Aortic Case Reviews:What Would You Do???

Jeffrey Jim, MD, MPHS, FACS

Associate Professor of Surgery

Program Director, Vascular Surgery Training Programs

DISCLOSUREJeffrey Jim, MD, MPHS

• Consulting Fee: Medtronic

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???

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Rupture

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Rupture

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

Department of SurgerySection of Vascular Surgery

Juxtarenal AAA – “with a twist”

Two LEFT accessory 3 mm renal Arteries

RIGHTstenosis

• What do you do???

Department of SurgerySection of Vascular Surgery

Juxtarenal AAA – “with a twist”

• What do you do???

Department of SurgerySection of Vascular Surgery

Juxtarenal AAA – “with a twist”

• 3V ZFEN: large fenestration for SMA and L renal arteries

Department of SurgerySection of Vascular Surgery

Juxtarenal AAA – “with a twist”

• Flouroscopy time 19 minutes: 78 mL Visipaque

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???

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Malperfusion

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Malperfusion

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Malperfusion

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

Department of SurgerySection of Vascular Surgery

Isolated Iliac Aneurysm

• What do you do???

Department of SurgerySection of Vascular Surgery

Isolated Iliac Aneurysm

Department of SurgerySection of Vascular Surgery

Isolated Iliac Aneurysm

Department of SurgerySection of Vascular Surgery

Isolated Iliac Aneurysm

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???

Department of SurgerySection of Vascular Surgery

Rupture – Failed EVAR

• Completion angiogram showed gutter leak

• What do you do???

Department of SurgerySection of Vascular Surgery

Rupture – Failed EVAR

• What do you do???

Department of SurgerySection of Vascular Surgery

Intraoperative Endoleak

• 69F incidental 5.9 cm AAA

• PMH: HTN, CHF, HC, COPD (home oxygen)

• Planned “standard” EVAR

Department of SurgerySection of Vascular Surgery

Intraoperative Endoleak

• What do you do???

Department of SurgerySection of Vascular Surgery

Intraoperative Endoleak

• What do you do???

Department of SurgerySection of Vascular Surgery

Intraoperative Endoleak

• What do you do???

Department of SurgerySection of Vascular Surgery

Intraoperative Endoleak

• “short” follow-up (2 weeks)

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???

Department of SurgerySection of Vascular Surgery

Chronic Aortic Dissection

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???

Department of SurgerySection of Vascular Surgery

Chronic Aortic Dissection

Department of SurgerySection of Vascular Surgery

Chronic Aortic Dissection

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

Department of SurgerySection of Vascular Surgery

Endovascular Graft Failure

Presents w/acute rupture

• What do you do???

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?

Department of SurgerySection of Vascular Surgery

Endovascular Graft Failure

• What do you do???

Department of SurgerySection of Vascular Surgery

Endovascular Graft Failure

Department of SurgerySection of Vascular Surgery

Endovascular Graft Failure