SET 2022 Abstracts

Brian Fazzone, Michol Cooper

brian.fazzone@ufl.edu, michol.cooper@surgery.ufl.edu

8642938120, 7342552451

University of Florida, University of Florida

1600 SW Archer Road
Attn: Dept of Surgery
Gainesville, FL 32608

Abstract Body:

This case presentation describes our management of a patient with extensive Iliocaval and femoral thrombosis due to caval stenosis several years after right nephrectomy for Wilm’s tumor. Prior to presentation to our hospital, the patient failed attempted thrombectomy and thrombolysis with tPA at a referring institution. We initially planned for elective repeat thrombolysis; however, the patient represented to our hospital with refractory pain and lower extremity swelling. Given the caval stenosis, prior failed thrombectomy with thrombolysis attempt, and patient’s severe symptoms, we proceeded with Iliocaval and femoral angioplasty and stenting. During this case presentation, we discuss choice of access site, use of IVUS, catheters and wires used for recannulation, and stent and balloon choice. Specific teaching points include how to recannalize chronic occlusions from the bilateral femoral veins up to the renal vein with durable results.

Relevant History, Physical Exam & Test Results

Teaching points:

Specific teaching points include how to recannalize chronic occlusions from the bilateral femoral veins up to the renal vein with durable results.

Sara Eileen Hensley, Michol Cooper

sara.hensley@surgery.ufl.edu, michol.cooper@surgery.ufl.edu

2702052502, (734) 255-2451

University of Florida, University of Florida

1600 SW Archer Road
Gainesville, FL 32608

Abstract Body:

Phlegmasia dolens is a highly morbid complication of lower extremity deep venous thrombosis (DVT) and is associated with a high risk of limb loss and mortality. Management options include catheter-directed thrombolysis, percutaneous mechanical thrombectomy, or open thrombectomy.

We present a case of phlegmasia in a patient who presented with bilateral lower extremity DVT with thrombus extending into the inferior vena cava (IVC) proximal to a previously placed IVC filter. His presentation and exam were concerning for early phlegmasia. He was initiated on a heparin infusion and taken urgently to the operating room for endovascular intervention. Bilateral posterior tibial (PT) venous access was obtained at the ankle and a bilateral venogram confirmed venous occlusion from the PT vein to the IVC. Thrombectomy of the bilateral PT, popliteal, femoral, external iliac (EIV) and common iliac veins (CIV) was performed using the CAT8 mechanical thrombectomy catheter. Repeat venogram showed residual thrombus in the right EIV and CIV. The right femoral vein was accessed and thrombectomy of the right EIV, CIV, and IVC filter using CAT12 mechanical thrombectomy catheter was performed. Repeat venogram and intravenous ultrasound (IVUS) showed widely patent venous system except for narrowing and scarring at the level of the IVC filter. Right internal jugular access was obtained and the IVC filter was retrieved via a 12 French catheter using the Cook IVC filter retrieval system. Repeat venogram and IVUS showed stenosis at the level of the previous IVC filter. Venoplasty of the IVC was performed using a 22 mm high pressure balloon. Repeat venogram showed residual scar/chronic thrombus at the level of the previous IVC filter which was removed using a CAT12 mechanical thrombectomy catheter. Completion venogram showed widely patient lower extremity veins and IVC. The patient was transitioned from a full intensity heparin infusion to Eliquis on POD 1 and discharged home on POD 2. He was seen in clinic one month post-operatively with resolution of his symptoms other than trace residual bilateral lower extremity edema. He will remain on lifelong oral anticoagulation.

Relevant History, Physical Exam & Test Results

The patient had history of DVT in 2016 after bilateral hip surgery at which time he underwent IVC filter placement and completed three months of low molecular weight heparin therapy. His IVC filter was never removed. He endorsed two weeks of numbness and tingling of the bilateral feet which prompted a MRI of the lumbar spine which was normal. The numbness and tingling progressed to bilateral lower extremity swelling, worsening pain, and inability to ambulate. He presented to an outside hospital at which time arterial duplex study showed patent arterial vasculature but noted non-compressible common femoral veins (CFV), femoral veins, and popliteal veins bilaterally. On initial examination in the emergency department (ED), the patient’s lower extremities were swollen and tender, and his dorsalis pedis pulses were palpable. Bilateral viscosities were noted. His leg compartments were soft and there were no signs of acute limb ischemia. Cross-sectional imaging confirmed extensive bilateral lower extremity DVT with extension into the IVC proximal to the previously placed IVC filter. His labs were unremarkable.

Teaching points:

Teaching points
(1) The importance of PT vein access to optimize inflow in the setting of extensive lower extremity DVT
(2) The ability to completely remove acute venous thrombus using PT and femoral vein access with mechanical thrombectomy
(3) The importance of removing IVC filters in a timely manner to prevent limb threatening complications

Brett Fowler, Michael McNally, Scott Stevens

bfowler1@utmck.edu, mmcnally@utmck.edu, sstevens@utmck.edu

8435988466, 2524140893, 8654068509

University of Tennessee Medical Center, University of Tennessee Medical Center, University of Tennessee Medical Center

1924 Alcoa Highway
Knoxville, TN 37920

Abstract Body:

6 Vessel Fenestrated Endovascular Repair of Type III Thoracoabdominal Aortic Aneurysm using Hybrid Physician Modified Endograft and Laser In-Situ Technique

Fowler BB, Stevens SL, McNally MM

PURPOSE: Case report demonstrating successful use of antegrade in-situ laser fenestration as an adjunctive tool in complex endovascular aortic aneurysm repair.
METHODS: 75-year-old woman presented with a symptomatic 6.4cm Type III thoracoabdominal aortic aneurysm after previous infrarenal aortic stent graft and left inferior renal artery stent. Preoperative imaging demonstrated enlargement of a known thoracic aortic aneurysm from 5.9 to 6.4cm in the paravisceral aorta with unique anatomy of bilateral paired renal arteries. Due to age and functional status, the patient elected to proceed with an endovascular repair. After spinal drain placement and 3D CTA fusion, a bare metal stent was placed in the right inferior renal artery to pair with the prior left inferior renal stent. A tapered thoracic aortic stent graft was deployed in the descending thoracic aorta. After visceral vessel fenestration alignment, a physician modified thoracic aortic stent graft(Medtronic Navion) was deployed between the thoracic stent graft and previous infrarenal stent graft. All four fenestrations were then cannulated and bridging stent grafts(Atrium Icast) were deployed sequentially with a 10×20 mm balloon angioplasty. A 12F Aptus steerable sheath and 1.7mm Spectronetics laser catheter were then used to make antegrade in-situ laser fenestrations for each inferior renal artery. Each prestented inferior renal artery was cannulated with 0.14 guidewire, fenestration dilated with 5x20mm balloon and bridging stent grafts(Atrium Icast) sequentially placed with proximal 10mm balloon angioplasty. Completion aortogram showed all stents to be patent with adequate end organ perfusion. The patient had an uneventful postoperative course and was discharged to a rehab facility.
RESULTS: One month CTA revealed a Type III endoleak at the celiac stent. Secondary intervention with celiac stent extension was performed with endoleak resolution. Surveillance imaging at 18 months showed durable repair with six visceral vessel stent patency and without endoleak.
CONCLUSION: In-situ laser fenestration technique in complex endovascular aortic surgery is a viable option in complex aortic anatomy otherwise not amendable to open repair or traditional endovascular techniques.

Relevant History, Physical Exam & Test Results

A 75 year old female with a symptomatic 6.4 cm Type III thoracoabdominal aortic aneurysm after prior EVAR.

Teaching points:

The In-Situ Laser Fenestration technique is a feasible alternative repair option in challenging aortic aneurysm anatomy and initial studies are encouraging.

Erik M. Anderson, MD, MS, Michol A. Cooper, MD, PhD

erik.anderson@surgery.ufl.edu, michol.cooper@surgery.ufl.edu

9499397318, 7342552451

University of Florida – UF Health Shands Hospital, University of Florida – UF Health Shands Hospital

1600 SW Archer Rd.
Gainesville, FL 32610

Abstract Body:

This case presentation describes the endovascular management of an acute type-A aortic dissection in a frail elderly female patient with limited mobility. Imaging was reviewed and we determined that the patient would be a suitable candidate for TEVAR coverage of the dissection, which was recommended given her poor operative candidacy. Intraoperatively, IVUS measured true lumen diameter as 34mm. A 10cmx40mm Gore Tag covered thoracic stent graft was selected and deployment was performed during rapid pacing via temporary pacing wires. Graft exclusion and patency of the coronary and innominate arteries were confirmed on post-deployment aortogram. The patient is currently recovering with resolution of dissection-associated symptoms. In conclusion, type-A aortic dissections can be selectively managed with thoracic stent grafts in poor surgical candidates. During the case presentation we will discuss the anatomic requirements for TEVAR coverage of the ascending aorta, operative considerations, as well as other device considerations (e.g. thoracic branch endoprosthesis).

Relevant History, Physical Exam & Test Results

The patient is an 80-year-old female who presented after experiencing severe tearing chest pain while she was transferring from bed to her wheelchair. She was stable on presentation with a heart rate of 56 beats per minute and a blood pressure of 112/70mmHg. Admission labs were: hemoglobin 13.1g/dL, hematocrit 40.7%, creatinine 0.97mg/dL, and lactic acid 2.23mmol/L. Imaging revealed a type-A aortic dissection with the entry tear located mid-zone 0.

Teaching points:

Acute type-A aortic dissections can be successfully managed with thoracic stent grafts in patients that are poor surgical candidates. However, there are several anatomic requirements for TEVAR use in the ascending aorta. The entry tear must be located distal to the aortic root and there should be no valvular involvement in the extent of the dissection. The patient cannot have a history of coronary artery bypass grafting, and distance from the sino-tubular junction to the innominate artery must be at least 10cm to accommodate the graft without coronary or innominate artery coverage. ~32% of type-A dissections meet these requirements. Gore Tag thoracic branch endografts may also be available in the future for the management of dissections of the ascending aorta. There is an ongoing investigational device exemption trial (ARISE) looking at the feasibility and outcomes of these thoracic branched devices.

Antony Gayed, Ricardo Yamada

gayed@musc.edu, yamada@musc.edu

8436701532, 8438143721

MUSC, MUSC

Department of Radiology Medical University of South Carolina
96 Jonathan Lucas Street CSB Suite 210
Charleston, SC 29425

Abstract Body:

A 39 year-old woman presented to the ER with one day of bloody stools. Her medical history included DMI and ESRD with a 2011 RLQ pancreas and LLQ kidney transplant complicated by acute rejection now requiring HD and insulin pump. At presentation, she has mild epigastric pain; Hb is 8.4. Started on a PPI gtt and admitted. GI consulted. She continues to bleed; EGD performed with no bleeding. Colonoscopy demonstrates blood-filled colon and blood “pouring” from IC valve. Requires 9u pRBCs and 6 FFP. VIR consulted for emergent embolization.

Relevant History, Physical Exam & Test Results

Teaching points: