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Endograft Explant and Open AAA Repair

It was a day I saved since two week prior, and I am sure my seniors did the same. It was a big case, an endograft explant and open AAA repair for a type 1a endoleak due to caudad migration of AneuRx graft. It was a day to look forward. In addition, the patient was a pleasant gentleman, which added more warmth to our excitement.

Intra-operatively, we made a midline laparotomy,  dissected down to the peritoneum, moved the omentum and transverse colon up, small bowel to the right in a bowel bag, set up the Omni retractor set up. For the AAA dissection, retroperitoneum was dissected  towards the L renal vein while staying to the right of SMA, and distally the iliac arteries/limbs of graft were vessel looped. We then gave a small amount of heparin and went to work.  Initially, clamp was placed below the left renal artery and above the right renal due to severe downward and left angulation of the aneurysm. Conveniently, his right kidney was small and likely diminished in function.  Aorta was then transected with bevel at posterior wall and the AneuRx endograft was taken out along with struts. We moved the clamp infra-renal, and completed the proximal anastomosis. Afterwards, we moved the clamp to the graft and finished the anastomoses to both distal endograft iliac limbs. Hemostasis took sometime, but we eventually closed the retroperitoneum, put the bowels back and closed the abdomen.

The preparation for surgery and post-op care were just as important as the intra-operative techniques. Bowel prep, medical adjustment and consultation, and patient instructions before the surgery day were extensive. Post-op, he was intimately followed by the SICU team as well as the vascular surgery team, and each aspect of his organ system management were analyzed and communicated thoroughly. To our amazement, despite having multiple co-morbidities such as COPD, CAD, DM, etc he made a complete recovery and was transferred to floor on POD#4 and discharged home soon after.

One paper states removal of endograft using a proctoscope, as it’s easy to resheath

Some of the takeaways and learning points are listed below:

– During explantation of prior endograft, don’t pull out graft too hard, as this can tear the neck and makes it fragile to sew. There is tissue ingrowth and retroperitoneal inflammation.
– After clamping with Fogarty hydrogrip (with padding), check the sac for pulsatility. If there is then it’s not adequately controlled and will bleed.
– Endoleak remains the most common reason for elective explant.
– Late AAA endograft explant: indication and outcomes (Northwestern) – Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home.
– If removal is due to infection, then should attempt to remove all barbs and not leave anything in situ. Proctoscope might help resheath.
– Partial explant (Cleveland Clinic) – 22 patients had a partial late EVAR explantation. Of these 22 patients, there were four patients with proximal components remaining, 17 patients with distal components remaining, and one patient with both proximal and distal components left. Nine of the 22 (41%) had postoperative and follow-up CT imaging, of which none of these patients had migration of their remaining graft components. The average length of follow-up in these nine patients was 25.9 months. Four of the 22 patients (18%) died secondary to postoperative infection, shock, and organ failure after explant.

Patient was extubated POD1, off of all pressors POD2, transferred to floor POD5 and discharged soon after. This has been one of those stories that makes you want to go into a particular specialty, and it was a pleasure caring for this patient, seeing him from pre-op all the way to stablization and discharge.

Your Inner GPS

I like to listen to podcasts when I cannot physically open up a book or don’t want to stare at screens anymore. Tonight, during a long ride of the A train in NYC, I listened to the Behind the Knife podcast episode with Dr. Freischlag. I became instantly amazed with her emotional intelligence, humility and aptitude for being a great mentor. She specifically addressed that not everything in life works out in your favor, and her input aspired me to write about the content below, which I named “Your Inner GPS”.

At this point, many of you know how to get back on track when a mistake has been made or when life throws you some dirt. For god’s sake, we are almost doctors, and we are more than capable of realigning our great ships, right? However, what you might not be good at is what to do when something goes wrong – completely wrong – and when you are forced to make a pit stop on your way to “greatness”. How well do you deal with things when you’ve worked so hard but are forced to change course, or worse, abandon? What about when you’re more than qualified, and you’re denied for a reason that shouldn’t be a reason at all? I’m sure many of you type As and overachievers also got completely chewed up by life from time to time, just like me. Of course, we get better and better at handling these bumps on the road, as we encounter more of them, like hypertensive arteriosclerosis. Let me assure you, none of us are perfect at handling lemons handed by life. We are young, and there’s still much to learn about how to best hit life’s curveballs.

Don’t despair. Take a step back, pause for a moment, think about the problem, come up with options, plan, and execute. We surgeons and doctors and teachers and parents and etc already got here with this method. This is our inner GPS, yet many of us still panic, complain, and ruin our along with our closed ones’ mood when we get into sticky situations laid down by life.

You have to be completely okay with not getting everything you ask for completely and all the time. In fact, you should rejoice (to a healthy degree) when you get something, especially when you worked so hard for it. There is no flow chart or algorithm in life that get you to exactly where you want to be.  Timing and serendipity are elements in addition to hard work that can make life so easy when present, and so miserable if without. Be prepared to fail and be lost for a bit. Enjoy, if you can, the process of learning from a rare mistake that you make, and be a better version of yourself. This self-searching process and reorientation would refine and sometimes define you.

Also, it should be okay for you to get rejected. It should teach you something every time, but the awkwardness and embarrassment that come with it should simply bounce off you. If they don’t, don’t worry, with few more rejections you will get there. Hey, I got here. Just think about this – under the circumstance that you are excellent, you’ve worked hard, and you’re true to yourself, you are simply filtering out your choices through rejections. Not everyone would like you even if you’re all of the above, but you will definitely have options, and eventually a great match.

Amidst all of these turmoils life gives you, try to stay the course and look at the big picture. There’s an expression that says you should look at the windshield, not the rear view mirror. I say look at both. Focus on the windshield and where you want to go and what you wanna achieve next, but also pay attention to the rear view mirror so you learn from the mistakes and never make them twice. You would be surprised the amount of takeaways and life lessons you can acquire from either direction.

Hold steady, and don’t let life ruin your party. Wherever you end up, be happy and never stop learning. There will always be someone ahead who you look up to, and someone behind who looks up to you. Don’t despair and certainly don’t lose purpose. Trust your inner GPS.

Extent III TAAA Sandwich Technique – Apprenticeship from Dr. McKinsey

I just had a week of sub-I at Mount Sinai West, where Dr. James Mickinsey practices. For those of you who don’t know, he is internationally known for treating complex aortic cases, and the primary reason I was so excited to extend my stay one more day in this hospital that I have to travel 40 minutes each way. Below is a description for a sandwich technique for an extent III TAAA case I scrubbed.

Patient is a 84 YO AAM who has been followed by Dr. MicKinsey for an extent III TAAA that was >5.5 cm and had ulcerative plaques. The method of repair was going to be so called “Sandwich technique”, where chimney graft for visceral arteries will be sandwiched by two aortic stent grafts (schematics shown below). This technique was designed to bypass the expensive, time consuming step of personally designing fenestrated/branched TEVAR graft for each patient with TAAA that needs visceral artery coverage, and allows off-the-shelf selection of stent grafts.

Schematic drawing of the repair. Top picture shows deployment of first thoracic stent graft and cannulation of celiac and SMA from bilateral brachial cutdown. Middle drawing shows the finished product after sandwiching the balloon expandable stents in celiac and SMA by another aortic stent graft at the distal end of the first one. Bottom drawing shows the cross section design of the aortic and chimney stents, as well as gutters.

RIght CFA, with less iliac tortuosity was accessed and dilated up to 22F for deployment of the first thoracic stent graft, and left CFA accessed with 5F sheath for aortogram. Usually, axillary arteries would be accessed with cutdowns to cannulate the visceral arteries and deploy the chimney stents. Due to a history of hemi-facial and hemi-torsal burn with prior skin grafts covering the left chest and axillary region, cutting down on the axillary would lead to future skin breakdown, so we performed bilateral brachial artery cutdowns instead. One setback for the brachial cutdown is that since the patient’s arms would be abducted and extended, rotating the C-arm to get lateral fluoro views would be difficult. We solved this problem by abducting patient’s arm minimally, giving just enough space for adequate rotation of the C-arm. This might not be possible for obese patients.

Bilateral CFA were accessed first. Aortogram was taken to assess the TAAA, access vessels and visceral branches. Right CFA with less tortuous iliac artery was chosen to be the route of deployment of the first thoracic stent. Bilateral brachial cutdowns were done (an attending at each side with Dr. McKinsey monitoring outside, a common set up of lineup in a complex aortic case here as I’ve heard). The celiac axis and SMA were cannulated from above, balloon expandable chimney stents were inserted and deployed at the same time, with the proximal ends above the upper border of thoracic stent graft. The second aortic stent graft was deployed, sandwiching the chimneys, and the whole system was dilated with CODA balloon, but carefully avoiding the origins of celiac and SMA. Completion angio showed no endoleak. Whether or not to cover the renals then deploying a third aortic stent graft for a second sandwich were discussed, but due to the elderly status of the patient and the extent of coverage possibly leading to spinal cord ischemia, we decided to call it a day.

What a wonderful case that shows how far vascular surgery has come. From open surgery 20 years ago to endovascular cases nowadays, the field of vascular surgery has truly evolved with respective to time and technological innovation. Dr. Frank Veith (surgeon who performed the first EVAR in the U.S.) said in his presidential address during SVS annual meeting a while ago that vascular surgery needs to evolve like Darwinism. Dr. McKinsey’s practice is not only fascinating and unparalleled, but also definitely a representation of Dr. Veith’s vision.