, confirming the patient, operative procedure, and location. Both
common femoral arteries were exposed through bilateral groin cutdowns and
encircled with Vesseloops as well as for side branches. Left common femoral
artery was cannulated with entry needle. Bentson guidewire was passed. A 6-
French short sheath was then passed. Using angled Glidewire and glide
catheter, I was able to manipulate the Glidewire up into the thoracic aorta
and passed the Glidewire over this. The Glidewire was removed and Meyer wire
was then passed. The patient was given a bolus of heparin 9000 units IV. The
right common femoral artery was cannulated with entry needle. A glide
catheter and a Bentson guidewire was then passed up into the aorta. A glide
catheter was then passed into the thoracic aorta and an 8-French sheath was
placed. Over the glide catheter, the Bentson guidewire was then exchanged for
a Meyer wire. A 16-French dry seal sheaths were then exchanged for the 8-
French short sheath. At the left sheath, a 26 x 12 x 18 main body/ipsilateral
limb was then positioned at the level of the renal arteries. At the right
limb, pigtail marker was then placed. Aortogram with runoff was performed.
This showed the location of the renal veins. Where the guidewires were fine
appeared to placed in standard graft and standard position instead of crossing
limbs. Proximal main body and contralateral limb was then deployed just below
the level of the renal arteries. The guidewire was passed. A 0.35 angled
Glidewire was then passed up to the pigtail catheter, which was drawn and
brought down in the right sheath and using an angled glide catheter was angled
to. I was able to cannulate the contralateral limb and passed the glide
catheter up into the main body. The glide catheter was then exchanged over
for the pigtail catheter. Aortogram was performed, which confirmed that I was
in the true lumen of the graft. At this time, the sheath was withdrawn and
oblique view was taken of the right common iliac artery. This showed the
location of the bifurcation of the internal and external iliac arteries and a
27 x 10 contralateral limb graft was then deployed in good position. The rest
of the ipsilateral limb was then deployed. It appeared to overlap over into
the internal iliac artery by just approximately 1 cm, so it was decided to
place a 12 x 7 left limb extension into the external iliac artery. Balloon
angioplasty was then performed of the graft using a Gore balloon. Pigtail
catheter was then passed up again the right sheath and angiogram was
performed. Repeat angiogram was performed. This showed no evidence of type 1
or type 2 endoleak with good position of the graft just below the level of the
renal arteries with again no type 1 or type 2 endoleak. At this time, I was
very happy with the results. Groin sheaths were removed. There was a small
piece of plaque, that was acting as a check flap valve in the left common
femoral artery. This was excised with Metzenbaum scissors. Both
arteriotomies were closed with 6-0 Prolenes. Routine flush __________.
Continuous wave Doppler showed strong triphasic signals in both distal common
femoral arteries. Wounds were irrigated out. Hemostasis was excellent.
Groin wounds were then closed in 4 layers with 2-0 Vicryl followed by 3-0
Vicryl. Skin was closed with staples. Dressings were applied. Estimated
blood loss 150 cc.
AAA repair codes
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