Sentara vascular surgeon Animesh Rathore, MD, presents the case of a 76-year-old man with a large abdominal aortic aneurysm measuring approximately 5.5 cm. Advanced COPD, congestive heart failure, and chronic renal failure made him unsuitable for open surgical repair.
Hello, everyone. My name is Animesh Rathore. I'm one of the vascular surgeons here at Centara Health. I'm also assistant professor of vascular surgery at Old Dominion University and involved in teaching our future vascular surgeon in our residency and the fellowship program. I work closely with the general surgery program and work closely with our cardiology and cardiothoracic surgery colleagues, um, and mostly involved in complex aortic interventions. Today we'll be talking about a patient who presented to us with a large abdominal aneurysm, about 5.5 centimeters. He's 76 years old, has advanced COPD, requires oxygen at home, also has congestive heart failure and chronic renal failure. So this patient was not a good candidate for the standard open repair, so we offered him a fenestrated repair for the for his abdominal aortic aneurysm, and we'll talk a little bit about the steps and advances of the surgery in this talk. All right, so let's look at his CT scan. This shows a thoraccoabdominal aneurysm with patent celiac SMA and the renal arteries with calcified vessels at the iliac level and severe disease at the common femoral artery level. This is a picture representation of his anatomy, um, and this is our surgical plan where we talk about the Clock position of different side vessels as well as the diameter of different vessels. In the operating room we perform a CT fusion where the existing CT scan could be fused. We start with our standard percutaneous access, placing our ProGlide sutures that allows us to stay with a percutaneous access. After establishing, we prepare our device by flushing all the air out, and this is our intraoperative plan where we are looking at the device, making sure we are oriented correctly. This is how it looks like when we start the surgery, marking all the branches and the green rings represent the side branches based on our CT scan. The device is now being introduced and being slowly deployed at the appropriate level, incorporating the The superior mesenteric artery, which would be the first branch for this device and both renal arteries. As the device is opened, we cannulate it from below to advance a sheath inside and then we sequentially will seek the Side branches in this case being the right renal artery, you can see the wire being advanced into the right renal artery, and we'll advance a catheter to confirm we are in the correct vessel and we'll move on with advancing sheath and wire through this branch via the fenestration with the plan for the plan for placing the stent subsequently. Same steps are repeated for the left renal artery and confirming. Followed by the placement of the sheath and parking the stents in the place. As we finish this, we finish the deployment and remove the delivery sheet, and this is followed by ballooning of this so it can take the final shape and get a good seal. The bridging stents are then subsequently deployed in both the renal arteries and are flared inside the aorta to allow for a nice funnel effect. You saw the right and now the left renal artery stent being deployed here. This is followed by advancement of the distal extension piece where we orient it outside the patient and then advance it from the right side and then the device is deployed within the fenestrated device followed by Opening the contralateral gate, which is cannulated on the other side by advancing the catheter, and we confirm with a pigtail and an angiogram. Extension stents into the common iliac artery are placed in the balloon to mold the stent inside the other one, followed by extension on the right side, which would be the ipsilateral side. Both the limbs are then ballooned to ensure the stent opens up completely to get a good quality seal with no leakage around. Here you are seeing the balloon being advanced through the entire length of the stent to be deployed. And this is then followed by our completion angiogram which shows patent mesenteric artery and the renal arteries with no endo leak, and the CT scan confirms that in the follow up in typically about a month with no endo leak, all the side branches are open. And the picture representation on the right side as well as a sketch of the PIC repair afterwards showing a successful repair. This patient did well. He went home on postoperative day one with minimal pain and percutaneous access. Thank you for this opportunity to share this case with you.
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