ANESTHESIA: See anesthesiology report for details.
PROCEDURE:
The abdomen and bilateral groins were prepped and draped in standard surgical fashion after anesthesia, provided by anesthesiology service.
Bilateral groin incisions were made in the oblique fashion and cut down exposing the bilateral common femoral arteries just below the inguinal ligament, by the vascular surgery team.
A 19 gauge introducer needle was inserted through tiny incisions inferior to the oblique incisions a 18 French sheath was placed into the right superficial femoral artery.
Subsequently, a 19 gauge introducer needle was inserted into the left common femoral artery, without difficulty and 6 French sheath was inserted. Subsequently access was obtained into the left brachial artery and a 7 French sheath was placed over the wire.
A pigtail catheter was inserted into the aorta and an angiogram was performed obtaining size measurements. Access was subsequently obtained into the left renal artery via the left brachial artery access. Over the wire a 7 mm x 15 mm covered via bond stent was placed into the left renal artery. A 36 mm 4. Aortic cuff was placed to the level of the renal arteries. A second aortic cuff was placed.
A Coda balloon was used to appose the graft against the aorta and a 7 mm balloon used to appose the stent against the left renal artery together in a kissing fashion.
Final angiogram was performed using a pigtail catheter. demonstrates patency of the SMA and renal arteries bilaterally.
Bilateral renal arteries, hypogastric arteries and external iliac arteries were patent.
Subsequently, all wires, catheters and bilateral sheaths were removed.
The bilateral groin cut down was closed by the vascular surgery team.
Patient tolerated the procedure well without apparent immediate complications.
Patient was given 5000 units of IV heparin with boluses during the course of the procedure.
IMPRESSION:
Successful revision of abdominal aortic aneurysm stent using an aortic cuff and left renal artery stent (Snorkel technique)
Frequently Asked Questions
What is the snorkel technique in endovascular aneurysm repair (EVAR)?
The snorkel technique in EVAR involves placing a stent into a branch artery, such as the renal artery, to ensure its patency while repairing an abdominal aortic aneurysm. This technique allows for the main aortic stent graft to be placed without blocking important branch vessels, similar to a snorkel allowing air passage above water.
In the AAA repair using the snorkel technique, an incision is made to access the femoral and brachial arteries. Catheters and wires are used to position a stent in the renal artery, and an aortic cuff is placed at the level of the renal arteries. Balloons help ensure the stent and graft fit tightly against the arterial walls, ensuring proper blood flow and stability.
What are the benefits of using a snorkel technique in EVAR?
The snorkel technique in EVAR offers the benefit of maintaining blood flow to critical branch arteries, such as the renal arteries, during the repair of an abdominal aortic aneurysm. This method can be particularly advantageous in complex cases where traditional EVAR might risk blocking these arteries.
What types of anesthesia are used in snorkel EVAR procedures?
Snorkel EVAR procedures typically require general anesthesia, which is administered by an anesthesiology team. This ensures the patient remains unconscious and pain-free during the surgical process, allowing a vascular surgery team to perform complex and precise maneuvers safely.
What complications can occur from the snorkel technique in EVAR?
While the snorkel technique can effectively maintain vessel patency, potential complications include bleeding, infection, stent migration, or blockage. However, with careful planning and execution, these risks can be minimized. Patients are closely monitored during and after the procedure to address any issues promptly.
Why might a patient require a revision of their abdominal aortic aneurysm repair?
A revision of an abdominal aortic aneurysm repair might be necessary if the initial stent graft fails to maintain vessel patency, if there are leaks around the graft, or if any complications such as stent migration occur. The revision aims to restore stability and ensure proper blood flow.
How are the arteries accessed during an EVAR snorkel procedure?
During an EVAR snorkel procedure, the common femoral and brachial arteries are accessed through small surgical incisions. These access points allow the surgical team to insert sheaths and guide wires needed to place the stents and grafts accurately within the aorta and renal arteries.
What is the role of a Coda balloon in snorkel EVAR?
A Coda balloon is used in snorkel EVAR to help appose, or press, the aortic graft against the aortic wall. This ensures a tight fit and helps prevent blood from leaking around the graft, maintaining the integrity of the repair and ensuring effective blood flow through the repaired vessel.