Southern Association For Vascular Surgery

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3D planning and robotic guided fenestration: a unique approach to a complex dissection.
Alan B Lumsden
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX

INTRODUCTION: 3D visualization using multiplayer reconstruction, permits complex anatomic structures to be better understood. When combined with the precision of endoluminal robotic steering and guidance planning, highly accurate targeting and procedure completion can be achieved. We demonstrated in this report how these tools were combined to permit development of a therapeutic option for a challenging clinical problem.
METHODS: In this endovascular video we demonstrate how to acquire a cone beam CT image which is then fused with a previously acquired CT angiogram. In a work station a guidance path to perform septal perforation is created to provide access to an isolated false lumen.
RESULTS: Type B dissection had been previously treated in this patient with a thoracic stent graft. On follow up the patient complained of new, persistent chest pain and was found to have some aortic dilation with a very unusual track through the false lumen. This appeared to be fed from a superior intercostal and communicated distally with the celiac artery, which arose from the false lumen. There was no traditional access route to the false lumen, permitting direct embolization. Using Cone beam to CTA fusion, on a work station we panned a path which would allow us to perforate from the true lumen directly into the flash lumen using a reentry needle. The selected point of perforation was marked on the septum in the workstation and that target pushed to the hybrid room C arm. Using a robotic endoluminal catheter, the reentry need was placed exactly on the point to be perforated and a needle advanced. This permitted an .014 wire to be immediately advanced into the endoleak tract. The fenestration was dilated to permit a diagnostic catheter to be advanced up to the superior intercostal artery and the entire endoleak track was embolized. Post procedure, the patient was pain free and the aortic dilation has remained stable.
CONCLUSIONS:The combination of multiplayer reconstruction and robotic steering, permits highly accurate and stable device placement. True 3D imaging is an emerging technology which could permit this to be refined even further.

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