lightning strikes twice: endovascular salvage of an early … pdfs/lig… · • axillary artery...

Kristine L. So, MD, Jo Cooke-Barber, MD, Kirstin Nelson, MD, Christopher

Walls, MD FACS, Sheppard Mondy, MD, FACSDivision of Vascular Surgery, Memorial University Medical Center, Savannah, GA

LIGHTNING STRIKES TWICE:

Endovascu lar sa lvage o f an ear ly

aort ic anastomot ic pseudoaneurysm

None applicable

DISCLOSURES

• Incidence 0.2 to 25%

• Likely underdiagnosed

• Incidence: femoral > iliac > aortic

• At diagnosis 8-40% are ruptured

• Mortality ranges from 61-67%

• Interval imaging at 3-5 years post-op

INTRODUCTION

• HPI: 61M transferred from an OSH with a 11.1cm AAA

with report of several weeks of epigastric, back, and left

flank pain

• PMH: MI s/p PCI 2016, HTN

• Meds: Plavix, Lisinopril, Lyrica

• Social: 30pk yr smoking hx

• Physical Exam:

▪ BP: 96/64 HR 68

▪ Epigastric tenderness, large pulsatile abdominal masses

▪ Palpable distal pulses

CASE PRESENTATION

CT abdomen/pelvis – PTD 0

• Bilateral iliac artery and suprarenal aorta

clamped

• Distal lateral wall blowout with laminated

thrombus – contained rupture

• 20mm tube graft

• Posterior wall secured with plegeted 3-0

prolene sutures

• End-to-end anastomosis to the aortic

bifurcation

PROCEDURE

• Extubated POD1

• Retained distal pulses

• Discharged home POD4

POST-OP

READMISSION

• Acute onset abdominal pain

• Hypotensive

• Emergent CTA

CTA OSH

OSH CT

• Femoral artery access for the aortic cuff

• Axillary artery access for visceral chimneys

• Patent visceral vessels

PROCEDURE OVERVIEW

• Axillary cutdown for axillary artery exposure

• Hemashield graft anastomosis for sheath access

• 3 x 7Fr sheaths in separate accesses

AXILLARY ACCESS

Bilateral renal arteries and SMA chimneys with Viabahn stents

VISCERAL STENTING

Overlapping aortic cuffs: 28 x 49 Endurant and 32 x 49 Endurant

AORTIC CONTROL

• High mortality rate

• Risk of pseudoaneurysm increases over time

• Inflammatory rind, difficult reoperative field

• Stent grafts also with complication risks: endoleaks,

thrombosis, migration, rupture, infections

• Serial post-operative imaging

• Endovascular approach is an excellent option for

pseudoaneurysm exclusion

DISCUSSION

LITERATURE CITED

Bez, L., Botelho, F., Maciel, J., et. al. Endovascular repair of abdominal aortic para-anastomotic pseudoaneurysm. J Vasc Bras. June 2013. 12 (2): 180-183.

Karkos, CD. Giagtzidis, IT, Kalogirou TE, et. al. Endovascular management of ruptured anastomotic pseudoaneurysm at the distal end of a prosthetic femoro-popliteal bypass: a “quick and easy fix.” Hippokratia 2015. 19 (2): 179-181.

Melissano, G., MD, Civilini, E., MD, Marrocco-Trischitta, M., MD, et. al. Resolution of an Anastomotic Aortic Pseudoaneurysm: 4 Years after Endovascular Treatment. Images in Cardiovascular Medicine. 2004. 31 (3): 330-332.

Trentadue, M., Puppini, G., Perandini, S., et. al. Endovascular Repair of an Unusually Complex Anastomotic Pseudoaneurysm of an Aorto-Basiliac Graft. Polish Journal of Radiology. 2017. 82: 244-247.