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Aortic Case Reviews:What Would You Do???
Jeffrey Jim, MD, MPHS, FACS
Associate Professor of Surgery
Program Director, Vascular Surgery Training Programs
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DISCLOSUREJeffrey Jim, MD, MPHS
• Consulting Fee: Medtronic
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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???
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Department of SurgerySection of Vascular Surgery
Acute Dissection w/Rupture
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Department of SurgerySection of Vascular Surgery
Acute Dissection w/Rupture
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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
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Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
Two LEFT accessory 3 mm renal Arteries
RIGHTstenosis
• What do you do???
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Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• What do you do???
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Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• 3V ZFEN: large fenestration for SMA and L renal arteries
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Department of SurgerySection of Vascular Surgery
Juxtarenal AAA – “with a twist”
• Flouroscopy time 19 minutes: 78 mL Visipaque
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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???
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Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
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Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
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Department of SurgerySection of Vascular Surgery
Acute Dissection w/Malperfusion
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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
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Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
• What do you do???
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Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
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Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
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Department of SurgerySection of Vascular Surgery
Isolated Iliac Aneurysm
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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???
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Department of SurgerySection of Vascular Surgery
Rupture – Failed EVAR
• Completion angiogram showed gutter leak
• What do you do???
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Department of SurgerySection of Vascular Surgery
Rupture – Failed EVAR
• What do you do???
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Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• 69F incidental 5.9 cm AAA
• PMH: HTN, CHF, HC, COPD (home oxygen)
• Planned “standard” EVAR
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Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
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Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
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Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• What do you do???
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Department of SurgerySection of Vascular Surgery
Intraoperative Endoleak
• “short” follow-up (2 weeks)
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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???
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Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
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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???
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Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
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Department of SurgerySection of Vascular Surgery
Chronic Aortic Dissection
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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
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Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
Presents w/acute rupture
• What do you do???
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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?
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Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
• What do you do???
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Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure
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Department of SurgerySection of Vascular Surgery
Endovascular Graft Failure