Cardiology

Aortogram with Runoff, the Left Brachial Approach

PREOPERATIVE DIAGNOSIS:  Disabling claudication and ischemic ulceration of the right heel, secondary to aortoiliac occlusive disease.

POSTOPERATIVE DIAGNOSIS:  Same.

PROCEDURE:  Aortogram with runoff, the left brachial approach.

ANESTHESIA:  Local sedation.

SURGEON:  R, MD.

ASSISTANT SURGEON:  L, MD.

INDICATIONS:  The patient is a 63-year-old woman with chronic renal failure, who is currently dialyzed through a peritoneal dialysis catheter.  She was noted to develop progressive disabling claudication at both lower extremities, and had absent femoral pulses on each side.  She underwent a Persantine thallium scan, which showed evidence of coronary artery disease.  Then she underwent coronary angiography and coronary stenting. She now returns for arteriography to define the opportunities for lower extremity revascularization.  This is also felt to be a necessity in anticipation of her undergoing renal transplantation.

FINDINGS:  The distal aorta is relatively small, although without focal occlusive disease.  The common iliac arteries were diffusely diseased bilaterally.  On the right side, the external iliac artery was occluded, but the superficial femoral and profunda femoris arteries reconstitute distally. The superficial femoral artery is patent in continuity with the popliteal artery, and the proximal three tibial arteries imaged below the level of the knee, but are not imaged more distally.  On the left side, the common iliac artery was diffusely diseased.  There is a tight stenosis in the proximal left external iliac artery.  The common and femoral artery is occluded with reconstitution of the profunda femoris and superficial femoral arteries on the left side.  On the left, the superficial femoral artery is patent and in continuity with a patent popliteal artery.  The proximal three tibial arteries are all imaged, but in the mid-calf and distally the arteries were well opacified.

PROCEDURE:  The patient was placed in the supine position and the left arm was extended on an arm board.  The left arm at the antecubital fossa, was sterilely prepped and draped.  The left brachial artery was cannulated and the wire advanced proximally using fluoroscopic guidance.  A 4 French ureteral sheath was placed.  2,500 units of heparin were administered through this sheath.

A wire was advanced proximally into the ascending aorta.  A 4 French pigtail catheter was advanced over the wire and was used to deflect the wire distally down the thoracic aorta to the abdominal aorta.  The pigtail catheter was advanced over the wire, and the wire withdrawn. An AP aortogram was performed at the level of the renal arteries.  The wire was then advanced through the pigtail catheter and was directed into the distal abdominal aorta using a multi-purpose catheter.  The pigtail was readvanced over the wire and the wire was withdrawn.  An AP pelvic aortogram was performed with the pigtail catheter at the level of the aortic bifurcation.

The runoff was imaged in both legs simultaneously by injecting contrast at the level of the aortic bifurcation and following the flow of contrast using a bolus-chase technique.

The pigtail catheter was straightened using a wire and the catheter and wire were withdrawn. The 4 French ureteral sheath was removed and pressure was applied at the level of the antecubital fossa until hemostasis was obtained. 

The patient tolerated the procedure well.

As the attending surgeon, I was present throughout the entire procedure.

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