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Interventional Cardiovascular Rounds

Coordinator: Dr. Hugo Londero
Moderator: Dr. Raúl Bretal

Case number 1: Complicated Endoprosthesis in an AAA

Presented by Dr. Oscar Mendiz

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He is a 60 years old male with the following arterial risk factors: Arterial Hypertension , previous smoker, Hypercholesterolemia and non-insulin dependent Diabetes Mellitus.
He has history of two previous Myocardial Infarctions (in 1981 and 1991).
In 1992 he received a Left Anterior descending coronary artery angioplasty.
In 1998 a PTA with two Stents implantation at the left femoral artery was performed in another hospital.
In August 1999 an abdominal CT Scan showed an AAA of 6.8 by 6.6 cm with eccentric mural thrombosis.
An Abdominal Aortic angiography was performed and confirmed the diagnosis, aneurysm had a 23 mm infrarenal neck with moderate angulation, the right External Iliac artery showed a moderate obstruction, (Figure N°1 A) an in-stent restenosis was observed at the left Profunda Femoris Artery (Figure N°1 B) and bilateral occlusion of Superficial Femoral Arteries.

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In September 1999 the AAA was treated with a bifurcated Stent-Graft implantation (26/12/165 Vanguard II - Boston Scientific. Co) and on the same procedure a plastic surgical reparation of the left Profunda Femoris artery (in-stent restenosis) was performed. (Figure N°2)

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Four days later he developed right lower limb acute ischaemia due to occlusion of the right limb of the prosthesis. (Figure N°3 A). The patient was treated with Fogarty embolectomy (Figure N°3 B) and PTA with a self expandable Nitinol Stent implantation at the External Iliac Artery (Figure N°3 C).

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The six months follow up Doppler scan detected an exaggerated expansive movement of the graft at the main body of the prosthesis.
Radioscopy (Video N°1 [static]  Video N°1 [animation]) and an angiographic study showed mesh stent-graft disruption at the main body, without obstruction or leakage.

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We have consulted two experts in the subject, Dr. Zvonimir Krajcer and Dr. Juan C. Parodi, regarding the interpretation and solution of the current case.

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