Case 2 Day 1
Case 2 ( please use evidence to support your answer when available)
A 82-year-old female with a history of chronic kidney disease and incidental finding of 6 cm abdominal aortic.
Q1: What is the important factors to consider in this lady’s history and clinical examinations.
Q2: What is your approach in management of this lady?
After discussions the patient choose to udergo endovascular aneurysm repair (EVAR). The procedure involves bilateral femoral access and the deployment of a stent graft.
Q3: What type of sheath is most appropriate for this EVAR procedure? Discuss your Access strategy.
1 hx factors ass with AAA .. advancing age , smoking hx HTN , family hx of connective tissue dx.
examination . General regarding vitals, tachycardia and hypotension may signify leakage, abdominal exam . Diffuse tenderness may indicate rupture , distal pulse assement including femoral for future access and tibial pulse doe postoperative follow up
2 preoperative planning including full lab. ECG and CXR , MRAortogram with out contrast of the pt is not on hemodialysis and I’d ESRD on dialysis for CTA Aortogram.
Sizing of the AAA with measurement of the lowest renal and neck size with measurement of max diameter and both iliacs with determining on landing zone distally including internal iliac artery patency and disease.
3 …6 f sheath for passage of wire and pigtail angiography, larder sheath size 22-24 sheaths are needed for deployment of the stent .
Q1:
In history: diabetes, HTN, hyperlipidemia, smoking, age, cardiac history, familial history
in examination: check for distal and all pulses, abdominal pulsation, exclude pop. Aneurysms, vital signs & HB level , conscious level
Q2: labs: CBC, coagulation profile, kidney function, liver function and virology, ECG and echocardiography
order MRA for lesser nephrogenic toxicity
patient education for her disease and her family about the nature of the diseaase and how the treatment and intervention will go
Q3:sheaths sizes usually ranges from 18-24F by femoral approach
first we begin with 6F sheath size with hydrophilic standard wire 0.035 then after angiography and using pig tail catheter replacable with super stiff wire and the larger sheath
depends with cut down or percutaneous approach if it is feasible for the patient
A1 in history
patient complain any abdominal or back pain any ecchymosis
risk factors like DM -HTN- smoking – hyperlipidemia
family history and drug history
other comorbidities like cardiac or CKD as it may increase complication
in examination
general like vital signs
abdominal for any pulsation – ecchymosis – palpation of aortic swelling any signs of peritonitis
limb examination for distal pulsation – any pop aneurysm
A2 approach
labs like CBC – kidney function test – coagulation profile
lipid profile
ECG – echo – pulmonary function test
imaging
CTA or MRA according to contrast toxicity and levels of kidney function
as patient old age and has CKD it is better to go with endovascular repair EVAR using low contrast or CO2 angio
and open surgery as a 2nd option
I will discuss with the patient her condition and her general status and treatment option and possible complication
A3 access through bil femoral
may be through cutdown and direct closure with prolene sutures or us guided puncture and closure devices
sheath
start with 6 FR sheath and exchange with large sheath from 18 to 24 fr sheath according to device
1- being a female with 6 cm aneurysm,her age group, ckd means heavy calcium load, elongated tortious rigid vessels, BMI, cardiac condition, Lower limb ischeamia, previous surgeries of abd or groins
2- prepare for EVAR with mra for planning and co2 for repair if not on dialysis, or if on dialysis contrast may be used for cta and repair with arrangement for dialysis after contrast use
3_ bilateral femoral cutdown and direct repair of femoral arteriotomies and brachial access for through and through wire to straighten highly tortous vessels if anticipated
Q1:
history :
>> CKD, as it increases the risk of contrast-induced nephropathy (CIN) during interventions.
mostly, i will go for CO2 angiography or reduced contrast use considered.
>> Age (82 years):
Advanced age drives me towards endovascular management.
>> symptoms : pain, back pain, abdominal discomfort as it may urge the intervention.
Clinical Examination:
>> Cardiovascular Examination:
for chest and heart for bruits, peripheral arterial disease, or signs of heart failure or chest disease.
check bp is important.
>> Abdominal Examination:
scars of previous abdominal surgeries as we may need open intervention any time
tenderness (possible sign of impending rupture).
Q2: Approach to Management
>> Imaging:
CT angiography with low contrast volume to assess aneurysm anatomy (diameter, length, neck , iliac artery condition ).
> preoperative fitness for surgery (especially cardiopulmonary and renal function).
> Medical Therapy as blood pressure control.
preoperative medications as acetylcysteine and sodium bicarbonate as they reduce CIN.
>> intervention EVAR is the preferred in elderly patients
Q3:
>> Sheath Type:
hydrophilic coated 12–18 French sheaths depending on the device.
*Use of hydrophilic-coated sheaths reduces vascular complications during large-bore access (Journal of Vascular Surgery, 2018).
>> Access :
US guided bilateral femoral access, if unsuitable we may consider brachial access
we can use percutaneous closure devices.
: Important Factors to Consider
History:
Age: Advanced age increases the risk of complications from both the aneurysm and the procedure.
Chronic Kidney Disease (CKD): CKD can increase the risk of complications, such as bleeding, infection, and poor wound healing. It also affects the choice of contrast agents and medications.
Medications: Review all medications, including anticoagulants, antiplatelet agents, and nephrotoxic medications, which may need to be adjusted before and after the procedure.
Prior surgeries: Any history of abdominal or vascular surgeries can influence the surgical approach.
Clinical Examination:
General physical examination: Assess overall health status, including cardiovascular and pulmonary function.
Abdominal examination: Palpate for an abdominal mass and auscultate for bruits.
Peripheral vascular examination: Assess peripheral pulses to evaluate lower extremity circulation.
Q2: Management Approach
Risk-benefit assessment: Discuss the risks and benefits of EVAR versus surveillance with the patient and family. Consider the patient’s age, overall health status, and aneurysm size.
Preoperative evaluation:
Imaging: Obtain a CT angiogram to assess the aneurysm size, morphology, and iliac artery anatomy.
Laboratory tests: Evaluate renal function, coagulation status, and complete blood count.
Consultations: Consult with a nephrologist, anesthesiologist, and a vascular surgeon.
Optimize medical conditions: Optimize blood pressure, blood sugar, and any other medical conditions.
Antibiotic prophylaxis: Administer appropriate antibiotic prophylaxis before the procedure.
Postoperative care: Monitor for complications, such as bleeding, infection, and graft thrombosis.
Q3: Sheath Size and Access Strategy
Sheath Size: The appropriate sheath size depends on the diameter of the iliac arteries and the size of the stent graft delivery system. Typically, sheaths ranging from 18 to 24 Fr are used for EVAR. However, larger sheaths may be required in some cases.
Access Strategy:
Bilateral Femoral Access: This is the most common access approach for EVAR.
Puncture Site: The common femoral artery is usually accessed below the inguinal ligament.
Sheath Insertion: The sheath is carefully inserted over a guidewire and advanced into the iliac artery.
Hemostasis: After the procedure, the access site is closed using a closure device (e.g., Perclose ProGlide) or manual compression.
Alternative Access Sites: In cases where femoral access is not feasible (e.g., previous groin surgery, iliac artery tortuosity), alternative access sites such as the axillary or brachial arteries may be considered.
Important Considerations:
Minimally Invasive Technique: Strive for a minimally invasive approach to reduce the risk of complications.
Patient-Centered Care: Involve the patient in the decision-making process and address their concerns and questions.
Multidisciplinary Approach: Collaborate with a multidisciplinary team, including vascular surgeons, interventional radiologists, anesthesiologists, and nephrologists.
Q1: general assessment for her condition and history for her renal condition followed by examination for her aneurysm and her rest arterial tree with ankle brachial pressure
Q2: the patient needs imaging to asses aneurysm diameter site and for planning the intervention but regarding her kidney disease CTA won’t be the preferred best option and should MRA be used +/- CT without contrast
Q3: according to diameter measurement by MRI wether to use bilateral femoral exposure or iliac exposure with iliac conduit
Then 6fr sheath initially followed by larger shethes like 18 fr
Left Brachial access for in ability to cross contralateral gate
Q(1):
History: assessing renal functions, hypertention, smoking, D.M
Examination:
Pulses of both CFAs, brachial artery, assessment of fitness for surgery, preoperative good hydration to prevent contrast induced nephropathy.
Q(2):
CTangiography with 3D imaging to asses the aorta (size, morphology), iliacs
MRA in case of contrast hypersensitivity or elevated renal functions.l
Control of BP and asess the surgical fitness, ECG.
Q(3):
start by bifemoral arteries cutdown and retrograde access of bpth using 8 frch sheath and introduction of stiff wires then change sheaths to 14 or 18 Frch and deployment of stent grafts.
Left brachial artery cannulation may be considered too or cut down of one of CFAs.
Important Factors in History and Clinical Examination
Assess renal function (eGFR, creatinine levels) to minimize contrast-induced nephropathy.
Pulses examination especially femoral pulses and Lt brachial pulse
Pre-procedure hydration and nephroprotective strategies are crucial.
Fitness and risk assessment
CTA for aneurysm assessment
Approach to Management
Preoperative work up for fitness and risk assessment then Renal function and hydration protocol. Then CT angiography (AAA size, morphology, iliac access)
Decision evaar vs surgery according to anatomy and fitness
Sheath and Access Strategy
Sheath Size: Typically 14-18 Fr sheaths are used for EVAR.
Access Strategy: Bilateral common femoral artery access under ultrasound guidance.
With preparation of Lt brachial a acsess if needed
Q1
-Personal H : smoking ,alcholism
-Past H : Dm, htn , valvular heart diseses
-Surgical H : abdominal op , piles , Varicose veins , flat foot , eye disease mesenchymal weakness
-Present H : abd pain radiated to back
palpitation
-Family history : prvious AAA
Clinical exam ::
General :
pulse ( volume, rate , rhythm
Biltaral ll pulse exam from cFA till pedal
Bp monitoring
Cardiac auscultation for mitral affection
Local :
Abd exam for rigidity , extension of pulse into flanks
—————-
Q2 aneurysm > 5.5 cm need
-elective repair EVAR
-Control BP < 138/90
-Open AAA repair
—————
Q3
Access bilateral femoral us guided by small sized sheath 8
Then introduce stiff wire bilateral
Then change to sheath 12/14 according to stent sizing
Using non ionic contrast media to avoid CIN as pt is CKD
Factors to be considered
Patient family history social for smoking medical for comorbidities DM HTN IHD CKD and stroke along with surgical history of previous abd ar cardiac surgery and history of allergies and medications like anti platelets or anti coagulation
Examinations include peripheral pulsations abdominl or groin and brachial scars cardiac condition and function any signs of infection or aneurysm complications
Approach
Clinical
Investigations through abd us CTA according to kidney functions may need good hydrartion and prepration before contrast and MRA for anatomical considerations regarding the planning and sizing in case of EVAR OR clamping time of the renals in case of surgery
Sheaths
Femoral cut down both sides or per cutaneous access with 8 F sheath to deliver the stiff wires bilat and exchange with the large sheaths to deliver the system according to device size
A1.. of important interest to ask about is history of smoking, DM, Hypertension, cardiac history and history of previous stroke.
Also family history of previous AAA
During exam in addition to local examination of the abdomen, peripheral pulse examination is very important as it gives us an idea about state of peripheral vessels (atherosclerotic occlusive disease or distal showering from the AAA)
A2.. since the guidelines advice intervention in female AAA when it is 5 cm or more according to ESVS2019 guidelines it is calssIIb Level c
So I will ask for MRA as the patient is CKD and contrast may increase the harm to his kidneys then I will plan for elective EVAR. Here there will be possibility of renal failure if contrast will be used during the procedure so EVAR with IVUS use to accurately locate the renal vessels is an option other wise open surgical repaired is a good choice
A3. FOR EVAR we need bilateral retrograde access from the groin and sometimes we need additional antigrade access from brachial artery
At first I will start by small sheathes 7 to 9 fr. I will use it to deliver the stiff wire to cross the aneurysm till the arch of aorta then I will replace it with a bigger sheath suitable for the main body size and contralateral gait size
Q1: Important Factors in History and Clinical Examination
Assess renal function (eGFR, creatinine levels) to minimize contrast-induced nephropathy.
Pulses examination especially femoral pulses and Lt brachial pulse
Pre-procedure hydration and nephroprotective strategies are crucial.
Fitness and risk assessment
CTA for aneurysm assessment
Q2: Approach to Management
Preoperative work up for fitness and risk assessment then Renal function and hydration protocol. Then CT angiography (AAA size, morphology, iliac access)
Decision evaar vs surgery according to anatomy and fitness
Q3: Sheath and Access Strategy
Sheath Size: Typically 14-18 Fr sheaths are used for EVAR.
Access Strategy: Bilateral common femoral artery access under ultrasound guidance.
With preparation of Lt brachial a acsess if needed
Q1: full history of diabetes and hypertension and smoking and hyperlipidemia
history of lower limb pain or abdominal pain
family history of any first degree relatives with same picture
examine all peripheral pulses
Q2:good control of the comorbidity if present like control of diabetes and hypertension
full labs and ECG if any abnormalities would refer to a cardiologist
assessment of the creatine level and if possible will go for CTA to assess the anatomy of the AAA and good planning and according to the guidlines female patient with 6 cm AAA this is an indication for intervention
i will offer her both options surgical or endovascular using CO2 as media for imaging
Q3:both femoral access can be accessed using either femoral cut down or totally percutenous using large bore sheath and closing using closure device
i will choose the side of good diameter femoral and iliac arteries with less tortuousity for the main body device