Management Of An Undersized Thrombosed Aortic Stent
Daniel Badia, DO, David Minion, MD.
University of Kentucky, Lexington, KY, USA.
DEMOGRAPHICS:A 57 year-old female presents with a several month history of acute onset of disabling claudication, progressing to rest pain and non-healing ulcers of the digits, bilaterally. Co-morbidities include Hypertension, Hyperlipidemia, COPD, tobacco abuse, DM, and Hypothyroidism. HISTORY:Past surgical history was remarkable for placement of an aortic stent 13 years prior for similar symptoms. Review of records revealed that her initial aortic stent was a self-expanding nitinol stent with a diameter of 10 mm. CTA confirmed occlusion of the stent and infrarenal aorta with severe undersizing of the stent. Pre-op stress test revealed a moderate reversible defect in the inferior wall. Family History was significant for aortic occlusive disease and her mother died from complications of aorto-bifemoral bypass. PLAN: After discussing options, patient elected for attempted endovascular salvage of the aortic stent. Despite the several month chronicity of the symptoms, a guidewire traversed the stent fairly easily, prompting an intra-operative decision for thrombolysis. The thrombus cleared over the subsequent 48 hours revealing a high-grade proximal in-stent stenosis, treated with angioplasty. To reduce the risk of recurrence, the patient subsequently underwent exclusion of the undersized stent by traversing a wire around the outer perimeter of the stent, then crushing it with an endograft deployed alongside in the aorta. The aortic bifurcation was further reconstructed using kissing iliac stent grafts overlapping into the aortic endograft. DISCUSSION:This case is consistent with our prior observations that even fairly chronic aorto-iliac occlusions will often respond to thrombolysis. Further, it demonstrates that undersized stents do not necessarily require explant, but instead can be excluded with advanced endovascular techniques.
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