Complete endovascular visceral reconstruction for mycotic paravisceral aortic aneurysm
Dimitrios Koudoumas, MD, PhD1, Mariel Rivero, MD2, Hasan H. Dosluoglu, MD2.
1SUNY at Buffalo, Buffalo, NY, USA, 2Division of Vascular Surgery, Department of Surgery, VA Western New York Healthcare System, Buffalo, NY, USA.
DEMOGRAPHICS: We report a case of 60-year-old male with history of polysubstance abuse, hypertension, hepatitis C, and coronary artery disease with recent stenting of the mid-circumflex artery.
HISTORY: He who presented with three week history of mid back pain, which started three weeks after a coronary intervention, had negative blood cultures, WBC:7.2 (48.6% neutrophils), CRP:1.1, ESR 46mm/h and CTA showed paravisceral aortitis with aneurysmal degeneration.
PLAN: After bilateral percutaneous femoral access and bilateral brachial artery exposure he underwent complete endovascular visceral reconstruction with 4-vessel-snorkel/periscope technique using Gore Excluder cuff x 3 (28.5 x 33 mm, 32 and 36 x 45 mm), balloon expandable covered endoprosthesis Gore VBX 8x29mm and 8x39mm for the celiac trunk, 8x59mm and 7x29mm for the superior mesenteric artery in snorkel fashion, self-expanding covered endoprosthesis Gore Viabahn 6x75mm and scaffold self-expanding bare metal endoprosthesis Medtronic EverFlex 7x60 mm for the right renal artery, Gore Viabahn 6x50mm and Medtronic EverFlex 7x40mm for the right renal. Postoperative CT showed infolding of the last placed cuff proximally with no infolding in the distal portion at the location of the renal stents. After celiac and SMA recannulation via brachial access, IVUS was used to verify the intraluminal position of the wire from femoral access and a Palmaz stent was placed with inflated balloons in the SMA and celiac arteries. Postoperative CT showed correction of the infolding. His abdominal pain subsided, he completed a three-month duration of IV ceftriaxone and vancomycin and transitioned to oral Bactrim for a total of 12 months. His follow up CT scan showed complete resolution of the aortitis. Thirteen months following initial intervention, he was planned to have colonoscopy and his antiplatelets were stopped. Following Golytely induced diarrhea, he developed flank pain and was found to have occluded renal stents bilaterally on CTA, although this was not read as such by remote radiologist. He was admnitted to ICU, was anuric, and vascular team was called in am and after 14-16 hours of warm ischemia he underwent emergent Angiojet thrombectomy and thrombolysis during which no abnormalities in the stents or the renal arteries by IVUS were identified. He required three sessions of hemodialysis.
DISCUSSION: Complete endovascular visceral reconstruction with snorkel/periscope technique may be a viable option especially in cases with mycotic paravisceral anureysms
Back to 2019 Abstracts