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Primary stenting immediatly after surgery in occluded anastomoses of aortoaortic tube graft: a case report.

Rabellino M, García-Nielsen L, Zander T, Baldi S, Estigarribia A, Zerolo I, Cheves H, Llorens R, Maynar M - Cardiol Res Pract (2010)

Bottom Line: The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results.The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques.One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

View Article: PubMed Central - PubMed

Affiliation: Department of Endovascular Therapy, Hospital Hospiten Rambla, General Franco 115, 38001 Santa Cruz de Tenerife, Spain.

ABSTRACT
The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results. The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques. Albeit infrequent, thrombosis can be present in the first 30 days. Its treatment consists in thrombectomy and anastomosis evaluation, but with an increase in morbidity, especially in patients with urgent reintervention. This is a case report of a patient with aortoaortic tube graft, who present critical left limb ischemia immediately after surgical procedure. Angiography showed complete occlusion of left common iliac artery, affecting the distal graft anastomosis. The occlusion was resolved with endovascular treatment, and a noncovered, self-expanding, nitinol stent was deployed (primary stenting) covering the distal bypass anastomosis, with no complications and complete lower limb perfusion recovery. One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

No MeSH data available.


Related in: MedlinePlus

(a) Angiographic image showing the distal aortoaortic tube graft anastomosis. It also appreciates the left common iliac artery occlusion.  (b) Angiographic image showing external iliac artery being perfused from the ipsilateral internal iliac artery.
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fig1: (a) Angiographic image showing the distal aortoaortic tube graft anastomosis. It also appreciates the left common iliac artery occlusion. (b) Angiographic image showing external iliac artery being perfused from the ipsilateral internal iliac artery.

Mentions: A 73-year-old man, with hypertension, hyperlipemia, noninsulin dependent diabetes, and previous coronary percutaneous revascularization, was admitted to our hospital for surgical repair of a 60 mm diameter infrarenal abdominal aortic aneurysm. Surgical technique was aortoartic tube graft with a 22 mm diameter. Proximal anastomosis was at infrarenal aorta segment while distal anastomosis was at both primitive iliac arteries ostium. Finally, the patient was sent to intensive care unit to continue postoperative recovery. One hour late, the patient suddenly felt left limb pain at rest. Physical examination revealed pale skin, coldness, and distal pulse absence. He underwent angiography diagnostic procedure through 5 f sheath placed in the right femoral artery. Patency of the aortoaortic bypass was confirmed but left common iliac artery was found to be occluded from its ostium, in coincidence with the distal anastomosis of the graft (Figures 1(a) and 1(b)). Heavily calcified lesions were observed at fluoroscopy. External iliac artery received blood perfusion from hypogastric artery with patency of the femoropopliteal segment. A decision to endovascular recanalization was made, mainly to avoid a new open surgery intervention. A 6 fr sheath was placed into the left femoral artery in a retrograde way, and iliac artery was recanalized using a 0.035 hydrophilic glide wire (Terumo Medical Corp. Somerset, NJ.) and 5 Fr hydrophilic multipurpose guide catheter (Terumo Medical Corp. Somerset, NJ). Finally we decided to deliver a self-expanding, noncovered, nitinol stent, principally to avoid the rupture of the surgical suture with the pressure exerted by the balloon of a balloon-expandable stent in a less than 2 hours anastomosis. At the same time, covering the lesion with a primary stent instead other techniques, like thrombectomy, may reduce the possibility of distal embolization manly because embolic material is trapped between the stent and the arterial wall. A 9 × 60 mm Smart stent (Cordis, Miami Lakes, FL) was delivered covering the distal graft anastomosis, with flow restoration. A residual stenosis was observed, and a 6 × 40 mm Opta balloon (Cordis, Miami Lakes, FL) was inflated, but 30%–40% residual stenosis still persisted (Figure 2). We decided to end the procedure, principally because flow restoration was achieved, and the risk of suture rupture was high.


Primary stenting immediatly after surgery in occluded anastomoses of aortoaortic tube graft: a case report.

Rabellino M, García-Nielsen L, Zander T, Baldi S, Estigarribia A, Zerolo I, Cheves H, Llorens R, Maynar M - Cardiol Res Pract (2010)

(a) Angiographic image showing the distal aortoaortic tube graft anastomosis. It also appreciates the left common iliac artery occlusion.  (b) Angiographic image showing external iliac artery being perfused from the ipsilateral internal iliac artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2913794&req=5

fig1: (a) Angiographic image showing the distal aortoaortic tube graft anastomosis. It also appreciates the left common iliac artery occlusion. (b) Angiographic image showing external iliac artery being perfused from the ipsilateral internal iliac artery.
Mentions: A 73-year-old man, with hypertension, hyperlipemia, noninsulin dependent diabetes, and previous coronary percutaneous revascularization, was admitted to our hospital for surgical repair of a 60 mm diameter infrarenal abdominal aortic aneurysm. Surgical technique was aortoartic tube graft with a 22 mm diameter. Proximal anastomosis was at infrarenal aorta segment while distal anastomosis was at both primitive iliac arteries ostium. Finally, the patient was sent to intensive care unit to continue postoperative recovery. One hour late, the patient suddenly felt left limb pain at rest. Physical examination revealed pale skin, coldness, and distal pulse absence. He underwent angiography diagnostic procedure through 5 f sheath placed in the right femoral artery. Patency of the aortoaortic bypass was confirmed but left common iliac artery was found to be occluded from its ostium, in coincidence with the distal anastomosis of the graft (Figures 1(a) and 1(b)). Heavily calcified lesions were observed at fluoroscopy. External iliac artery received blood perfusion from hypogastric artery with patency of the femoropopliteal segment. A decision to endovascular recanalization was made, mainly to avoid a new open surgery intervention. A 6 fr sheath was placed into the left femoral artery in a retrograde way, and iliac artery was recanalized using a 0.035 hydrophilic glide wire (Terumo Medical Corp. Somerset, NJ.) and 5 Fr hydrophilic multipurpose guide catheter (Terumo Medical Corp. Somerset, NJ). Finally we decided to deliver a self-expanding, noncovered, nitinol stent, principally to avoid the rupture of the surgical suture with the pressure exerted by the balloon of a balloon-expandable stent in a less than 2 hours anastomosis. At the same time, covering the lesion with a primary stent instead other techniques, like thrombectomy, may reduce the possibility of distal embolization manly because embolic material is trapped between the stent and the arterial wall. A 9 × 60 mm Smart stent (Cordis, Miami Lakes, FL) was delivered covering the distal graft anastomosis, with flow restoration. A residual stenosis was observed, and a 6 × 40 mm Opta balloon (Cordis, Miami Lakes, FL) was inflated, but 30%–40% residual stenosis still persisted (Figure 2). We decided to end the procedure, principally because flow restoration was achieved, and the risk of suture rupture was high.

Bottom Line: The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results.The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques.One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

View Article: PubMed Central - PubMed

Affiliation: Department of Endovascular Therapy, Hospital Hospiten Rambla, General Franco 115, 38001 Santa Cruz de Tenerife, Spain.

ABSTRACT
The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results. The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques. Albeit infrequent, thrombosis can be present in the first 30 days. Its treatment consists in thrombectomy and anastomosis evaluation, but with an increase in morbidity, especially in patients with urgent reintervention. This is a case report of a patient with aortoaortic tube graft, who present critical left limb ischemia immediately after surgical procedure. Angiography showed complete occlusion of left common iliac artery, affecting the distal graft anastomosis. The occlusion was resolved with endovascular treatment, and a noncovered, self-expanding, nitinol stent was deployed (primary stenting) covering the distal bypass anastomosis, with no complications and complete lower limb perfusion recovery. One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

No MeSH data available.


Related in: MedlinePlus