Transcript SIR RFS Aortic Pathology Angioclub

SIR RFS AORTIC PATHOLOGY ANGIOCLUB
Amit Bhakoo, MD
Mount Sinai Medical Center, Miami Beach, FL
CHIEF COMPLAINT & MEDICAL HISTORY
•
CC: Generalized weakness and abdominal pain
•
HPI: Patient is an 86 year old African American male who presented as an outpatient with
generalized weakness and abdominal pain. He denies any nausea, vomiting, diarrhea or
constipation. The onset of symptoms has been gradual with no alleviating or aggravating
factors. He describes the pain as dull, nonradiating and moderate in severity. No particular time
course for his time course throughout the day. No associated symptoms.
•
ROS: Twelve-point review of systems otherwise negative
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PMHx: HTN, anemia, gout, GERD
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PSHx: None
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Meds: ASA, Coreg, Plavix, Colchicine, Sucralfate, Vitamin B12
•
Allergies: Bactrim, ACEi
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FamHx: Non-contributory
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SocHx: Retiree, widowed, no history of alcohol, tobacco or illict drug use
PHYSICAL EXAM
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VS: Temp: 98, HR: 80, BP: 148/92, RR: 12, O2 Sat: 99%
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Gen: Well-appearing male, in no acute distress
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Skin: Intact, no ecchymoses, bruises or open wounds
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Psych: Normal mood and affect
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HEENT: NCAT, PERRLA, EOMI
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CV: RRR, Nl S1, S2, no M/R/G
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Pulm: CTAB
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Abd: Palpable, pulsatile mass above the umbilicus. Easily reducible R inguinal mass
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MSK: Decreased muscle tone otherwise normal
•
Neuro: Normal
•
Extr: Warm, well-perfused, no clubbing, cyanosis or edema
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Vasc: Palpable UE pulses, 1+ DP/PT
NON-INVASIVE IMAGING
Contrast-enhanced CT images through the abdomen and pelvis show eccentric
mural thrombus throughout the aneurysmal infrarenal aorta and bilateral
common iliac arteries
6.3 x 6.4 x
9.4 cm
infrarenal
aortic
aneursym
with
extension
into the right
common
iliac artery.
Aneursymal
dilation of
both
common
iliac
arteries, 3.3
cm on the
right, 2.4 cm
on the left
NON-INVASIVE IMAGING
Extensive mural thrombus is
seen throughout the aorta
and bilateral iliac arteries.
The irregular contour of the
contrast-opacified lumen is
seen in these images.
DIAGNOSIS AND TREATMENT OPTIONS
•
Diagnosis: Infrarenal AAA and bilateral common iliac aneursyms
•
Treatment options:
•
Endovascular stenting with embolization of the right internal iliac artery
• Technically less challenging but with the potential for claudication or ischemia to the
pelvic organs, bowel or lower extremity musculature.
•
Endovascular stenting with right external iliac to internal iliac grafting to maintain pelvic
perfusion on the right
• Technically challenging and with potential complications from additional
surgery/intervention to create external iliac - internal iliac graft
•
Endovascular stenting with branching stent grafts to the aorta and iliac vasculature
• Maintains native blood flow but with significant technical challenges
•
Open surgical repair
• Significant risk of morbidity and mortality in this 86 year-old male, higher risk of
infection and other complications
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
•
Using sterile technique, the left common femoral artery was punctured. Using proper catheter
and guidewire technique, a 6-French sheath was placed across the iliac bifurcation with its tip in
the area of the right internal iliac artery.
•
The right internal iliac artery lumen contained thrombus related to the 4-cm aneurysm.
•
A microcatheter was then used to cannulate at least three divisions of the anterior division of
the right internal iliac artery. The ultraselective cannulation was performed and embolization
with coils was performed using the Penumbra coil system. Embolization of three ultra selective
branches was performed with the coils extending back up into the ostium of the anterior
division.
•
Following this, microcatheter technique was used to ultraselectively cannulate three branches
of the posterior division of the right internal iliac artery. Coils were then deposited within the
three separate ultraselective branches of the right internal iliac artery posterior division. The
embolization was then performed back up to the ostium of the internal iliac artery.
•
Two coils were placed within the distal aspect of the right internal iliac artery distal to the large
accumulation of thrombus. This was confirmed angiographically.
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
•
Using sterile technique, an 18-French sheath was inserted into the right common femoral
artery and a 16-French sheath was inserted into the left common femoral artery.
•
A 23 x 12 x 18 excluder modular bifurcated prosthesis was placed via the right groin and
deployed. A small type 1 leak was seen but then corrected using a 16 x 12 x 7 distal
extension.
• This extended the device into the mid aspect of the right external iliac artery and
post-deployment and dilation, good seal was seen distally.
•
The left-sided device was then deployed through the left groin which was previously
cannulated using a Kumpe catheter and stiff Terumo guidewire. The left-sided prothesis
measured 23 x 10 with a bell-bottom shape.
•
Following placement of the contralateral limb and post dilatation, imaging was performed
in multiple projections showing no evidence for type 1, type 2, type 3, or type 4 endoleak.
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Catheter
angiography of
the aorta and
iliac vessels
show
aneursymal
dilation of the
aorta and
proximal
portions of the
bilateral
common iliac
arteries, arrow
points to pigtail
catheter in the
aorta
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Aneursymal dilation of the bilateral
common iliac arteries
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Embolization of the right internal
iliac artery with the penumbra coil
Technically successful embolization
of the anterior and posterior
branches of the right internal iliac
artery
INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Status-post placement of aortoiliac stent graft
SUMMARY
•
86 male presented with abdominal pain and weakness
•
Found to have an infrarenal AAA with bilateral common iliac aneursyms
•
Treatment options included endovascular repair with internal iliac embolization,
endovascular repair with branching stent grafts, endovascular repair with ipsilateral
external-internal iliac bypass or open surgery
•
Patient was thought to be best suited for endovascular repair with internal iliac
embolization which was completed successfully