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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3726_Библиотеки_им_академика_М_И_Перельмана.pdf
122
4 Abdominal Vascular Emergency
Fig. 4.9 Details from the emergency endovascular treatment. An occlusive balloon was placed via the left femoral artery (white arrows). The right femoral artery was
used to perform embolization of the right internal iliac
artery with microcoil occlusion of the “back door” (blue
arrows). Advancement of the two stent grafts, the rst,
measuring 8mm×59mm, placed distally in the external
iliac artery, and the second, with a diameter of
9mm ×59mm, placed proximally with complete pseudoaneurysm exclusion
4.1 Abdominal Aortic Emergencies
123
Fig. 4.10 Control contrast-enhanced CT 3months after
treatment. The –stent graft is open, and no endoleak is
shown. The proximal pseudoaneurysm is scheduled for
treatment at a later date. The pseudoaneurysm of the anastomosis on the left side will be treated together with the
scheduled proximal anastomosis treatment
124
ab
4 Abdominal Vascular Emergency
c
Fig. 4.11 Index CT scan (a and b) showing an “unusual” infrarenal aortic aneurysm. (c) FDG-PET scan showing
infective aneurysm (arrows)
4.1 Abdominal Aortic Emergencies
125
Fig. 4.12 Control contrast-enhanced CT showing a proximal anastomotic pseudoaneurysm and evidence of rupture
(arrows)
Fig. 4.13 An aortic stent tube graft was deployed infrarenally with an excellent outcome. The blue arrow indicates the
proximal anastomotic pseudoaneurysm
126
4 Abdominal Vascular Emergency
Fig. 4.14 Control contrast-enhanced CT 1 month after stent graft deployment shows a satisfactory result and no
endoleak. The patient developed a pseudoaneurysm in the right groin (blue arrow)
Fig. 4.15 Control CT 2months after stent graft deployment showed a new rupture and pseudoaneurysm on the distal
anastomosis (arrows), probably induced mechanically due to stiffness of the stent graft
4.1 Abdominal Aortic Emergencies
Fig. 4.15 (continued)
127
Fig. 4.16 FDG-PET scan showing infection of the right
axillo-femoral bypass and in both groins
one more surgery for removal of the infected
right axilla femoral bypass and creation of an
axillo-femoral bypass on the left side (Fig.4.17).
A few weeks after the last surgery, the patient
was readmitted again with abdominal pain, and
CT showed blowout syndrome and aortic stump
rupture (Fig.4.18). There were no further surgical options for the patient.
4.1.5 Abdominal Aorto-Iliac Occlusion
Key Points
• Extensive aorto-iliac occlusive diseases
can be treated with a covered stent with
good patency.
• The percutaneous approach under local
anaesthesia works for the majority of
the patients.
• Familiarization with some re-entry
devices is recommended.
128
4 Abdominal Vascular Emergency
Fig. 4.17 Control CT after the creation of a left axillo-femoral bypass-(orange arrows). Blue arrow indicates an
occluded intrarenal aortic stump
4.1.5.1 Aetiology andClinical
Presentation
A 67-year-old overweight patient with a long history of intermittent bilateral claudication was
admitted. Recently, the patient experienced signicant reduction and increasing pain during
everyday work. The ankle-brachial index (ABI)
was 50% on the right side and 55% on the left
side. The patient was a heavy smoker and took
antihypertensive medication.
4.1.5.3 Endovascular Treatment
Percutaneous access was achieved via both
femoral arteries under local anaesthesia, and a
preclosure suture was deployed. After some
time, it was possible to recanalize the occluded
common iliac arteries and infrarenal aorta.
Predilatation with 8 and 10 mm balloons was
performed. After that, a covered aortic stent
graft measuring 16mm×48mm was deployed
above the aortic bifurcation, followed by
deployment of two covered stents measuring
4.1.5.2 Pre-interventional Diagnosis
Contrast-enhanced MRI showed occlusion of the
infrarenal aorta and both common iliac arteries
(Fig. 4.19). The external iliac arteries, femoral
arteries, popliteal arteries and all three crural
arteries were open bilaterally.
9 mm × 59 mm in the common iliac arteries
bilaterally (Fig.4.20). Post-dilatation was performed with a balloon, and the nal angiography showed good results and no distal
embolization. There was no problem with
haemostasis.
4.2 Visceral Artery Aneurysms
129
Fig. 4.18 Blowout syndrome and aortic stump rupture- (arrows)
4.1.5.4 Outcome
4.2.1.1 Aetiology andClinical
The patient was discharged from the hospital the
next day and continued to be treated with acetylsalicylic medication. The ABI increased to 90%
bilaterally.
A 59-year-old patient with arterial hypertension
underwent contrast-enhanced CT due to unspecic abdominal pain lasting a few weeks after
ultrasound of the abdomen that showed aneurysm
in the visceral vessel. The patient did not experi-
4.2 Visceral Artery Aneurysms
ence vomiting, nausea, diarrhoea or blood in the
stool and was afebrile. White blood cell count
4.2.1 Splenic Artery-I
and other blood analyses were within normal
limits. There was no anamnestic information on
trauma or invasive vascular examination.
Key Points
• A plan B and even a plan C must be
considered.
• If the “back door” cannot be occluded,
the aneurysm can be embolized.
• Ultrasound can be used during the follow- up in stable cases.
4.2.1.2 Pre-interventional Diagnosis
Contrast-enhanced CT of the abdomen showed
an unruptured 59 mm splenic artery aneurysm
(Fig. 4.21). The patient had not undergone any
previous diagnostic examination. The strategy
was to attempt to deploy a stent graft via the left
brachial artery or, if not possible, to perform
Presentation
130
4 Abdominal Vascular Emergency
Fig. 4.19 Contrast-enhanced MRI of the lower extremities showing occlusion of the infrarenal aorta and common iliac
arteries (arrow)
embolization and occlusion of the splenic artery
with the stent graft.
attempt failed; therefore, the diagnostic catheter and later a microcatheter were advanced
to embolized the “back and front doors” of
4.2.1.3 Endovascular Treatment
A 6 Fr long sheath was advanced percutaneously
into the descending aorta through the left brachial artery, and an attempt was made to navigate a diagnostic catheter and guidewire across
the aneurysm and advance the stent graft. This
the aneurysm. It was not possible to advance
the microcatheter distally to occlude the “back
door”, and so the aneurysm itself was lled with
micro-coils. Finally, the main splenic artery
was occluded with 10mm micro-coils distal to
the dorsal pancreatic artery to allow vascular-
bc
ef
4.2 Visceral Artery Aneurysms
a
d
131
gh
Fig. 4.20 (a, b) angiography after recanalization show-
ing occluded distal abdominal aorta and iliac arteries
bilaterally. (c–e) pre-dilatation with 8- and 10-mm balloons on both sides. (f, g) deployment of a covered stent in
the aorta and both common iliac arteries and postdilatation. (h, i) control angiography showing a satisfactory result
i