How to deal with symptomatic Abdominal Aortic calcified occlusion

This didactic procedure concerns a 77 years old Women with diabetes , HBP, Dyslipidemia , presenting infra abdominal and lower limbs resting pain and bilateral trophic ulcers , due to distal abdominal aortic calcified occlusion . After multimodality assessment of lesions, she has undergone percutaneous abdominal aortic angioplasty and stenting with good final result.

Step-by-step procedure: How to deal with symptomatic Abdominal Aortic calcified occlusion

Educational objectives

• How to manage patients with lower limbs resting pain and abdominal Aortic occlusion
• Multimodality assessment of aortic occlusion before the intervention
• How to plan access, procedural steps, and selection of devices
• How to preserve renal artery and mesenteric artery during distal abdominal aortic occlusion
• How to prepare for stenting by Intra-Vascular Lithotripsy

1) Access sites:

• Brachial access : 6 French access using micro puncture system (COOK)
• Femoral access: 7 French access using micro puncture system (COOK)
• Heparin administration

2) Abdominal Aorta catheterization:

• Continuous flushing of the guiding catheter while introducing guidewire
• Advance softly an 6 Fr JR 4 guiding catheter to the descending aorta over a J 3 0.035’’ GUIDEWIRE
• Advance the 0.035” Guidewire towards the top of the aorta occlusion
• Advancing 70 cm 6F Braided SHEATH (Cook Flexor ® )

3) Crossing Aortic occlusion :

• With the support of the 6F catheter and a stiff angulated guidewire “0.018” Halberd wire Asahi®.

4) Pre-dilatation of the lesion with 6 x 80 mm Sterling balloon BSC

5) IVL Dilatation of the lesion with SHOCKWAVE balloon 8 mm x6cm , inflated to 4 ATM

6) Femoral retrograde recrossing of the aortic lesion using 0035’’ guidewire Advantage Terumo ® and BERENSTEIN 6F Catheter MERIT MEDICAL ®

7) Switching to Femoral introducer Sheath 12F , 45 cm Cook Flexor ®

8) Stenting

• Select the precise spot of stent deployment , in order to preserve collaterals . Control by brachial introducer
• Deployment of 14 x 49 mm Stent BeGraft Peripheral BENTLEY ® inflated to 5 ATM (two times)
• Control post stenting result , renal artery and mesenteric artery preserved
• Verify if there is any dissection or Rupture

9) Final angiographic control: ( 2 views Frontal & Lateral)

10) Vascular femoral closure with an 8 Fr Angio-Seal™

11) Medical adjunctive treatments

• Pre-procedural: Heparin , propofol and midazolam.
• Post procedural : double therapy: Aspirin 75mg o.d. + Clopidogrel 75mg o.d for one month
• After one month : Stop Clopidogrel and continue Aspirin 75mg

Bibliography