Description of Event or Problem · 1
A 28 MM DIAMETER X 16 MM DIAMETER X 13.5 CM LENGTH ANEURX BIFURCATED STENT GRAFT AND ITS COMPONENTS WERE IMPLANTED IN A PT FOR ENDOVASCULAR TREATMENT OF A 5.3 CM ABDOMINAL AORTIC ANEURYSM IN 2003. THE NECK DIAMETER WAS 25 MM AND THE ANEURSYM LENGTH WAS 70 MM. VESSEL MORPHOLOGY IS UNKNOWN. THE PT HAS A HISTORY OF A MYOCARDIAL INFARCTION, CORONARY ARTERY DISEASE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPERTENSION, AND PERIPHERAL VASCULAR DISEASE. IT WAS REPORTED THAT THE PHYSICIAN CHOSE AND SUCCESSFULLY DEPLOYED A SHORT BIFURCATED STENT GRAFT PER RESULTS OF MMS (MEDICAL MEDIA SYSTEMS) EVAL. THE STENT GRAFT REACHED FROM BELOW THE RENAL ARTERIES TO THE AORTIC BIFURCATION. POST DEPLOYMENT OF THE STENT GRAFT THE PHYSICIAN LOST GUIDEWIRE ACCESS. IN ATTEMPTING TO RECANNULATE THE ANEURYSM SAC WITH THE GOAL OF CANNULATING THE CONTRALATERAL LIMB, THE PHYSICIAN UNKNOWINGLY CANNULATED THE IPSILATERAL LIMB. A CONFIRMATION ANGIOGRAM WAS NOT DONE BECAUSE A MARKER PIGTAIL CATHETER WAS NOT AVAILABLE. THINKING THAT THE CONTRALATERAL GATE WAS CANNULATED, THE PHYSICIAN DEPLOYED AN ILIAC LIMB STENT GRAFT. THE PHYSICIAN THEN ADVANCED A 16 F SHEATH ON THE CONTRALATERAL SIDE BUT MET MUCH RESISTANCE. AS THE PHYSICIAN DEPLOYED THE CONTRALATERAL STENT GRAFT, THE STENT GRAFT MARKERS WOULD NOT ALIGN, HOWEVER, THE PHYSICIAN DEPLOYED THE STENT GRAFT, WHICH RESULTED IN A AORTO-UNI-ILIAC CONFIGURATION, AND A FEMORAL-FEMORAL BYPASS WAS PERFORMED. FINAL ANGIOGRAM DEMONSTRATED AN ACCEPTABLE OUTCOME WITH NO ENDOLEAK. NO CLINICAL SEQUELAE WERE REPORTED, AND THE PT IS REPORTED TO BE FINE.