The patient was kept on the operating table and general anesthesia was given, fully catheter was introduced and connected to gravity drainage bag, a line was placed. Abdomine was then prepped and draped in the usual fashion extending from nipples up to the mid thighs. Groin towel was placed and secured in place with the help of staples. Vertical incision was made in the right groin at the palpable pulsations of the common femoral arteries. The skin and subcutaneous tissues were cut in the line of incision, bleeding points encountered were coagulated with the help of Bovie, approximately 1 and 1/2 inch of the common femoral artery was dissected free and encircled with the help of vessiloops, a second identical incision was made on the left side of the palpable pulsation of the left femoral artery. Skin and subcutaneous tissues were cut in the line of incision and bleeding points encountered were coagulated with the help of Bovie.
Common femoral artery was dissected free and encircled with the help of vessiloops, 5000 units of heparin were given intravenously both the vessels were entered using 18 gauge angiocath and 0.035 glide wires were placed on both sides, 7 french sheath was placed. Angiograms were performed from both sides to identify the iliac anatomy, they looked like normal non-tortuous fairly large sized iliac arteries. At this time the guide wire was advanced superiorly into the aorta using a five french guide and angioscan an angiogram was performed. We identified the openings of both renal arteries and the aneurysm was clearly identified and so was the bifurcation. A marker board was placed behind the patient on the table and the superior line was aligned to the renal arteries inferior to the bifurcation, at this time the markers were counted and it seemed like a 15 centimeter long graft was appropriate so a 16 millimeter graft was obtained. This graft was initially prepped by irrigating heparinized saline solution through the capsule and through the introducing lumen and the balloon was nicely deflated.
The wire was exchanged to a 0.035 length super stiff Amplatz wire from the right side then a 25 french by 20 centimeter long ancure sheath was introduced over the guide wire and under fluoroscopy control could easily be seen. The dilator was pushed to expand the sheath and then the dilator was withdrawn, the sheath was secured at a position with help of a number 20 silk stitch, on the contralateral side the sheath was exchanged to an 11 french pinnacle sheath that was also secured into positon with the help of a number 30 silk stitch. A large snare was then introduced by the radiologist from the left side and the contralateral wire was then introduced through the sheath as the device was placed over the guide wire. The contralateral wire was introduced which was snared and brought out through the left side, we noticed a wrap and then the device was withdrawn back, it was rotated 360 degrees and then reintroduced, at this time a wrap was seen. At the bifurcation the device was totally introduced into the aorta and taken super renal to completely be taken into the aortic aneurysm.
After proper orientation of the capsule on the left side the sheath was withdrawn and unjacketed. After placement of a 5 french angiogram catheter an angiogram was performed to identify the bifurcation real nicely. The bifurcation was nicely marked the device was withdrawn back as the left limb was taken down on the left side, the markers were placed right at the origin of the renal artery on the left side which is the lowest renal artery, then number 2 portion of the device was pulled to release the stint. At this time the mean pressure was dropped to 70 systolic and then the balloon lock was released. Balloon was withdrawn into the proximal stint and then inflated to 2 atmospheres to nicely place the stint within the lumen within the wall of the aorta. The balloon was inflated 3 times then it was deflated to fill the graft nicely, inflation was kept superiorly.
A torque catheter was introduced by the radiologist who locked the capsule on the left side, it was withdrawn nicely into the left iliac limb using a cutter the overlying sheath was cut and then the left limb was nicely deployed allowing the wire to go up nicely into the aorta, leaving the wire there angioplasty was performed using a 12.5 balloon at 1 to 2 atmospheres and then the balloon was deflated completely to allow the right limb to fill. The right limb was deployed by first unjacketing the right limb and then a number 4 portion of the device was pulled releasing the stint, the entire device was then pulled down the jacket guard was brought through the stint nicely the balloon was postioned within the stint and angioplasty was completed at 1 atmosphere.
Then the balloon and the device withdrawn the second 12.5 balloon was then introduced, angioplasty was performed at 2 atmospheres both balloons were taken in both limbs and angioplasty was performed in a kissing fashion. The angiogram catheter was then inserted again and just above the attachment sight angiogram was performed, no leak was seen, nice filling of the graft and complete exclusion of the aneurysm was seen. At this time the wire was withdrawn from the left side and arteriotomy was closed with the help of number 5.0 proline purse string sucher, the arteriotomy was closed on the right side after withdrawing the sheath.
We applied the angle debakey clamps to common, profunda, and superficial femoral arteries, our rectirotomy was closed with help of number 5.0 prolene before suchers were tied and back bled in all directions. Suchers were tied flow was initially established to the profunda and to the superficial femoral artery, both feet were carefully examined they were nice and pink with doppler signals present in both sides. The wound was thoroughly irrigated and closed in 2 layers using a number 3.0 pds for the subcutaneous tissues and skin was approximated using staples. Sterile dressings were applied, patient was awaken on the table and transferred to the recovery room in a very stable condition.