descending thoracic aneurysm complicating …...resume outcome •so we end up by a remodeling that...
TRANSCRIPT
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Descending Thoracic Aneurysm complicating subacute aortic dissection
with significant right common iliac secondary tear and static malperfusion of
right kidney, unexpected outcome
Prof. Dr. A. El Samadoni M.D
Cairo University
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Our Patient• LATE 40’S MALE
• RECENTELY DISCOVERED HYPERTENSIVE
• PRESENTED WITH EPIGASTRIC PAIN MISTREATED FOR GASTRITIS
• DYSPNEA ON LYING FLAT
• ECHOCARDIOGRAPHY COMPRESSION OF RIGHT ATRIUM
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CT ANGIOGRAPHY
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Strategy
• Lt. Brachial access• Lt. femoral cut down for device
– Gore TAG 40 X40 X 150 mm
• Rt. Femoral percutaneous 6 Fr access • Plan
– Cannulation / fenestration of right renal artery – Device positioning flush with Celiac artery – Covered stent 6 mmX 39 mm right renal – Covered stent 10 mm X 59 mm right common
iliac
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Procedure
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Negotiation of RCIA Tear
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Cannulation RRA
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Post Deployment
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Challenges
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Out Come
• Failed to trail a device along the right renal wire
• Choose to abort the procedure (1 hour)
• Plan for three weeks procedure with appropriate tools e.g. Microcatheter
• Post operative – Tight control of blood sugar
– Slight temporary rise of S. Creatinine
– Discharged with planned procedure in two weeks
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Later on
• The patient skipped his follow up for 9 months
• Presented for regular follow up with
– Controlled blood pressure
– No more Dyspnea
– Good renal function
• Ordered for follow up CT
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EXPECTATIONS
Progression of Malperfusion and Loss of Rt. Kidney
Expansion to infrarenal Aortic aneurysm
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POST CT
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AnalysisAt Main Entry
post pre
Expansion of the true lumen with rim thrombosis of the false
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At Celiac Artery
post pre
Maintained Expansion of true lumen with flow at shrinking false lumen with thick matured flap
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At Rt. Renal Artery
Post Pre
Perfusion of the Rt, renal artery with mature flap 5-6 mm With maintained expansion of the true lumen
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Infra-Renal Aorta
Post Pre
Expansion of the TRUE Lumen and maintained 12 mm channel for rt. Kidney perfusion
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Resume
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Outcome
• So we end up by a remodeling that result in
– Aneurysm shrinkage
– Expansion of the true lumen
– Nature induced tube like channel resembling an ilio-renal bypass
• The patient is scheduled for tight follow up watching for further ?? Positive Remodeling
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Option ???If things goes wrong
• Without aortic diameter increase
– Right common iliac covered stent with surgical Ilio-Renal Bypass
• With Aortic diameter increase
– EVAR deployment and Ilio-Renal Bypass
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WARM GREETINGS FROM CAIRO UNIVERSITY