Operative Note |
PROCEDURE: Modular repair of abdominal aortic aneurysm with Gore endograft device and planning aortogram through bilateral femoral cut downs. |
|
SUMMARY: With the patient supine on the operating table under
adequate sedation and spinal anesthesia, the abdomen and groin were prepared with DuraPrep solution, draped with sterile sheets and
towels and Ioban drape. Oblique incisions were made over the femoral arteries and carried down to where they entered under the
inguinal ligament. We placed vessel loops around the vessels and gave the patient 5000 units of heparin. We placed an
18 French sheath on the left, a 12 French sheath on the right, and through the 18 French sheath we placed a pigtail catheter, did
a planning aortogram documenting the level of the renal artery, which was on the left. The patient had obvious right renal artery
stenosis in a middle renal artery, which was the biggest. A superior pole artery was above that. There was a very low
small inferior pole artery on the right, which we did cover. On the left side, the renal artery appeared to be single and was
mildly diseased, which we later stented, which will be described.
After we placed the 18 French sheath, we placed a 28
by 14 by 16 Gore endograft from the level of the left renal artery down into the left common iliac. The graft appeared to deploy
a little bit high and I was a little bit worried about the renal artery having a piece of fabric in front of it; although, the blood
flow to the renal artery was brisk and unremarkable. We watched it for a while. The kidney made contrast and appeared
to function normally. We cannulated the gate from the right side to the 12 French sheath and placed a 14 by 12 limb down into
the right common iliac. Both of the common iliac limbs landed above the hypogastric. We placed the Reliant balloon and
sealed all the sites, shot an aortogram and found no leaks present with a good seal. Because of my concern about the left renal
artery, I placed a .035 guidewire into it, and through that placed a renal double curve, and through that placed a 6 mm by 17 mm balloon-mounted
stent with proximal end of the stent sticking out slightly into the aorta. Upon ballooning it, it opened up nicely, and a confirmatory
angiogram showed evidence of good flow to the left kidney. After we did that, we removed the sheath and repaired the femoral
artery with interrupted 5-0 Prolene sutures on the right side, being cautious in approximating the anterior wall as there was a big
calcific atherosclerotic cholesterol plaque in the common femoral posteriorly. After we finished the closures bilaterally, there
was reasonable pulse on both sides at the femoral. We then closed the wound in layers with 2-0 Vicryl in the deep tissue, 3-0
Vicryl in subcutaneous and the skin was closed with a skin stapling device. The patient tolerated the procedure well and was
taken to the recovery room in good condition with diminished pulses in the right foot, which had been present preoperatively.
|
