aortic case reviews: what would you...
TRANSCRIPT
Aortic Case Reviews:What Would You Do???
Jeffrey Jim, MD, MPHS, FACS
Associate Professor of Surgery
Program Director, Vascular Surgery Training Programs
DISCLOSUREJeffrey Jim, MD, MPHS
• Consulting Fee: Medtronic
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Rupture
• RW: 57M presented w/acute chest and back pain
• CT showed acute type B dissection with contained rupture and transferred
• What do you do???
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Rupture
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Rupture
Department of SurgerySection of Vascular Surgery
Juxtarenal AAA
• 76 CAD (EF 25%), COPD, creatinine 1.3 w/5.9 cm juxtarenal AAA
Case from Dr. Starnes
Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
Two LEFT accessory 3 mm renal Arteries
RIGHTstenosis
• What do you do???
Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• What do you do???
Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• 3V ZFEN: large fenestration for SMA and L renal arteries
Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• Flouroscopy time 19 minutes: 78 mL Visipaque
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
• LF: 77F admitted to OSH w/acute chest, back and abdominal pain
• CT showed acute type B dissection
• Admitted for monitoring, had two blood BMs
• Eventually transferred
• Abdominal pain, elevated WBC/lactate
• What do you do???
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
• 60 neurosurgeon, pulsatile LLQ mass, no PMH/PSH, healthy and works out everyday
Case from Dr. Starnes
Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
• What do you do???
Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
Department of SurgerySection of Vascular Surgery
Rupture – Failed EVAR
• 87M w/acute abdominal pain
• Failed repair of migration 9 months prior
• Juxtarenal is about 5 cm
• RIGHT renal coming off aneurysm sac
• On Xarelto
• What do you do???
Department of SurgerySection of Vascular Surgery
Rupture – Failed EVAR
• Completion angiogram showed gutter leak
• What do you do???
Department of SurgerySection of Vascular Surgery
Rupture – Failed EVAR
• What do you do???
Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• 69F incidental 5.9 cm AAA
• PMH: HTN, CHF, HC, COPD (home oxygen)
• Planned “standard” EVAR
Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• “short” follow-up (2 weeks)
Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
• 81M w/acute TBAD two months ago, medically management
• PMH: Prior endovascular iliac aneurysm repair
• On follow-up, thoracic aorta enlarged from 5.6 cm to 6.4 cm
• What do you do???
Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
• On follow-up, thoracic aorta enlarged from 6.4 cm to now 7.6 cm
• What do you do???
Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
• 84M w/multiple EVAR procedures in the past
• 1998: straight tube EVT
• 2003: bifurcated EVT (proximal endoleak)
• 2007: Palmaz stent (type III endoleak)
• Presents w/proximal type Ia endoleak, type Ib (L iliac limb)
• PMH: end stage renal disease on hemodialysis, atrial fibrillation, coronary artery disease, congestive heart failure
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
Presents w/acute rupture
• What do you do???
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
• Aorto-uni-iliac repair
• AUI graft 32-113 (SMA to LEFT external iliac artery)
• Occluded to RIGHT CIA
• Extensive endarterectomy and femoral to femoral artery bypass
• Symptoms resolved
• CT showed resolution of prior hematoma but contrast in aneurysm sac
• Persistent in second CT scan (2m)
• What do you do?
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
• What do you do???
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure