Endovascular repair of complex Juxtarenal aortic ...

Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx

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Cardiovascular Revascularization Medicine

Endovascular repair of complex Juxtarenal aortic aneurysm using a combined fenestrated endograft and chimney technique Zaher Fanari a,b,c,⁎, Nilesh J. Goswami a a b c

Prairie Heart Institute, Springfield, IL, United States Heartland Cardiology, University of Kansas, Wichita, KS, United States Wesley Medical Center, University of Kansas, Wichita, KS, United States

a r t i c l e

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a b s t r a c t

Article history: Received 25 October 2017 Accepted 15 November 2017 Available online xxxx

Chimney EVAR (CHEVAR) and Fenestrated EVAR (FEVAR) are two options for management of very complex abdominal aortic aneurysm (AAA). While some anatomical factors may favor one strategy over the other, there are some cases where the anatomical challenges may require using a hybrid approach. We are reporting the case of an 84-year-old male with a 6.8 × 5.7 cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. This case shows that a combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy. © 2017 Elsevier Inc. All rights reserved.

Keywords: Fenestrated Snorkel Juxtarenal AAA

Contents 1. Introduction . . . . . . . 2. Case report. . . . . . . . 3. Planning for the procedure 4. Procedure details . . . . . 5. Discussion . . . . . . . . 6. Conclusion . . . . . . . . References . . . . . . . . . .

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1. Introduction Endovascular aneurysm repair (EVAR) emerged as reasonable alternative to surgery for abdominal aortic aneurysm (AAA) repair with lower rates of perioperative morbidity and mortality, shorter length of hospital stay, and comparable reduction of long term mortality [1,2]. However, aortic neck anatomic criteria and variation makes conventional EVAR using commercially available endografts feasible in 40–50% of patients [3]. Fenestrated EVAR (FEVAR) emerged as solution that will allow extending the proximal sealing zone of the graft while maintaining perfusion to the visceral vessels using fenestrations and scallops [3]. This

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strategy showed excellent mid-term results in high-risk patients and was associated with a possible lower perioperative mortality compared to surgery [4,5]. However secondary to the cost and lengthy manufacturing time associated with FEVAR, a new strategy of Chimney EVAR (CHEVAR) where conventional EVAR is coupled with parallel stenting of visceral arteries to achieve the combined goal of more proximal sealing of the graft while maintaining visceral flow. We report the first case where challenging anatomy of AAA was managed successfully by using a combined fenestrated endograft and chimney technique.

2. Case report ⁎ Corresponding author at: University of Kansas School of Medicine, Wichita, KS, Heartland Cardiology/Wesley Medical Center, 551 N Hillside St #410, Wichita, KS 67214, United States. E-mail address: [email protected] (Z. Fanari).

An 84-year-old male with known history of coronary artery disease, prior bypass graft surgery as well as ischemic cardiomyopathy, and a history of VF arrest status post ICD placement. His ejection fraction

https://doi.org/10.1016/j.carrev.2017.11.008 1553-8389/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Fanari Z, Goswami NJ, Endovascular repair of complex Juxtarenal aortic aneurysm using a combined fenestrated endograft and chimney technique, Cardiovascular Revascularization Medicine (2017), https://doi.org/10.1016/j.carrev.2017.11.008

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Z. Fanari, N.J. Goswami / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx

was around 35% to 40%. He has 6.8 × 5.7 cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. A discussion with vascular surgeon deemed the patient to be very high risk so a decision was made for endovascular repair. He has been turned down for an endografting and a fenestrated stent grafting in the past. Computed Tomography Angiography (CTA) showed severe tortuosity in the distal descending thoracic aorta and 6.8 × 5.7 cm infrarenal abdominal aortic aneurysm (Fig. 1A & B). The aneurysm arises immediately below the level of the renal arteries and extends down to just above the bifurcation with significant mural thrombus noted within the aneurysm. The celiac artery (CA) and inferior mesenteric artery (IMA) are occluded proximally; the superior mesenteric artery (SMA) is patent and supplies the CA and IMA territories as well. The right renal artery has a caudally oriented takeoff and an 80% proximal stenosis. The left renal has a cranially oriented takeoff and an 80% proximal stenosis as well. 3. Planning for the procedure Giving that the aneurysm start right below the renal arteries and SMA with very short neck, the choices were to use either a fenestrated graft or a snorkel technique with endograft. The angulation of the aorta and caudally oriented right renal artery made the sole choice of fenestrated graft sub-optimal. Similarly the need to stent the SMA and both renal arteries coupled with the cranially oriented left renal made using a primarily snorkel strategy unrealistic. A combined strategy with fenestrated graft for the SMA and left renal and snorkel for the right renal artery seemed to offer a reasonable option. 4. Procedure details Using modified Seldinger technique, both right and left femoral arteries were accessed and an angiogram was performed to confirm

that the arteriography was above the femoral bifurcation. Then, both sides were managed with Perclose technique with 2 ProGlide sutures (Abbott Vascular, Lake Bluff, IL) on each side and then we upsized the sheath on both sides for an 8-French sheath. Then under ultrasound guidance the left brachial artery was accessed using micropuncture needle placing 6-French sheath there. Then, we utilized a JR4 catheter and Glidewire to engage the right renal artery and then we placed a Supra Core stiff wire (Abbott Vascular, Lake Bluff, IL) and exchanged over for 7 × 90 cm destination sheath (Terumo Interventional Systems, Somerset, NJ). Then, we parked a 6 × 59 mm Viabahn balloon expandable (VBX) stent (W. L. Gore and Associates, Newark, DE) in the right renal artery (Fig. 2A). After that, we exchanged the sheath of the right groin for a 20-French Cook sheath (COOK MEDICAL INC. Bloomington, IN), and through the left access, we advanced the 30 × 124 mm Zenith Fenestrated AAA Endovascular Graft (COOK MEDICAL INC. Bloomington, IN) and deployed the upper part slowly. Then after multiple attempts we successfully engaged the left renal artery and SMA subsequently utilizing a deflectable sheath (8.5 F, 61 cm; Agilis NxT; St. Jude Medical, St. Paul, Minnesota) going through the 20 French sheath. After engaging the ostium of each artery we advanced a Glidewire (Terumo Interventional Systems, Somerset, NJ), and over the Glidewire, we advanced CXI catheter (COOK MEDICAL INC. Bloomington, IN), and then exchanged for a Supra Core stiff wires (Abbott Vascular, Lake Bluff, IL). Then, we exchanged the Agilis sheath for a 7 × 45 cm Ansel sheath (COOK MEDICAL INC. Bloomington, IN) for the superior mesenteric artery and 6 × 45 cm Ansel sheath (COOK MEDICAL INC. Bloomington, IN) for the left renal artery. We parked a 6 × 22 mm iCAST stent (Atrium Medical Corporation, Hudson, NH, U.S.) in the left renal and an 8 × 29 mm VBX (W. L. Gore and Associates, Newark, DE) in the SMA (Fig. 2B). Then we deployed the rest of the main body. Then we deployed first the snorkeled 6 × 59 mm VBX stent in the right renal with the stent ostium extending above the graft. At the same time we post-dilated the upper part of main body with Reliant balloon (Medtronic, Minneapolis, Minnesota) (Fig. 2C). Then, we deployed the 8 × 29 mm VBX stent in the SMA (Fig. 2D). and the 6 × 22 mm iCAST in the left renal artery (Fig. 2E). and then flared all three ostia with good results. After that, we post-dilated the

Fig. 1. A- CTA imaging showing the aneurysm and the dominant superior mesenteric artery (arrow) system that fills through collaterals celiac and inferior mesenteric artery. B- CTA imaging showing the abdominal aortic aneurysm. Notice the caudally oriented right renal and cranially oriented left renal artery (arrows).



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Fig. 2. A- 6 × 59 Mm Viabahn Balloon Expandable (VBX) stent advanced from left brachial access and parked in the right renal artery. B- A 6 × 22 mm ICAST and an 8 × 29 mm VBX stent parked in the left renal artery and the superior mesenteric artery respectively. C– deployment Of 6 × 59 mm VBX stent in the right renal extending the ostium above the graft while post-dilated the upper part of main body with reliant balloon. D- deployment of the 8 × 29 Mm VBX stent in the superior mesenteric artery. E. Deployment of the 6 × 22 Mm ICAST in the left renal artery. F- Final abdominal aortography showed well-opposed graft and no signs of endoleaks and good flow in both renal arteries and SMA.

main body with Reliant balloon (Medtronic, Minneapolis, Minnesota). Then we deployed a bifurcated graft of 12 × 28 × 76 mm. Then we deployed a right extension of 20 × 90 mm and a left extension of 20 × 56 mm with distal end above the ostia of internal iliac arteries. Then, we post-dilated both the bifurcation and extension grafts with Reliant balloon with good results. Final abdominal aortography showed well-opposed graft and no signs of endoleaks and good flow in both renal arteries and SMA (Fig. 2F). Hemostasis was achieved in both groins using the ProGlide sutures placed earlier, while the left brachial sheath was pulled with manual compression in the cath lab. 5. Discussion Endovascular techniques emerged as less invasive methods of treating infrarenal abdominal aortic aneurysms (AAAs) especially for patients with severe comorbidities with lower rates of perioperative outcomes and comparable reduction of long-term mortality [1,2,6]. However anatomic constraints around the proximal neck of the aneurysm reduce the ability to perform elective conventional endovascular repair in up to 50% of AAA patients [2,7]. Juxtarenal aortic aneurysm (JAA) defined as complex AAAs with very short proximal necks represent almost 15% of all AAAs and constitute a real challenge due to proximal neck adequacy for endograft seal zones [2,8]. Fenestrated EVAR (FEVAR) were developed to aneurysms with short proximal necks by extending the proximal sealing zone from the infrarenal segment to the juxtarenal aorta while using fenestrations (holes) in the graft or scallops (gaps in the upper graft fabric margin) to maintain perfusion of the visceral vessels [9]. Another technique to manage juxtarenal AAA was developed by Greenberg and colleagues utilizing chimney or snorkel grafts which consist of additional off-the-shelf stents parallel

to the main body graft to maintain branch vessel perfusion while allowing the main graft to extend more proximally to achieve graft seal [10]. Both techniques seem to offer a reasonable alternative for these patients. In a meta-analysis of 42 relevant studies and 2264 patients with aortic aneurysm, both FEVAR and Chimney EVAR had comparable cumulative 30-day mortality was 2.4% and 3.2% (P = 0.459). Follow up mortality seems to be lower in FEVAR [1.4% vs. 3.2% (P = 0.018)]. There was no significant difference in the rate of either type I or type II endoleaks. However, FEVAR was associated with a higher re-intervention rate (11.7% vs. 5.6%, p = 0.001). The decision to pursue one approach or another seems to depend on the urgency of the procedure and many anatomical factors. Commercially available FEVAR grafts require usually 3–4 weeks to manufacture and deliver; therefore while FEVAR is limited to elective case, Chimney EVAR can be done in more urgent cases [11]. Chimney EVAR seems to be a better choice in patients with hostile iliofemoral access, caudal-directed renal arteries, target vessel stenosis, close proximity of superior mesenteric artery and most cranial renal artery, prior aortic reconstruction and tortuous visceral aortic segment [11]. On the other hand, FEVAR seems to be a favorable choice in the presence of cranially directed renal arteries, upper extremity occlusive disease, difficult arch, atheromatous thoracic aorta and proximal renal artery branching and baseline renal impairment [11]. In our case, the angulation of the aorta and down going takeoff of the right renal artery made the sole choice of fenestrated graft sub-optimal. Similarly the need to stent the SMA and both renal arteries coupled with the up going takeoff made using a primarily snorkel strategy unrealistic. A combined strategy with fenestrated graft for the SMA and left renal and snorkel for the right renal artery seemed to offer a reasonable option.


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6. Conclusion A combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy.

References [1] Dillavou ED, Muluk SC, Makaroun MS. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg 2006;43(3):446–51. [2] Li Y, Hu Z, Bai C, Liu J, Zhang T, Ge Y, et al. Fenestrated and chimney technique for Juxtarenal aortic aneurysm: a systematic review and pooled data analysis. Sci Rep 2016;6:20497. [3] Caradu C, Berard X, Midy D, Ducasse E. Influence of anatomic angulations in chimney and fenestrated endovascular aneurysm repair. Ann Vasc Surg 2017;43:104–14. [4] Linsen MA, Jongkind V, Nio D, Hoksbergen AW, Wisselink W. Pararenal aortic aneurysm repair using fenestrated endografts. J Vasc Surg 2012;56(1):238–46.

[5] Sun Z, Mwipatayi BP, Semmens JB, Lawrence-Brown MM. Short to midterm outcomes of fenestrated endovascular grafts in the treatment of abdominal aortic aneurysms: a systematic review. J Endovasc Ther 2006;13(6):747–53. [6] Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. Dutch randomized endovascular aneurysm management (DREAM)trial group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351(16):1607–18. [7] Nordon IM, Hinchliffe RJ, Holt PJ, Loftus IM, Thompson MM. Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair—a systematic review. Eur J Vasc Endovasc Surg 2009;38(1):35–41. [8] Ayari R, Paraskevas N, Rosset E, Ede B, Branchereau A. Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification. Eur J Vasc Endovasc Surg 2001;22(2):169–74. [9] Faruqi RM, Chuter TA, Reilly LM, Sawhney R, Wall S, Canto C, et al. Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft. J Endovasc Surg 1999;6(4):354–8. [10] Greenberg RK, Clair D, Srivastava S, Bhandari G, Turc A, Hampton J, et al. Should patients with challenging anatomy be offered endovascular aneurysm repair? J Vasc Surg 2003;38(5):990–6. [11] Ullery BW. Snorkel/chimney versus fenestrated endovascular aneurysm repair: what works and when? Evtoday 2016;15(3):76–81.
