Loves labour lost !!! HYBRID REPAIR OF COMPEX ABDOMINAL AORTIC - - PowerPoint PPT Presentation

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Loves labour lost !!! HYBRID REPAIR OF COMPEX ABDOMINAL AORTIC - - PowerPoint PPT Presentation

Aug 18, 2022 581 likes •1.31k views

Loves labour lost !!! HYBRID REPAIR OF COMPEX ABDOMINAL AORTIC ANEURYSM Anil Dhall VS Bedi Disclosure Statement of Financial Interest I, ANIL DHALL, DO NOT have a financial interest/arrangement or affiliation with one or more

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Love’s labour lost !!!

HYBRID REPAIR OF COMPEX ABDOMINAL AORTIC ANEURYSM Anil Dhall VS Bedi

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Disclosure Statement of Financial Interest

I, ANIL DHALL, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

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(Dr) Col Anil Dhall, Sena Medal MD ,DM, FACC, FSCAI Director & Head Department of Cardiology Artemis Health Institute Gurgaon

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Chandra

81 years old retired Army Officer

  • Old case of CAD
  • CABG 1993

– Angioplasty 1997 – 2003 – 2005 –

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Clinical

Sudden abdominal pain

  • Pulsatile lump abdomen
  • Borderline kidney dysfunction
  • USG: AAA & Hydronephrosis Left with
  • PUJ obstruction

CT Angio: 6cm Supra-Renal AAA

  • SMA involved
  • Coeliac Borderline
  • Tandem aneurysms
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MSCT Evaluation

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Options

I: Open Surgery

  • II: Fenestrated device/ chimney
  • III: Hybrid with visceral debranching and
  • bypass
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Open Surgery

High risk of morbidity/ mortality

  • Post operative paraplegia
  • Pulmonary complications
  • Peri-operative MI
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Fenestrated/ Chimney

Economics

  • Procurement time
  • Chimney ? Experimental
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Hybrid

Doable

  • Economics
  • No cross clamping of Aorta & hence
  • minimal complications

Option of Single stage or two stage

  • Two stage for better preservation of Renal
  • function
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Plan

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Our option: Two stage

Stage I: Ilio Renal & Ilio Visceral Bypass

  • using 6 mm Intering (PTFE ringed graft)

No ligation of Renal arteries & Celiac

  • Post-op: Urine output good with marginal
  • increase in BUN/ Creatinine

Hypo protenemia

  • Hyponatremia
  • Depression
  • Recovery period 3 weeks
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Post op

Turbulent post op period

  • CRF
  • Hyponatremia
  • Hypoprotenemia
  • Depression
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Stage II: Life is never simple!!!

3 of the 4 grafts developed thrombosis

  • Options:
  • Re-explore
  • Our choice
  • Femoral exposure and each graft cannulated

– Over the wire Fogarty embolectomy – r-TPA infusion –

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Pharmacomechanical recanalisation

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Pharmacomechanical???

Intravascular rtPA

  • Over the wire Fogarty
  • Voila!!!!!!!!! It worked
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STENT GRAFTS

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Wish life could become simpler!!!

Cook Zenith main device deployed across the

  • rigins of Celiac, SMA & Renals

Contra gate did not open!!!!!!

  • WHAT TO DO??????
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CONTRA –GATE DID NOT OPEN

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ENTERING CONTRA-GATE FROM ABOVE

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ENTERING CONTRA-GATE FROM ABOVE

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BALLOONING CONTRA-GATE

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KISSING GATE BALLOON

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TRYING TO ENTER FROM LFA

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SNARING FROM LFA

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BALLOONING FROM BELOW

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TOP END BALLOONING

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ON THAT DAY

Cook Zenith main device deployed across the

  • rigins of Celiac, SMA & Renals

Contra gate did not open despiteTips & Tricks

  • AUI not available at hand
  • Abandoned on that day
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FINALLY ON THAT DAY

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TEN DAYS LATER……

AUI Device (Cook Zenith)

  • Coiling of L CIA
  • Fem-Fem Bypass
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TEN DAYS LATER ….AUI CONVERTER DEVICE

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AUI CONVERTER OPENING

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AUI OPENED

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AUI BALLOON

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AUI CLOSED

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LEFT ILIAC OCCLUDER

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LEFT ILIAC OCCLUDED

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AUI BALLOON TOUCH-UP

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FINAL RESULT

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Fem Fem Cross over

  • Small Type II Endoleak
  • Recovery
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Why ????

Device malfunction ???

  • Anatomic reasons ???
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