|VASCULAR CLINICS: IMAGES & TECHNIQUES 3
|Year : 2020 | Volume
| Issue : 2 | Page : 164-177
Complex aortic aneurysm repairs
|Date of Web Publication||17-Jun-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Complex aortic aneurysm repairs. Indian J Vasc Endovasc Surg 2020;7:164-77
Aneurysm is a focal dilatation of 50% of the arterial diameter. The normal aortic diameter decreases from28mm in thoracic aorta to 20 mm in abdominal aorta. These aortic diameters are about 2mm smaller in females and perhaps in Indian population where the perceived diameter of the aorta can be 4 to 5 mm less than above. Majority aortic aneurysms are in infra renal aorta though 5 to 15% can extend above the renal arteries (supra renal) and juxta-renal is the term applied when the aneurysm arises less than 1 cm below the renal arteries. The second commonest site is the thoracic aorta. Majority of aneurysms are asymptomatic and size criteria have been defined where the rupture, the most dreaded and lethal complication of aneurysms, increases exponentially – this is 5.5 cm for AAA (Abdominal Aortic Aneurysm) and 6 cm for TAA (Thoracic Aortic Aneurysm) and TAAA (Thoraco Abdominal Aortic Aneurysms). All aneurysms reaching the above sizes and all symptomatic aneurysms irrespective of the size, and possibly saccular aneurysms (as opposed to usual fusiform) should be repaired, open, endovascular hybrid procedures, depending on several patient risk factors. The term “complex aneurysm” is applied to the repair which involves re-implantation of any visceral vessel or extends beyond routine repair. These are challenging and frequently, daunting, time consuming procedures. But when performed by well-trained vascular surgeon with excellent infra structure, the results are excellent. Here, in this and the next issue, we present pictorial depiction of several such patients who had complex thoracic, thoraco-abdominal and abdominal aortic aneurysms repair with surgical, endovascular and combined hybrid techniques. These procedures continue to evolve and showcase the ingenuity and innovation of these specialists – Editors
| I. Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; Dr. Shivaneshan|| |
| 1. Infra Renal Inflammatory Abdominal Aortic Aneurysm – Open Repair|| |
A 65 yrs. old hypertensive presented with Rt. sided flank pain and abdominal pain. CT Angiogram showed a infrarenal aortic aneurysm (4.5cm) with bilateral common iliac aneurysm (max 5.6cm) with Rt common iliac aneurysm compressing on Rt ureter causing Rt hydro uretero nephrosis. Urine routine and culture sensitivity was normal. His ESR was 55 and CRP was high. He underwent preoperative ureteric stent. Intra op found to have features of inflammatory aneurysm (Duodenum and sigmoid mesentery densely adherent with aneurysm). So minimal dissection at neck and bilateral EIA was done. Endoaneurysmorrhaphy
using 16x8 mm coated polyester graft was done (distal anastomosis to bilateral EIA and suture closed CIA just above bifurcation to preserve internal iliac artery). Patient had a good post-operative recovery and the ureteric stent was removed in the follow up.
| 2. Hybrid Tevar in Thoraco Abdominal Aortic Aneurysm|| |
A 70 yrs old hypertensive with previous h/o CAD s/p PCI to RCA presented with severe backache for 2 months. Ct images showed Type 3 Thoraco abdominal aortic aneurysm with maximum diameter of 7cm. There was intervening viscero renal segment which was normal. Due to high risk of total open repair of the procedure, he was planned for hybrid repair. We took the advantage of the normal viscero renal segment in between and treated the aneurysm as 2 separate aneurysms (a thoracic component and a juxta renal component). Patient initially underwent open repair of Juxta renal aneurysm along with viscero renal debranching followed by TEVAR to address the thoracic component of the aneurysm. The procedure was done in two different stages with 4 week's time interval between them. Patient made a good post op recovery.
| II. Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi.|| |
1. Dr. Nikhil Chaudhari, Clinical Assistant, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, Delhi. firstname.lastname@example.org
2. Dr. (Surg cmde) V S Bedi, Chairman and Senior Consultant, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, Delhi. email@example.com.
3. Dr. Ajay Yadav, Vice-chairman and Senior Consultant, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, Delhi.firstname.lastname@example.org.
4. Dr. Apurva Srivastava, Consultant, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, Delhi. email@example.com.
Case details 1: Complex Stanford Type B Aortic Dissection, with horseshoe kidney; Hybrid Procedure
A 55 years old hypertensive female presented with complaints of sudden onset abdominal pain since 15 days. Physical examination revealed no abdominal mass. Contrast enhanced CT scan of abdomen and thorax revealed a triple barrelled Stanford type B sub-diaphragmatic aortic dissection with aneurysmal dilatation of aorta from T12 – L2 level for a length of around 9-10 cm involving the origin of celiac artery, SMA, right and left renal artery of maximum diameter 5.4x5.2cm [Figure 1]. Horse shoe kidney located just above the aortic bifurcation.
Hybrid aortic aneurysm repair: Transabdominal (open) debranching of the SMA with right common iliac artery to SMA bypass (Ringed PTFE graft 8mm) followed by fenestrated EVAR (fenestration for left renal artery). The aortic stent graft used was (28x28x150mm Valiant thoracic, Medtronic Inc, Minneapolis, USA) with on table fenestration was created at 3 o'clock position corresponding to the origin of left renal artery as per the preoperative CT angiogram and pre-wiring of fenestration was performed [Figure 4].
Left renal artery stent-Balloon expandable stent (6x38mm, Bentley Innomed, Hechingen, Germany) [Figure 6]. Postoperative aortogram confirmed the complete exclusion of the aneurysm with patent reconstructions of SMA, left renal artery and reformation of GDA and celiac axis with no endoleak [Figure 7].
The patient's postoperative course was relatively uneventful and was discharged on 5th postoperative day. Contrast enhanced ultrasound was performed on 3rd month follow up revealing no endoleak [Figure 8].
Case details 2:
A 50 year old male patient known case of diabetic, hypertensive and chronic smoker presented with pain abdomen on right side since 8 days. Clinical examination revealed pulsatile mass palpable in right lower quadrant of abdomen, approximately 10 X 8 cm in size. All peripheral pulses were palpable.
A large aneurysm of right common iliac artery measuring 7.8 cm x 6 cm x 5.3 cm, involving internal iliac artery origin. There was a fusiform pararenal aortic aneurysm with maximum diameter of 2.9 cm associated with aneurysms of common hepatic artery (3 cm x 2.4 cm) at its origin and another smaller aneurysm (1.6 cm x 1.5 cm) was also seen at the origin of the right renal artery.[Image 1]
Physician modified (on table) Fenestrated/ Chimney Endovascular Aortic Repair (left renal fenestration, right renal and SMA- chimney).
Coil embolization of celiac artery and right internal iliac artery was done; using homemade teflon coils.
Device used was Zenith Flex(Cook Medical, Bloomington, USA) aortic stent graft (Main body-28x96mm, Right limb-14x107mm, Left limb-14x90mm),
Stents used were Advanta stents (Balloon expandable, covered stents, 7x24mm for left renal, 8x59mm for right renal and 9x59mm for the SMA) for the branches.[Image 2]
| III.Complex Taaa, Aaa – Prof. Unnikrishnanan:|| |
46 yr old hypertensive male patient presented with intractable postprandial pain of 5 days duration. He reported abrupt severe back pain radiating to his lower back 10 days before for which he was being treated at local hospital for Aortic Dissection. Though his chest pain subsided his postprandial abdominal pain appeared and he was referred to us for management
CT Aortogram had confirmed Stanford B dissection and aortic size of <4cms, but SMA was committed to false lumen. Attempt to fenestration was unsuccessful so 8 mm ID coated Dacron graft was used to revascularize SMA successfully relieving his abdominal pain.
Since his BP could be controlled he was discharged from hospital.4 months later definitive treatment of replacing the upper DTA was performed on CP Bypass with circulatory arrest through left posterolateral Thoracotomy. Proximal anastomosis of 20mm ID Dacron graft was performed immediately distal to LSA origin and distal to mid DTA after unifying true and false lumen. At 4 years post op patient remains well
| IV. Care Hospital, Hyderabad|| |
Title: Mycotic abdominal Aortic aneurysm: repair with bifurcated tube graft fashioned from
bovine pericardial patch
P C Gupta, A Gnaneswar, Y Vamsi Krishna, Rahul Agarwal, A Viswanath
63-year old diabetic, hypertensive smoker male presented with h/o fever and back pain since one month. Ultrasound was suggestive of aortic aneurysm. A CT angiography done elsewhere showed a mycotic AAA just above aortic bifurcation [Figure 1]a and [Figure 1]b. At presentation, he was febrile, hemodynamically stable and had back pain. All investigations were normal except for neutrophilic leukocytosis. Widal test was positive 20 days back. Started on IV Piperacillin/Tazobactum, Ceftriaxone and Clindamycin.
He was taken up for emergency surgery under combined spinal epidural anesthesia. Approach: Transverse transperitoneal abdominal incision. Standard infrarenal aortic and bilateral common iliac artery control taken. Bifurcated graft fashioned using bovine pericardial patch. Proximal anastomosis made to infrarenal aorta and distal to each CIA [Figure 2]. Recovering well post op and became afebrile. Oral feeds started on Post op day 1. Blood culture showed no growth. Tissue culture from aneurysm grew Salmonella More Details enterica sensitive to multiple antibiotics including Ceftriaxone and ciprofloxacin. Leucocyte count coming down. Plan to continue Ciprofloxacin for 6 weeks.
Patient has come during peak COVID-19 pandemic. PCR or antibody test not available to us. HRCT chest for COVID screening was normal.
EVAR was considered to minimize the surgery. However, he was febrile and that would increase risk of stent graft infection. We used bovine pericardium so that we could reduce surgical morbidity by avoiding harvesting of femoral vein. We used PPE and it did make us uncomfortable towards the end of surgery.
| IV. Srmc, Chennai|| |
Aorto bi iliac bypass with extension to right internal iliac artery
Dr Naveen from Sri Ramachandra medical college, Chennai
a 20 year old female who presented with pain abdomen and vomiting with on and off episodes of fever. This woman had a history of post partum cardiomyopathy on treatment and also chronic kidney disease since 2 months on medical treatment. She was diagnosed with infrarenal aortic aneurysm with iliac extension and left hydronephrosis caused by Acinetobacter baumannii ex. Bilateral double J stenting followed by aneurysm repair and aorto-iliac bypass and right graft limb to internal iliac bypass. Long term antibiotics given as per culture report. Post op recovery good with normalised renal function.
Department of Vascular Surgery, Nizam's institute of medical sciences, Hyderabad
DEBRANCHING OF VISCERAL ARTERIES OF TAAA+ TEVAR
Dr. SANDEEP MAHAPATRA Dr. VENU GOPAL MUSTYALA
A 45 years old male, known HYPERTENSIVE presented with chief complaints of :
1) pain abdomen (post meals) and
2) chest pain with difficulty in breathing since 3months.
On clinical examination :
1) Tenderness over epigastrium + 2) Periumbilical tenderness +
3) No palpable mass + 4) Bruit + / thrill -
(5) Peripheral pulses palpable
CT AORTOGRAM :
- Fusiform aneurysm involving the distal descending thoracic and suprarenal abdominal aorta with partial peripheral thrombus and eccentric calcifications.
- Calcified plaques at the origins of celiac and SMA causing mild stenosis at celiac artery origin and moderate stenosis at SMA origin.
- Short segment of mild to moderate stenosis involving the infra renal abdominal aorta.
- Moderate to significant stenosis at the origin of right & left main renal arteries.
- Well defined wide mouthed saccular aneurysm arising from the proximal segment of right main renal artery.
- Its Crawford Type-V TAAA.
- Major visceral arteries (Celiac, SMA and both Renals) arising from the aneurysmal sac.
- IMA origin was at very low level and NOT arising from the aneurysmal sac.
SCHEMATIC PLAN OF ACTION
LAPAROTOMY WITH EXPOSURE OF INFRA RENAL ABDOMINAL AORTA AND BOTH ILIACS
Y LIMB STEM ANASTOMOSIS TO THE ILIAC ARTERY WITH DEBRANCHING
(Rt Y debranching to Coeliac artery and Rt Kidney, Lt Y Debranching to SMA and Lt kidney)
AORTOGRAM SHOWING THE PATENT TWO DEBRANCHING STEMS
DEPLYMENT OF ANKURA DEVICE WITH AORTIC ANEURYSM EXCLUSION
FOLLOW UP CT ANGIOGRAM (6 MONTHS)
- Other routine investigations, 2D-Echo, PFT, RFT, LFT were within normal limits
- The case was discussed with inerventional radiologists and cardiologist.
- In our case, as major visceral arteries were arising from the aneurysmal sac, we proceeded with Aortic Debranching.
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