Author + information
- Kiyonori Nanto1,
- Osamu Iida1,
- Shin Okamoto1,
- Takayuki Ishihara1,
- Takuya Tsujimura1,
- Koji Yanaka1,
- Shota Okuno1,
- Yosuke Hata1,
- Naoko Higashino1 and
- Masaaki Uematsu1
Patient initials or identifier number
Relevant clinical history and physical exam
An 84 years-old male admitted to our hospital due to continuous bleeding of puncture site on dialysis and treatment for melena. On his past medical history, endovascular aneurysm repair (EVAR) has been performed for abdominalaortic aneurysm (AAA) by using Endurant stent-graft. Enhanced CT imaging detected type Ib endoleak from right leg landing zone associated with aneurysm expansion. We judged continuous bleeding was associated with DIC due to the endoleak from laboratory data.
Relevant test results prior to catheterization
From CT and colon fiber findings, it was thought that melena associated with ischemic colitis due to SMA occlusion. Accordingly, we planned additional stent-graft implantation to improve coagulation factor at first stage and performed EVT for SMA occlusion at second stage.
Relevant catheterization findings
At first stage, we performed additional EVAR for treatment of type Ib endoleak. Under general anesthesia, we expose common femoral artery with cut down and 14Fr sheath inserted.Because type IV endoleak, which was more frequently observed by using Endurant stent-graft, was one of the reasons for aneurysm expansion, we packed aneurysm cavity with coil. Because the proximal diameter of conventional contra-lateral-leg was not sufficiently larger than previous graft diameter, we selected large type of contra-lateral-leg and implanted the device that reversed. Two weeks after the procedure, we performed EVT for SMA occlusion as second stage. Under local anesthesia, 6Fr guiding sheath introduced to celia cartery from brachial artery. 0.014-inch guide wire accompanied with micro-catheter advanced to distal site of SMA occlusion using trans-collateral channel from celiac artery. Guide wire easily passed the occlusion site by retrograde approach. The tip of guide wire held with 3-loop En Snare Endovascular System and then pulled into the guiding sheath to externalize. After that, we performed intervention antegradely from tip of the guide wire. After pre-dilation with 4 mm balloon catheter, we check the lesion morphology. From IVUS findings, concentric fibrous plaque existed. Finally, we implanted balloon expandable stent (EXPRESS 6 mm x 15 mm) with IVUS marking, Final angiography revealed sufficient antegrade flow from SMA.
We experienced patient with DIC status after treatment for AAA because of type Ibendoleak, and additional EVAR improved the DIC status. Revascularization of SMA occlusion succeeded with endovascular procedure without any complication by using trans-collateral approach from celiac artery.