Interventional Cardiologist: Dr. A

Co-Surgeon: Dr. B

TITLE: Percutaneous endovascular repair of abdominal aortic aneurysm with
stent in the graft.

INDICATION FOR THE PROCEDURE: This is a gentleman with
diagnosed abdominal aortic aneurysm, without rupture. The aneurysm was
followed and had a CTA performed earlier in the year, with the size of the
aneurysm at 62 mm. The patient has known coronary artery disease with
status post bypass surgery and recent percutaneous coronary intervention
with drug-eluting stent of his left main and circumflex. He also has
known bilateral peripheral vascular disease with bilateral fem-pop
bypasses. Pros and cons of endovascular procedure was in detail discussed
with the patient. Consent was obtained, procedure was commenced.

ANESTHESIA: Anesthesia was provided by anesthesia Department. The
patient was intubated and sedated by protocol.

DESCRIPTION OF PROCEDURE: Vascular access was obtained first to the right
common femoral artery with micropuncture kit. The access was obtained
with a 7 French sheath to the right common femoral artery. The 6-French
IM catheter was placed through the sheath and angiogram of the left iliac
and femoral artery was obtained. Then, under the angiogram control, an
access of the left common femoral artery, again with a micropuncture kit
was performed. The arteriotomy site was preclosed with two PerClose
closure devices, then a stiff wire was placed and access was predilated
with 10 and 14 dilator and then 17-French sheath into the ipsilateral left
femoral artery was placed. Angiogram was performed to remeasure vessel
length, reevaluate the anatomy and suitability of a percutaneous
intervention and the ipsilateral left and contralateral right access
vessels were not predilated. The initial stiff Bentson wire was exchanged
on the ipsilateral side for super stiff 0.035 inch wire. Then, we loaded
the 25-110-20-30 AFX2 bifurcated device until the stiff wire from the left
access and advanced the contralateral wire up through the 17-French AFX
introducer sheath using wire guide. Contralateral wire was snared with a Tulip
snare and pulled out from the contra side. AFX2 bifurcated device was then
transferred into the AFX introducer sheath and advanced under fluoroscopy
control until the distal limbs were above the aortic bifurcation releasing the
limbs of the graft. Then, entire system was pulled down onto the aortic
bifurcation and the main body of the graft was deployed by pulling on the
control cord handle. We deployed the
contralateral limb by pulling the yellow limb, then advancing a pigtail
catheter over the contra wire until the tip was in contact with the wire
lock. Held the pigtail catheter in place and pulled on the contrawire to
relieve it from the wire lock.

Deployed the ipsilateral limb by pin the inner core and retracting the AFX
introducer sheath. Then we advanced and deployed the 28-95 infrarenal and
the graft and performed angiogram to visualize the renal arteries. The
endograft was deployed exactly below the renal arteries without any
obstruction.

At 20-25/55, iliac extension was placed on the left side and deployed. We
performed the final angiogram with a pigtail catheter positioned to the
abdominal aorta which showed excellent procedural result with excellent
stent graft position, no evidence of endoleak and full coverage of the
aneurysm. Then the catheters were removed. The 7 French sheath from the
left femoral artery was pooled and proglide sutures were tightened. This
allowed excellent hemostasis on the left. The heparin used during the
procedure was reversed by protamine. The right femoral sheath was pulled
and access site controlled with a manual pressure. Procedure was
completed.

CONCLUSION:

1. Large abdominal aortic aneurysm 6.2 cm in diameter, nonruptured.
2. Successful percutaneous endovascular repair of the abdominal aortic
aneurysm with Endologix bifurcating AFX2 devise with infrarenal graft
extension and left iliac covered stent extension.
3. The patient to
continue his current medications and will be followed by standard
protocol, expect discharge on 06/28/2017.