Co-Surgeon 1
FINDINGS: There was total occlusion of the prior aortobifemoral graft without any mechanical component found in a patient who does have protein S deficiency. Thrombectomy was done of the infrarenal aorta, disclosing firm/rubbery thrombus with final thrombus remnant covered by 3 overlapping iCast 10 x 39 mm Endografts, with good flow restored. Bilateral iliac limb occlusion was present due to soft degenerative thrombus, which was fully cleaned by thrombectomy bilaterally. Scant thrombus was found in the femoral arteries which was easily removed by retrograde thrombectomy. The final result showed a widely patent aortobifemoral graft with torrential flow down both iliac limbs.
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PROCEDURES:
1. Aortogram with bilateral runoff.
2. Exploration of the bilateral femoral arteries and repair.
3. Thrombectomy of the infrarenal abdominal aorta.
4. Thrombectomy of the bilateral iliac limbs.
5. Thrombectomy of the bilateral femoral arteries.
6. Placement of Endografts in the infrarenal aorta.
7. Balloon dilatation of the infrarenal aorta and iliac limbs.
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DESCRIPTION OF PROCEDURE: The patient was placed on the hybrid operating room table in satisfactory position, with all surfaces carefully padded and protected and full hemodynamic monitoring, with a good level of general endotracheal anesthesia. The abdomen, groins, both legs circumferentially were prepped and draped in sterile fashion in contiguity. Vertical incisions were made over the site of prior aortobifemoral limb placements, and these were taken down to the level of the Endografts. The hood on the femoral arteries was exposed. The patient was systemically heparinized, and ACT results were used to maintained therapeutic anticoagulation during the procedure.
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The grafts were opened transversely after preparation for control using silastic loops of Potts configuration and vascular clamps. Large amount of degenerative thrombus and degeneration products was removed from the iliac limbs. Thrombectomy was done with Fogarty catheters of multiple sizes and with over-the-wire Fogarty as well. Fluoroscopy was used to monitor the position and effectiveness of the Fogarty devices. The abdominal aorta was imaged multiple times and thrombectomy controlled with angiographic puff imaging. Multiple devices and equipment were used to thrombectomize the infrarenal abdominal aorta. These included Coda balloons, 10 mm Fogarty balloons, large tulip snare, front-runner catheter to macerate the thrombus, and Coda balloon to compress the thrombus against the infrarenal aortic and graft wall. Large sheaths were placed bilaterally, up to 12-French on the right side and up to 16-French on the left side, which would fit only a centimeter or 2 within the graft limb. This was later replaced by a 14-French graft limb sheath, through which the final thrombectomy was carried out in the aorta.
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Both limbs were fully cleared of degenerative thrombotic material. This left a rubbery-appearing, well-formed ovoid thrombus in the infrarenal aorta with multiple maneuvers now allowing blood flow across this into the iliac limbs. At this point, continued passage of large Fogarty catheters was able to further macerate and expel more of this material, to the point where it appeared that the remaining thrombus could be compressed against the aortic and graft wall. Therefore, iCast stent grafts were passed and placed just at the origin point of the thrombus. The grafts were dilated to 16 mm in the most proximal graft, 12 mm in the 2 overlapping distal grafts. Angiography in the lumen disclosed complete resolution of thrombus in the flow channel. Final aortography showed the renals patent and no complication in the visceral circulation. The flow through the bilateral iliac limbs was torrential when the sheaths and all wires and catheters were removed.
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The step-by-step details of the procedure are not recounted in exact detail because of their complexity. The procedure required advanced endovascular techniques, and required the presence of 2 endovascular/open surgeons, who were required to perform precise maneuvers simultaneously. The surgeons were required to apply dual skills and complimentary analyses to conduct this operation. The operation also qualifies for a 22 modifier on the basis of the redo nature, the complex vascular elements which were dealt with, and the massive extent of thrombus in 3 major arteries, as well as the need for rapid technical responses to prevent excessive blood loss

Co-Surgeon 2:
COMPLICATIONS: Multiple interventions required. This was a significantly more complicated surgery because of the complexity of her problem and the requirements for multiple attempts at intervention to mechanically lyse and evacuate her distal aortic thrombus, requiring a 22 modifier and a co-surgeon as well
OPERATION PERFORMED: Bilateral femoral exploration, thrombectomy of aortofemoral graft, placement of wires and catheters, aortic angiograms with runoff. Multiple attempts with snares, wires, and multiple balloon catheters to try to fracture, lyse and/or retrieve her intraabdominal thrombus. Subsequent aortic angioplasty and stent placement x3 with iCast 10 x 39 stents, completion angiography, repair of femoral arteries. Also, distal thromboendarterectomy of the femoral, popliteal arteries bilaterally.
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DESCRIPTION OF OPERATION: The patient was placed on the operating room table in the supine position. After adequate endotracheal anesthesia, the abdomen, left axilla, and both legs were prepped and draped in the usual sterile fashion. Her previous longitudinal incisions were utilized. They were taken down through skin and subcutaneous tissue. Hemostasis was obtained with a Bovie electrocautery. The dissection was carried down on both sides to the limbs of the aortofemoral graft. The dissection was carried down to the anastomosis to the common femoral artery bilaterally. These anastomoses looked fine. There did not look to be any significant stenosis. The patient was systemically anticoagulated with heparin. After adequate anticoagulation, transverse graftotomies were performed on both distal limbs of the aortofemoral graft. Fogarty thromboembolectomy was performed, and the limbs were opened. However, it seemed like there was a significant plaque or thrombus in the proximal aortofemoral graft. Through catheter manipulation, we were able to get past this significant thrombus. Pieces of it were able to be divided from the main body, and when these pieces were harvested, they looked like fibrous rubber tissue. Multiple attempts with catheters, wires, and snares were utilized to try to break this thrombus up and deliver it out of the aortofemoral graft. Multiple angiograms were obtained as well. These attempts will be dictated separately by Dr. John Conn. These attempts were unsuccessful. However, we were able to make a significant channel up to the normal aorta, just below the renal arteries. For this reason, it was elected to trap or cage this plaque material by performing aortic angioplasty and stent placement. The patient’s aorta measured about 14 mm in maximal diameter. For this reason, we utilized iCast stents x3 to trap the plaque or thrombus against the graft and aortic wall. The proximal iCast stent was overextended to 14 mm. The remaining iCast stents were overextended to 12 mm. This caged or trapped the plaque or thrombus nicely, and gave a nice smooth infrarenal aortic lumen down to the bifurcations, which were then cleared out again with Fogarty balloons. At this point, there was indeed good inflow. Fogarty thromboembolectomy was performed distally, and good backbleeding was obtained. It needs to be noted that the patient was systemically anticoagulated throughout these procedures. Completion angiography again showed widely patent aortic lumen, no evidence of endoleaks, and good flow to the femoral vessels. The renal arteries were also visible and filled well postprocedurally. The lumens were flushed to remove any air or debris. The arteriotomies were reapproximated with running 6-0 and 5-0 Prolene, the wounds irrigated and inspected. It was noted hemostasis was intact. There was good flow in the native superficial femoral arteries bilaterally. The subcutaneous tissue was reapproximated with multiple layers of running 3-0 Vicryl, skin closed with skin staples, and sterile dressings applied. The patient tolerated the procedure well, having about 400 cc of blood loss. No blood was replaced. After the operation, all sponge, needle, and instrument counts were correct x2. The patient was delivered to the recovery room, breathing spontaneously and in stable condition.