Aortic Case Reviews: What Would You...

Aortic Case Reviews:What Would You Do???

Jeffrey Jim, MD, MPHS, FACS

Associate Professor of Surgery

Program Director, Vascular Surgery Training Programs

DISCLOSUREJeffrey Jim, MD, MPHS

• Consulting Fee: Medtronic

Department of SurgerySection of Vascular Surgery

Acute Dissection w/Rupture

• RW: 57M presented w/acute chest and back pain

• CT showed acute type B dissection with contained rupture and transferred

• What do you do???


Acute Dissection w/Rupture


Juxtarenal AAA

• 76 CAD (EF 25%), COPD, creatinine 1.3 w/5.9 cm juxtarenal AAA

Case from Dr. Starnes


Juxtarenal AAA – “with a twist”

Two LEFT accessory 3 mm renal Arteries

RIGHTstenosis




• 3V ZFEN: large fenestration for SMA and L renal arteries



• Flouroscopy time 19 minutes: 78 mL Visipaque


Acute Dissection w/Malperfusion

• LF: 77F admitted to OSH w/acute chest, back and abdominal pain

• CT showed acute type B dissection

• Admitted for monitoring, had two blood BMs

• Eventually transferred

• Abdominal pain, elevated WBC/lactate



Acute Dissection w/Malperfusion


Isolated Iliac Aneurysm

• 60 neurosurgeon, pulsatile LLQ mass, no PMH/PSH, healthy and works out everyday

Case from Dr. Starnes


Rupture – Failed EVAR

• 87M w/acute abdominal pain

• Failed repair of migration 9 months prior

• Juxtarenal is about 5 cm

• RIGHT renal coming off aneurysm sac

• On Xarelto




• Completion angiogram showed gutter leak



Intraoperative Endoleak

• 69F incidental 5.9 cm AAA

• PMH: HTN, CHF, HC, COPD (home oxygen)

• Planned “standard” EVAR



• “short” follow-up (2 weeks)


Chronic Aortic Dissection

• 81M w/acute TBAD two months ago, medically management

• PMH: Prior endovascular iliac aneurysm repair

• On follow-up, thoracic aorta enlarged from 5.6 cm to 6.4 cm




• On follow-up, thoracic aorta enlarged from 6.4 cm to now 7.6 cm



Endovascular Graft Failure

• 84M w/multiple EVAR procedures in the past

• 1998: straight tube EVT

• 2003: bifurcated EVT (proximal endoleak)

• 2007: Palmaz stent (type III endoleak)

• Presents w/proximal type Ia endoleak, type Ib (L iliac limb)

• PMH: end stage renal disease on hemodialysis, atrial fibrillation, coronary artery disease, congestive heart failure



Presents w/acute rupture




• Aorto-uni-iliac repair

• AUI graft 32-113 (SMA to LEFT external iliac artery)

• Occluded to RIGHT CIA

• Extensive endarterectomy and femoral to femoral artery bypass

• Symptoms resolved

• CT showed resolution of prior hematoma but contrast in aneurysm sac

• Persistent in second CT scan (2m)

• What do you do?

Aortic Case Reviews: What Would You...

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