Surgery for chronic ruptured contained abdominal aortic aneurysm- a case report Grant Medical College Mumbai Dr Suraj.

Slides:



Advertisements
Similar presentations
23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric.
Advertisements

YASMINE DE BRUYNE SYMPOSIUM 14/01/95 AN UNUSUAL USE OF A VASCULAR ALLOGRAFT IN THE REPAIR OF AN INFECTIOUS AORTO-PULMONARY FISTULA H.C. Jumet CLINICAL.
Endovascular Treatment of Acute Aortic Emergencies: Early Results Badr Aljabri, MD, FRCSC King Khalid University Hospital Riyadh, Saudi Arabia.
Aortic Aneurysms Mark A. Farber, MD.
Epidemiology, Risk Factors, Diagnosis and Intervention of Abdominal Aortic Aneurysms By, Sultan O Al-Sheikh.
Abdominal Aortic Aneurysm (AAA) LECT7 ALI B ALHAILIY.
Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE Concept Sophie C. Hofferberth 1, Andrew E.
Aneurysms & Aneurysm Screening
SIR-RFS AngioClub Ethan M. Dobrow, PGY-4 Maine Medical Center, Portland, Maine (The Freeman Hospital, Newcastle-Upon-Tyne, UK)
What Is Being Done Where
Dr R H Stables Cardiothoracic Centre Liverpool, UK Thoracic Aortic Stent Grafting.
SURGERY of AORTIC ANEURYSMS
Ross Milner, MDUniversity of Chicago Mark Russo, MD, MS Center for Aortic Diseases.
AORTIC ANEURYSM Prepared by: Dr. Hanan Said Ali. Objectives Define aortic aneurysm. Enumerate causes. Classify aortic aneurysm. Enumerate clinical manifestation.
Aneurysm. It is a blood sac that communicates with the lumen of an artery They are classified according to –Etiology congenital Acquired –pathological,
Aortic Emergencies LISA BROUGHTON, PHD, RN, CCRN.
Repair of a Thoracic Aorta Aneurysm
Notice anything? Calcified infrarenal aortic aneurysm – posterior view.
TAA Incidence: – TAA is diagnosed in approximately 15,000
Ravi K. Ghanta, MD, John A. Kern, MD 
Drawings illustrating an extent II repair of a thoracoabdominal aortic aneurysm (A) that extends from the left subclavian artery to the aortoiliac bifurcation.
Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,
A 68-year-old man with history of hypertension and coronary artery disease (coronary artery bypass graft surgery in the past) with no follow-up in the.
Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms  G. Chad.
Thoracic Aortic Frontier: Review of Current Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR)  Jehangir J. Appoo, MDCM, FRCSC,
Volume 16, Issue 1, Pages 4-9 (July 2008)
Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology  Salvatore T. Scali, MD, Dan Neal, MS, Vida Sollanek, BS,
Lee J. Goldstein, MD, Combiz Rezayat, MD, Gautam V
Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes  Muhammad Aftab, MD, Jay J. Idrees, MD,
Aorto-caval fistula from acute rupture of an abdominal aortic aneurysm treated with a hybrid approach  Matthias Siepe, MD, Sabrina Koeppe, MD, Wulf Euringer,
Ravi K. Ghanta, MD, John A. Kern, MD 
Endovascular grafts for noninfected aortoiliac anastomotic aneurysms
Branched Endovascular Therapy of the Distal Aortic Arch: Preliminary Results of the Feasibility Multicenter Trial of the Gore Thoracic Branch Endoprosthesis 
Acute bilateral renal artery chimney stent thrombosis after endovascular repair of a juxtarenal abdominal aortic aneurysm  Salvatore T. Scali, MD, Robert.
Reverse extra-anatomic aortic arch debranching procedure allowing thoracic endovascular aortic repair of a chronic ascending aortic aneurysm  Ludovic.
Impact of transrenal aortic endograft placement on endovascular graft repair of abdominal aortic aneurysms  Michael L. Marin, MD, Richard E. Parsons,
Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair  Hazim J Safi, MD, Anders Winnerkvist, MD, Charles C Miller, PhD, Dimitrios.
Treatment of complex abdominal aortic aneurysms by a combination of endoluminal and extraluminal aortofemoral grafts  James May, MS, FRACS, FACS, Geoffrey.
Overt colon ischemia after endovascular aneurysm repair: The importance of microembolization as an etiology  Nishan Dadian, MD, Takao Ohki, MD, Frank.
Aneurysm.
Type IV Thoraco-Abdominal Aortic Aneurysm (TAAA IV) with Occlusion of Celiac and Superior Mesenteric Arteries in a High Risk Patient: Successful Treatment.
Posterior reversible encephalopathy syndrome from induced hypertension during endovascular thoracoabdominal aortic aneurysm repair  Gustavo S. Oderich,
Stent-Grafting of the Thoracic Aorta by the Cardiothoracic Surgeon
Bitubular graft as an adjunct for laparoscopic hybrid repair of an abdominal aortic aneurysm  Raphaël Coscas, MD, Clément Capdevila, MD, Olivier Goeau-Brissonniere,
Endovascular stent-graft repair for penetrating atherosclerotic ulcer in the infrarenal abdominal aorta  Yoshihiko Tsuji, MD, Yosuke Tanaka, MD, Atsushi.
Entire Stent Grafting of the Thoracoabdominal Aorta in a Renal Transplant Recipient Subsequent to Extra-Anatomical Bypasses of the Main Abdominal Vessels 
Simplified hybrid repair with true lumen recycling for retrograde renovisceral perfusion in a complex chronic aortic dissection  Ricardo Castro-Ferreira,
Hybrid Endovascular Repair of a Right-Sided Thoracoabdominal Aortic Aneurysm  Mamoru Hamuro, MD, Tomoyuki Yamada, MD, PhD, Kenji Yamamoto, MD, PhD, Sakae.
Recurrent Aorto-iliac mycotic false aneurysm
Successful surgical treatment of multilevel aortic aneurysms combined with renal transplantation  Ivan Matia, MD, PhD, Jan Pirk, MD, PhD, Květoslav Lipar,
Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair  Adel Bin Jabr, MD, Bengt Lindblad, MD,
Management of acute type B aortic dissection
Aorto-caval fistula from acute rupture of an abdominal aortic aneurysm treated with a hybrid approach  Matthias Siepe, MD, Sabrina Koeppe, MD, Wulf Euringer,
The use of an aortoiliac side-arm conduit to maintain distal perfusion during thoracoabdominal aortic aneurysm repair  Kenneth Ouriel, MD  Journal of.
Anthony Carnicelli, BA, Adam Doyle, MD, Michael Singh, MD 
Gorav Ailawadi, MD, Asheesh Bedi, BS, David M. Williams, MD, James C
Treatment of an early type II endoleak causing hemorrhage after endovascular aneurysm repair for ruptured abdominal aortic aneurysm  Olivier Hartung,
Dissection of the abdominal aorta in blunt trauma: endovascular or conventional surgical management?  Jean-Philippe Berthet, MD, Charles-Henri Marty-Ané,
Axillobifemoral bypass and aortic embolization for the treatment of two patients with ruptured infrarenal aortic aneurysms  David Coleman, MD, Theodore.
Endovascular management of thoracic aortic aneurysms
An operative method for surgical revision of a late failure after endovascular repair of an abdominal aortic aneurysm  Suhail Anwar, FRCS, Yousif Al-Khattab,
Primary aortoesophageal fistula from aortic aneurysm: Successful surgical treatment by use of omental pedicle graft  Joseph S. Coselli, MD, E.Stanley.
Sukgu M. Han, MD, Warren J. Gasper, MD, Timothy A.M. Chuter, MD 
Retrograde visceral vessel revascularization followed by endovascular aneurysm exclusion as an alternative to open surgical repair of thoracoabdominal.
Hybrid Repair of an Aortic Arch Aneurysm Using Double Parallel Grafts Perfused by Retrograde Flow in Endovascular Repair Combined With Left Subclavian.
A novel percutaneous double-lumen stent graft technique for treatment of chronic type B aortic dissection under local anesthesia  Sophie Wang, BS, Mahmoud.
Combined Endovascular and Surgical Procedure for Recurrent Thoracoabdominal Aortic Aneurysm  Masato Yoshida, MD, Nobuhiko Mukohara, MD, Tsutomu Shida,
Complete regression of a symptomatic, mycotic juxtarenal abdominal aortic aneurysm after treatment with fenestrated endovascular aneurysm repair  Jonathan.
A staged replacement of the entire aorta from the ascending arch to the hypogastric arteries using a hybrid approach  Juan Carlos Jimenez, MD, Wesley.
William J. Quiñones-Baldrich, MD, Thomas F. Panetta, MD, Candace L
Presentation transcript:

Surgery for chronic ruptured contained abdominal aortic aneurysm- a case report Grant Medical College Mumbai Dr Suraj Wasudeo Nagre-Associate Professor CVTS MBBS,MS,M Ch CVTS,DNB CVTS Dr Krishnarao N. Bhosle-Professor and HOD CVTS MBBS,MS,M Ch CVTS,FIACS

Introduction A chronic contained rupture of an abdominal aortic aneurysm (CCR-AAA) is a well- documented subtype of abdominal aortic aneurysm (AAA) rupture in which the hematoma is sealed by the retro-peritoneum first described by Szilagyi et al. in 1961. A diagnostic and therapeutic dilemma - lack the typical features of hemorrhagic shock

A chronic contained rupture of an abdominal aortic aneurysm (CCR-AAA) constitute only 4% of all ruptured aortic aneurysms. Patients are often stable for variable periods of time and may only present with abdominal or back pain.

Chronicity of the rupture is suggested by the clinical presentation and is confirmed at operation by the presence of organised thrombus within an extra-mural mass, which communicates with the abdominal aorta

Treatment Options Endovascular stenting - Costly Open surgery - Morbid Hybrid approach- combination of both open surgery and endovascular stenting

Case Report 27 year-old indian female who presented with a 6-month history of low back pain and a mass per abdomen. Patient also had past history of pulmonary kochs ten years back for which she received six months of antitubercular therapy. On examination, she had a pulsatile expansile abdominal mass with good femoral and distal pulses

A contrast enhanced CT scan with an aortogram demonstrated a 8 A contrast enhanced CT scan with an aortogram demonstrated a 8.8cm partially thrombosed pseudoanerysm just after the origin of superior mesenteric artery extending to both the common iliac artery. The length of the aneurysm was approximately 12.5cm of the aorta and 0.5 cm of the common iliac arteries.CT also showed involvment of both renal arteries origin in the aneurysm

Treatment Option We have two treatment option hybrid approach [surgical bypass Y grafting of both renal arteries from external iliac artery followed by stenting of abdominal aorta by intervension radiologist ] and other option is total open surgical. But the patient is not affording for hybrid treatment as stent is costly so decision taken for total surgical repair of the abdominal aortic aneurysm.

Technical Challenges The possibility of aortic wall infection and abdominal sepsis required careful pre- operative planning-clinical examination Kidneys protection during the entire surgery was planned preoperatively-DTPA scan and cold perfusion of kidneys with less ischemic time. Thrombosed aneurysm mass to excise- Proper vascular control Both iliac artery perfusion-Using Y graft

Planning

Left Thoracoabdominal Approach

Cutting Diaphragm by cautery

Mobilising Left Kidney

Suturing of 6 mm PTFE graft to left renal artery

Left Ileorenal bypass grafting with 6 mm PTFE graft

Cannulating descending thoracic aorta above the diaphragm

Abdominal aortic aneurysm

Aneurysm opened with cautery

Excised thrombus from aneurysm [ 8cm by 8cm ]

End to end aortobiiliac Y grafting [ 24mm by 9mm ]

Right Kidney The right renal artery was canulated using a coronary canula and cold ringer lactate was infused to maintain cold ischemia of the right kidney during the entire procedure. Right renal artery then anastomosed directly on the graft

Closed left thoracoabdominal incision

Postopt Course Patient extubated after 6 hours and discharged after ten days. Cultures of the aortic wall and thrombus all yielded negative results for bacteria and fungi including TB and brucellosis. A follow up ultrasound abdomen showed no collection in the peritoneum/retroperitoneum and a patent functioning aorto biiliac graft and a left iliorenal graft .

Conclusion The results of planned repair of AAAs are generally superior to those of urgent repair, it seems advisable that, once diagnosed, repair of a chronically contained ruptured AAA should proceed as a planned event, allowing time for adequate pre-operative preparation and the gathering of appropriately skilled personnel.

Open surgery as compared to endovascular management is technicaly challenging but cost effective. Patients with low financial income - open surgery was the only valid and better option. Though it was difficult but with proper planning and protocols ,surgery seems to be easy with better results.

The one who works with his hand is a craftsman The one who works with his hand is a craftsman. The one who works with his mind is a scientist. The one who works with his heart is an artist. But the one who works with his hand,mind and heart is a CARDIAC SURGEON…….