Antonio D'Urso

Management of Carotid Dacron Patch Infection: A Case Report Using Median Sternotomy for Proximal Common Carotid Artery Control and In Situ Polytetrafluoroethylene Grafting

We report on a 58-year-old male who presented with an enlarging cervical hematoma 3 months following carotid endarterectomy with Dacron patch repair, due to septic disruption of the Dacron patch secondary to presumed infection. The essential features of this case are the control of the proximal common carotid artery gained through a median sternotomy, because the patient was markedly obese with minimal thyromental distance, and the treatment consisting of in situ polytetrafluoroethylene bypass grafting, due to the absence of a suitable autogenous saphenous vein. Median sternotomy is rarely required in case of reintervention for septic false aneurysms and hematomas following carotid endarterectomy but should be considered whenever difficult control of the common carotid artery, when entering the previous cervicotomy, is anticipated. In situ polytetrafluoroethylene grafting can be considered if autogenous vein material is lacking.

Iliac side branch device for bilateral endovascular exclusion of isolated common iliac artery aneurysms without brachial access.

A 74-year-old man with an asymptomatic pulsatile abdominal mass was found on computed tomography scan to have nonruptured, bilateral, isolated common iliac artery aneurysms measuring 4.7 cm on the right and 3.0 cm on the left. Arteriography demonstrated a favorable angle of origin of 50° for both hypogastric arteries (A), so endovascular exclusion of both the aneurysms with iliac bifurcation devices was performed. An iliac bifurcation device (Cook Inc, Bloomington, Ind) was advanced from the right femoral artery until the side branch was over the ostium of the right hypogastric artery. The delivery sheath was partly withdrawn, the distal end of the side branch was deployed, and the indwelling guidewire was advanced above the aortic bifurcation. A snare catheter was advanced through an 18F introducer sheath through the left femoral artery to retrieve and extract the guidewire. An 8F crossover sheath was advanced from the left to the opening of the side branch, in the right iliac bifurcation device. The introducer sheath of the iliac bifurcation device was further withdrawn, and the device was fully deployed. The crossover guidewire was removed, and a 0.035-inch guidewire was advanced from the left side into the distal right hypogastric artery, within the crossover sheath. This sheath was then further advanced into the left hypogastric artery. An 859-mm Advanta V12 stent graft extension (Atrium Medical, Hudson, NH) was advanced into the right hypogastric artery. The crossover sheath was withdrawn. The stent graft was deployed and balloon-expanded between the side branch of the iliac bifurcation device and the hypogastric artery. The same procedure was then performed on the left side by introducing crossover guidewires, sheath, and stent graft through the right femoral artery, without a brachial access (B). Finally, a Zenith aortobiiliac device (Cook) was deployed. Completion angiography was satisfactory (C). At 1 month, the patient is in good condition. A well-patent reconstruction, with no endoleak, is evident on the computed tomography scan (Cover).