EndoAAA repair - Reilly
Preop: CT (preferably with contrast) to measure aorta and iliac length, diameters. Also assess how long
neck is and relationship of renal takeoffs. Non-con CT ok if creat high.
Instruments and Equipment
Major Vascular Pack A & B
1 Ioban Drape – 6650
1 C- arm Drape
1 Petri Dish
1 Medium Weck Clip
2 10cc Syringes
1 Steristrips ½”
2 18fr Red Robinson Catheters cut into 3” pieces)
1 Sterile Sleeve
Minor Vascular Pan 1
Neuro Basin
Major Vascular Pan 1 & 2
Vascular OMNI Pan 1 & 2
1 Angled Artery Clamp
2Rummel Stylets
2 Henly Retractors
1 Castroviejo Needle Holder
1 Doppler – prn
1 Dull Weitlaner
1 Lateral Retractor
2-0, 3-0, 4-0 Silk Ties
3-0 Silk dtach 18”
5-0 Prolene x 4
3-0 Ethilon x 2
Dacron Tape x 3
Vessel Loops x 2
2-0 Vicryl SH x 2
3-0 Vicryl SH x 2
4-0 Monocryl x 2
1 Large Gelfoam
1 20,000u Topical Thrombin
2 Heparin 10,000u
1 Bacitracin 50,000u
Marcaine 0.25%
Visipaque from Pyxis – center core
ZENITH GRAFT – Opened by circulator and Surgeon onto long back table as well as:
1 10cc Syringe
Neuro Basin
Setup:
Art line before induction, General anesthesia (local not ok), kefzol 1g IV, no TEDS, no SCDs, Foley, 2 good
IVs, no OG. Arms tucked bilaterally. Clipper groin hair. Setup joystick and rails for CArm controller. Prep
nipples to knees with chlorhexidine wash then duraprep. Towel off perimeters. Use towel, then sleeve to
groin. Ioband all. Drape with 2 U drapes, then endodrape on top. Set up 2 bovies, 2 suckers. C-arm comes
in from patient’s left.
Operation:
1. open Zenith stents, confirming size and lengths for patient. Pull back packaging wire, breakaway
sheath, and tip cover. Flush back end with heparin 10U/mL. Fill sheath chamber with 5cc heparin
(1000U/cc), then flush with mini heparin (10U/cc). repeat for leg extensions.
2. incisions bilateral: 4-5cm transverse (slight oblique) 1cm below inguinal ligament, centered on CFA
3. dissect transversely to femoral sheath then vertically incise fem sheath sheath, dissect out 4cm
length of CFA.
4. pass umbo tape + rommels prox and distally. Use blue vessel loops to control side vessels.
Proximally, get above circumflex iliacs if possible. Double loop side branches.
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place tunneling counter-stab inferiorly with 11 blade. then use double puncture needle set to enter
CFA bilaterally. Insert roadrunner wire and then dilate both sides up to 7F sheath
give ~100U/kg heparin. Check ACTx q30min and rebolus 1000-2000U to keep ACT 2x normal
From right, guide 0.035 angled glidewire (200cm) + 5F Kumpfe (65cm) through AAA to aortic knob
Pull angled glidewire, insert Lunderquist “stiff” wire with tip at aortic knob.
On the left, guide angled glide wire or roadrunner to aortic arch, then use it to guide 100cm
angiographic catheter (straight, mult sidehole) with tip near takeoff of SMA (above renals). This is
about the level of L1.
On right, confirm main body graft has been loaded correctly by manufacturer by fluoro and confirm
orientation of limb. Then pull right 7F sheath and insert main body graft into R CFA and guide into
aorta.
Shoot angiogram to identify renal takeoffs (20cc x 20cc/sec with power injector). Mark on screen.
Deploy stent with mesh just under renal takeoffs
Upcap and deploy top part to anchor stent
Reinsert angled glide into left angiocath to fill in holes, then withdraw angiocath and exchange for
Kumpfe catheter.
Cannulate left limb of main body graft. Pull angled glide
Rotate 5F Kumpfe to ensure free within lumen of main graft on 2 views
Reinsert angled glide and advance Kumpfe superior to main body stent. Pull angled glide, use
kumpfe to shuttle Amplatz stiff wire, remove Kumpfe
Shoot angio thru 7F sheath to identify hypogastric takeoff, then pull 7F sheath and insert left
extender graft. Deploy. Leave in wire. Withdraw gray portion entirely, leaving black sheath.
Now withdraw main body delivery system after recapturing cap. Sheath stays in.
Load right limb extension into main body sheath. Place tip in external iliac.
Shoot angiogram via main body sheath (pre-fill chamber with contrast, then flush out with hep
sailine) to indentify R hypogastric takeoff.
Insert right limb stent and deploy. 1.5-2 segment overlap.
Dilate each limb and aorta with 32cm CODA balloon catheter, syringe injection by hand with 1/3
strength contrast.
If necessary, deploy wallstents or Palmaz stents to smooth out distal limbs and plasty. Stents are
always 12mm because 12mm is the diameter of the limb extension stents, regardless of the distal
(iliac) diameter.
Shoot final angiogram to r/o endoleaks, occluded sidebranches
Lights on, pull sheaths
Close arteriotomies with 5-0 prolene
2-0 dexon, 3-0 dexon, the 4-0 monocry to skin
Check distal pulses
Postop:
Pulse checks q1h overnight in ICU, po pain + morphine BTP, continue ASA, no SQ heparin, no other
anticoagulation (want endoleaks to clot). Transfer ward POD1. Home POD1 or 2. Postop fevers typical from
repair and generally not infectious.
f/u 2 weeks.
CT A/P 4-6 weeks after to diagnose endoleaks + PA, lat, RAO, and LAO views.