1. Vascular DnC Sundeep Guliani April 23, 2015

2. Dx: Type 2 thoracoabdominal aneurysm Procedure: 1) Aortomesenteric debranching 2) Thoracoabdominal stent grafting Complication: Post-operative intracranial bleed, death

3. HPI 71 yo lady 6.7 cm thoracoabdominal aneurysm PMH: CHF (EH 40%), obese

4. Case Two stage management – Mesenteric Debranching – Thoracoabdominal stent grafting Stage 1: Mesenteric debranching – Complicated by SMA/R renal artery graft thrombosis requiring revision

5. Stage 2 Initial prolonged ICU course, transfer out of ICU, renal recovery POD 22 TEVAR/EVAR – L Subclavian Artery uncovered Post op ICU admission: Spinal Cord precautions – Lumbar drain, MAP push – Normal movement/sensation

6. POD 29/7 Awaiting lumbar drain removal, Tx out of ICU Altered MS, intubated Large intraventricular/ intraparenchymal bleed Withdrawal of care On aspirin, SQ heparin, normotensive (no MAP push), no therapeutic anticoagulation

7. Catheter-directed thrombolytic therapy Use increasing – Acute limb ischemia, deep vein thrombosis, mesenteric ischemia, PE

8. Contranidications to catheter directed thrombolysis

9. High incidence of adverse events Increase incidence of blood transfusions, intracranial bleeds, hematoma associated with catheter directed thrombolytic therapy

11. ICU Monitoring Monitoring for complications of thrombolytic therapy Strict control of hypertension Fibrinogen, hemoblobin checks, changes in neurological exam Duration generally limited to 48 hours because of increase incidence of bleeding/intracranial events

12. Conclusions Unclear if this complication was avoidable by modifying our management Adequate risk stratifying for thrombolytic therapies for other surgical diseases can modulate risk of intracranial bleeds