Case 2 Day 2
Q4: Which guidewire is most appropriate for tracking the stent graft into the aneurysm sac? What other wires you need to use in this case ?
Q5: You notice that the external Iliac artery on the left side is heavily calcified and stenosed ? How to do you approach this?
Q6: In your final angiogram run you notice that there is no flow down your left EIA and CFA. What are your next steps?
Q6: After the procedure, what closure strategy is most appropriate for managing the large-bore femoral access site?
A4 super stiff wire for adequate support and leverage of stent , Rosen wire or hydrophilic for pigtail guiding for angiography
A5 retrograde balloon angioplasty , or transbrachial delivery of stent
A6 exploration with iliac exposure and endarterctomy with patching
A7 large bore closure can be done by suture closure device in percutaneos access or closure by 6/0 proline in open CFA exposure
Q4: superstiff wire to be delivered within the graft system ,preceded by standard hydrophilic 0.035 wire within pigtail 5F catheter for angiography
Q5: to be dilated before the procedure before the delivery of the main body , because if failed , it could go for unilateral graft system and fem-fem bypass
Q6: it may be due to thrombosis, kinking and recoil or dissection , so you need to reballoon or put a self expanding stent at EIA or another covered stent
Q7: it will need direct surgical closure by prolene 5-0
A1 we start with standard wire to cross the aneurysm sac then exchange it with extra stiff wire like Lundquist to insert the stent graft
A2 we may use balloon diltation or atherectomy devices
we may use dilators
A3may be due to thrombosis which is managed with Fogarty thrombectomy or mechanical thrombectomy
may be a dissection and it managed with stent graft of EIA
may be due to malposition of the stent graft so we do revision
we may need to do fem- fem crossover bypass
A4 closure either through direct suture with prolene in case of CFA cutdown
or closure devices as poglide in U/s access
4- super stiff wire landerquest with fixed distal end on the table, standard wire for angiogram
5- heavily calcified EIA can be bypassed by iliac conduit as in TEVAR, or some companies has serial arterial dilators, or cancelled from the start with aorto uniiliac device and fem fem bypass
6- if the problem is tortiousty led to obliterate the outflow of distal end of the iliac limb or flow limiting dissections and the wire inplace, an extention self expanding endograft may be deploed with overlap into the iliac limb til a healthy segment
If endo reopening failed or the lt iliac limb is fractured a femfem bypass is done
7-direct surgical repair by transforming the sheath inlet into transverse arteriotomy patch repair
Q4:
the main guidewire is Lunderquist guidewire as it is ideal for stent graft tracking due to its extra stiffness, also we will use hydrophilic Terumo wire intially.
we may use Rosen Guidewire for more challenging anatomy.
Q5:
>> retrograde balloon angioplasty using high-pressure balloon as it is calcified.
>> If it is not feasible we may consider contralateral femoral access with crossover techniques or other access brachial..
Q6:
the possible causes are
> Thrombosis: Acute thrombus formation within the vessel.
or
> Dissection: Traumatic vessel injury during the procedure, or from pre procedure ballooning
or
> Device Malposition.
Management according to the cause:
Thrombosis:
intra-arterial thrombolysis or thrombectomy using a Fogarty catheter for clot removal if necessary.
Dissection:
insertion of a covered stent.
Device Malposition:
Reposition the stent graft limb.
we also may consider fem fem bypass
Q7:
MANTA Closure Device as it is designed for large-bore arterial access (up to 20 Fr).
Q4: lunderquist guide wire , treumo stiff guide wire
Q5: angioplasty for the for EIA , brachialor axillary access
Q6 ballooning of the iliac limb of the evar if there is kink ,crumbling or even extension of stents grafts
Thrombectomy to the CFA and EIA the taking another DSA if still occlusion present then I should use plug and fem-fem bypass
Q7: open approach the classic closure with 6-0 sutures
If percutaneous approach was used the proglide should be used
Q(4):
Lunderquist guide wire for tracking and stabalization of the stent graft of lesion.
Terumo hydrophilic guide wire to cross the calcific lesion.
Q(5):
Trial of retrograde balloon dilation of LT EIA or brachial access.
In case of failure: Aorto-uni-iliac stent graft and fem-fem bypass using synthetic graft.
Q(6):
Trial of thrombolysis of thrombosed sent graft of LT EIA and CFA.
Or CFA thrombectomy and FEm-Fem bypass.
Closure device in case of percutaneous access or suturing in case of cutdown.
Guidewires for EVAR
Lunderquist guidewire (stiff wire): For tracking and stabilizing the stent graft.
Hydrophilic wire (e.g., Terumo Glidewire): To cross stenosed or calcified iliac arteries.
Management of Heavily Calcified and Stenosed Left Iliac Artery
Aortic uni iliac graft+fem fem. Or Pre-dilatation or Use of a covered stent if severe diseases
Or use brachial access
No Flow in Left EIA and CFA on Final Angiogram
Thrombectomy Vs Balloon Angioplasty to Re-expand the stent if it is collapsed.
Closure Strategy for Large-Bore Femoral Access Site
Open access by classic surgical tech if percutaneous access we use of closures device
First we use hydrophilic 0.35 terumo wires and exchane to superstiff wires
In case of lt EIA stenosis i will avoid by delivering the main body through the rt side and angioplasty of the lt would be preferable before deployment of the contralat limb
In case of lt side with no flow i will make sure that the sheath is not occluding the artery and if it is not the cause i will try aspiration thrombectomy or trans femoral thrombectomy and dissection should be excluded first
Closure device in case of percutaneus access or stitching of arteriotomy with prolene
A1. Stiff landriquest wire of cook is used for teaching the stent graft and also trauma guide wire is used at first to facilitate crossing the aneurysm at first
The stenosed calcified iliac vessel can be solved by angioplasty at first using CO2 As an imaging tool or using iliac conduit
A3.. if it could not by solved by endo vascular means as thrombolysis if it is thrombosis or embolectomy I think fem-fem. Bypass is a good option
A4.. closure depends on the approach if percutaneous I will use the preclose suture based closure devices. And if I uses open access . Siple direct closure by proline sutures
Q4: Guidewires for EVAR
Lunderquist guidewire (stiff wire): For tracking and stabilizing the stent graft.
Hydrophilic wire (e.g., Terumo Glidewire): To cross stenosed or calcified iliac arteries.
Q5: Management of Heavily Calcified and Stenosed Left Iliac Artery
Aortic uni iliac graft+fem fem. Or Pre-dilatation or Use of a covered stent if severe diseases
Or use brachial access
Q6: No Flow in Left EIA and CFA on Final Angiogram
Thrombectomy Vs Balloon Angioplasty to Re-expand the stent if it is collapsed.
Q7: Closure Strategy for Large-Bore Femoral Access Site
Open access by classic surgical tech if percutaneous access we use of closures device
Q4 super stiff guide wire and hydrophilic guide wire to deliver the diagnostic pig tail catheter
Q5:i will choose the right side for deployment of the main device
and may do ballooning for the stenotic lesion before deployment of the contralateral gait
Q6: i may use extension stent to secure the run off of the contralateral limb
Q7: using preclosure device