Shane S. Parmer, MD, Jeffrey P. Carpenter, MD

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Presentation transcript:

Techniques for large sheath insertion during endovascular thoracic aortic aneurysm repair Shane S. Parmer, MD, Jeffrey P. Carpenter, MD Journal of Vascular Surgery Volume 43, Issue 2, Pages A62-A68 (February 2006) DOI: 10.1016/j.jvs.2005.10.063 Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 1 Balloon angioplasty of the external iliac artery is performed via a femoral arteriotomy. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 2 A ringed stripper is passed through the arteriotomy to further define the dissection plane. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 3 The dissected atheromatous plaque, including the intima and inner media, is removed with a clamp. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 4 Upon completion of the stent graft procedure residual disease within the common iliac artery is treated with a stent and the arteriotomy is closed. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 5 Incision placement for retroperitoneal exposure of the common iliac artery or distal aorta. Only the surface of the access vessel needs to be exposed. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 6 Placement of a double pursestring suture in the access vessel. Each of the concentric purse strings is constructed of 4-0 polytetrafluoroethylene-impregnated polyester suture for native vessels and 2-0 polypropylene sutures for Dacron graft initiated on opposite sides of the vessel and held by rubber tourniquets. The artery is punctured in the center of the purse string and a guidewire is inserted and manipulated into the proximal aorta. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 7 Sheath placement. The sheath with its tapered dilator is placed over the stiff wire and fluoroscopically guided into the common iliac artery or aorta. The tourniquets can be used to control any puncture site bleeding around the sheath. All further exchanges occur through the sheath with its hemostatic valve. Sheath removal is accomplished with simultaneous traction on both purse-string sutures to relieve tension on the puncture and maintain hemostasis while the sutures are sequentially tied. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 8 Avulsed external iliac artery after deployment of the endovascular stent graft. Journal of Vascular Surgery 2006 43, A62-A68DOI: (10.1016/j.jvs.2005.10.063) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions