Successful Hybrid Management Of Iatrogenic Complicated Aorto-bi-iliac Dissection After Cardiac Catheterization
Matthew Vuoncino, M.D., William J. Yoon, M.D..
University of California-Davis, Sacramento, CA, USA.
DemographicsThe patient is an 82-year-old man with a complex medical history including atrial fibrillation and coronary artery disease with prior coronary artery bypass graft.
HistoryThe patient was undergoing cardiac catheterization at an outside hospital who then developed bilateral iliac artery dissection with extension into the distal abdominal aorta with occlusion of distal aorta and bilateral iliac arteries with a significant retroperitoneal hematoma. Upon arriving at our institution, the patient had bilateral femoral arterial sheaths, right femoral venous sheath and retained wire through the right femoral arterial sheath which was cut externally and clamped with an instrument from the outside institution.
PlanWe performed a complex endovascular repair of the aorta and bilateral iliac arteries with left common femoral artery repair and left lower extremity fasciotomies.
DiscussionBecause the right femoral sheath was occupied with the aforementioned retained wire, the left femoral sheath was used to obtain an angiogram, which revealed severe aorto-bi-iliac dissection with a retained wire. Through the left femoral sheath, a dissection stent was placed to re-establish infra-renal aortic flow. Subsequent angiogram through the right femoral sheath revealed complex right iliac artery dissection. Despite several attempts, it was difficult to enter into the same dissection channel from the contra-lateral access; thus, we created a fenestration in the distal abdominal aorta, above the aortic bifurcation, followed with aorto-bi-iliac stenting in a kissing fashion. It was then evident that the previously placed left femoral sheath at the outside hospital was in the false lumen, necessitating mechanical thrombo-embolectomy with the deep and superficial femoral arteries and patch angioplasty of the common femoral artery. Completion angiogram had great flow of the abdominal aorta, bilateral common iliac, bilateral external iliac and right internal iliac artery. Due to prolonged ischemia, left lower extremity four compartment fasciotomies were performed.
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