Endovascular Therapy of a Penetrating Atheromatous Aortic Ulcer of the Descending Aorta (PAU, TEVAR)

To ensure a central DSA and marking of the origin of the subclavian artery and celiac trunk, insertion of a 6F sheath over the exposed left brachial artery using Seldinger technique. Insertion of a Terumo® wire through the sheath. Local administration of 2000 IU heparin-saline solution.

Note:

The puncture or probing of the brachial artery is not absolutely necessary if the anatomical boundary markers for the origin of the subclavian artery and the celiac trunk can be clearly determined after a DSA via the groin or iliac access.

After insertion of the relatively rigid endoluminal aortic prosthesis together with the delivery system, the markings may occasionally deviate from the actual position of the markers. In cases of close distances between the prosthesis end and the subclavian artery or celiac trunk as in the video example, a repeat DSA is required before releasing the prosthesis body to ensure that the lumina of the aforementioned vessels are not inadvertently occluded.

Insertion of a pigtail catheter over the indwelling Terumo® wire.

Via an oblique incision in the left lower abdomen, the extraperitoneal exposure of the external iliac artery is performed. After skin incision and division of the subcutis, the external aponeurosis is split in the direction of the fiber course. Blunt, digital separation of the transverse and oblique abdominal wall muscles. Using a liver retractor, the peritoneal sac is held medially, then exposure of the external iliac artery, which is encircled and looped with vessel loops. Puncture and insertion of a Terumo® wire as well as a 7F sheath according to Seldinger. Local administration of 2000 IU heparin-saline solution.

Note:

The extraperitoneal exposure of the external iliac artery is performed due to two previous vascular surgical operations in the left groin and severe atherosclerosis of the pelvic-leg arterial system. These preconditions suggest difficult probing of the vessel as well as risk of dissection with deviant procedure. For the same reason, a soft Terumo® wire is primarily used for splinting and not the rigid wire of the sheath set.