ENDOVASCULAR REPAIR OF COMPLEX EXTRA-CRANIAL SUPRA-AORTIC ANEURYSMS
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1 ENDOVASCULAR REPAIR OF COMPLEX EXTRA-CRANIAL SUPRA-AORTIC ANEURYSMS Deep Chandh Raja, MD DM DNB Fellow in Interventional Cardiology, The Madras Medical Mission, India Primary Operator: Dr George Joseph, MD DM Head of Department, Cardiology, The Christian Medical College, Vellore, India
2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company The Madras Medical Mission The Madras Medical Mission nil The Madras Medical Mission nil nil nil
3 Disclosure Statement of Financial Interest I, Deep Chandh Raja DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation
4 Case 1 CT angiogram-3d reconstruction 46-year-old woman Anterior view Pulsatile right-sided neck swelling Hoarseness of voice - right vocal cord palsy x 6 months Road traffic accident 5 years back No infections, CAD, DM, HTN
5 A Intra-thoracic extension Compression of esophagus Displacement of trachea B Retro-clavicular position
6 Anterior view Complex anatomy 1. Width: 52 mm 2. Mouth: 37 mm 3. Bifurcation 4. RCCA arising
7 Treatment options Surgical Hybrid Endovascular
8 Hybrid option RCCA to right axillary artery bypass 2. Vascular plug in right subclavian artery beyond aneurysm 3. Innominate to RCCA stent-graft
9 Treatment options Surgical Hybrid Endovascular
10 Anterior view Vertebral dominance: Left Subclavian: 8 mm Carotid : 7 mm Innominate: 11 mm
11 Exteriorized guidewire
12 Deployment of self-expanding stent grafts Carotid: 10x80 mm; Subclavian: 10x120 mm
13 Super-imposition of self-expanding bare metal stents Carotid: 10x60 mm; Subclavian: 10x80 mm
14 Kissing-balloon dilatation
15 Hemostasis: Femorals: Proglide R vascular closure device Radial: Wrist band Post-op: Palpable right arm and carotid pulses Self-limiting pyrexia DAPT x 1 year
16 Follow- up CT angiogram at 6 months Patent Stents; No endo-leaks
17 Case 2 62-year-old-woman Pulsatile Left neck swelling x 3 years H/O trauma 6 years back No DM, HTN, CAD, infective etiology
18 Baseline CTA Coronal Sagittal Axial Location- LICA; LICA diameter- 6mm Aneurysm neck- 30 mm; Size- 36x24x25 mm
19
20 Self-expanding stent graft 8x60 mm
21 Reinforced with Self-expanding bare-metal stent 8x80 mm
22 Final angiograms- No endo-leaks Tortuous distal course of LICA Tortuous proximal course of LCCA
23 Procedure uneventful Hemostasis: Femoral: Proglide R vascular closure device Post-op: No neurological deficits DAPT x 1 year
24 CT ANGIOGRAM 6 MONTHS AFTER PROCEDURE - Patent stent graft - No endo-leaks
25 Challenges overcome: Case 1 Bifurcation aneurysm with Carotid arising Innovative techniques- Kissing-Stent Subclavian tortuosity Exteriorized guidewire- Rail-Road Pre Post
26 Pre Challenges overcome: Case 2 Carotid tortuosity Minimizing manipulations angled Terumo guide wire (260 cm) cut short 2-3 steps Post
27 ACKNOWLEDGEMENT OPERATOR: Dr George Joseph, The Head of Department, Christian Medical College, Vellore, India Physicians: Dr Ezhilan Janakiraman Dr Jaishankar Dr Ajit S Mullasari Thank you Team from: The Madras Medical Mission, Chennai, India -id: deepchandh@gmail.com
28 Challenges overcome Case 1 Bifurcation aneurysm with Carotid arising Innovative techniques- Kissing-Stent Subclavian tortuosity Exteriorized guidewire- Rail-Road Case 2 Carotid tortuosity Minimizing manipulations angled Terumo guide wire (260 cm) cut short 2-3 steps
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