جراحة إصلاح تمدد الأوعية الدموية في الأبهري البطني المريضة: امرأة تبلغ من العمر 51 عاماً وسبق أن خضعت لجراحة استبدال الصمام التاجي MVR منذ 21 عاماً وجراحة فتح البطن قبل 8 أعوام وتعاني
من آلام في البطن وورم شرسوفي نابض Epigastrium.
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*Patient History* (According to patient) Aneurysm was detected in check up Patienet has abdomen pain around a month History of thrombectomy 6 years ago History of OSR 8 years ago History of heart valve surgery 28 years ago Age: 51
*Anatomical Measurements* (According to CTA dated: 6 Sept 2021, Salar sizing date: 18 Sept 2021) short 5cm dacron tube-graft noted in the abdominal aorta anastomosed from the mid abdominal aorta to the level of the aortic bifurcation proximal to the dacron tube-graft, there is a 62mm saccular anastomotic saccular pseudo-aneurysm the infra SMA aorta is also irregular and diseased the Right CIA is also aneurysmal, measuring 19mm in diameter and is irregular in shape 5mm access vessels bilaterally caudal facing visceral arteries diminuative SMA (3.6mm) and renal arteries (3.4mm R renal and 3.5mm Left renal artery) 19mm ILD (inner luminal diameter) in the visceral aorta no significant aortic angulation or iliac tortousity
*Proposed Treatment Strategy* Standard EVAR not possible due to lack of infra renal landing zone Chimney EVAR not possible due to lack of infra-SMA landing zone, and also the young age of the patient t-Branch EVAR anatomically contra indicated due to the diminuative viscerals (~3mm in diameter), low access vessels (~5mm), and small aortic ILD (~18mm) Fenestrated EVAR anatomically contra indicated due to the diminuative viscerals and small access vessels
Therefore: Plan A: Hybrid repair (visceral vessel debranching to the level of the aortic bifurcation, followed by TEVAR from the supra-celiac aorta to the level of the dacron tube-graft in the abdominal aorta) Plan B: Complete surgical repair
*Procedural complexity* Plan A: surgery will be technically challenging due to previous abdominal surgical repair, but then endo repair will be very straightforward Plan B: May have higher morbidity and mortality due to need for aortic clamping, and difficult access to the diaphragmatic aortic level (must be confirmed by cardiac/vascular surgeon) The plan based on the available data is to be taken in the context of a suggestion only. The confirmation of the measurements and the decision as to whether to proceed with this plan in whole, in part, or not at all, rests with the physician.