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Introduction: Chronic juxtarenal (i.e., flush infrarenal) aorto-iliac occlusions are generally considered a contraindication to endovascular revascularization because of concern for atheroembolism to the renovisceral vessels. To overcome this limitation, we have adopted a technique utilizing balloons or parallel endografts in the renovisceral vessels for protection during aortic recanalization. The purpose of this study is to review our experience with this strategy for treating chronic juxtarenal aorto-iliac occlusions.
Methods: A retrospective review of all consecutive patients undergoing endovascular recanalization for chronic juxtarenal aorto-iliac occlusions at our medical center was performed. Patients were excluded if there was a relatively disease-free infrarenal aortic segment of 5 mm or greater or if angioplasty/stenting was used as an adjuvant to thrombolysis or thrombectomy for acute/subacute occlusions. For the majority of patients, balloons or covered stents were placed in the involved reno-visceral vessels from a left axillo-brachial exposure and bilateral iliac covered stents were extended from femoral access into the disease-free suprarenal aorta in parallel fashion (which we refer to as the “pipeworks” configuration.)
Results: Fourteen patients with chronic juxtarenal occlusions were recanalized using renovisceral protective measures. Average age was 59 years (Range: 40-87) and ten were male. Two patients had prior side-to-end aorto-bifemoral bypass and multiple failed revisions. Three had been declined intervention at outside facilities previously because of co-morbidities, with one patient placed on high-dose narcotics in hospice for gangrene and rest pain.
Twelve patients were treated with placement of multiple iliac and renovisceral parallel endografts (“pipeworks” procedure). Of these, five cases involved three parallel stents (two iliac and one renal), six cases involved four (two iliac and two renals), and one case involved five (two iliacs, two renals, and SMA). Another case utilized an aortic stent and bilateral renal and iliac stents. One patient was treated with angioplasty alone. Adjuvant common femoral endarterectomy was required in two cases due to extent of disease.
Technical success was 100%. At follow-up ranging from 1 to 57 months, all aorto-iliac stents have remained patent. One renal stent occluded and discovered at the initial post-operative scan. In retrospect, the parallel stents were not extended proximal enough to a disease-free segment. Two patients required late stenting of previously untreated external iliac arteries. There were no peri-operative deaths. Median post-operative length of stay was one day.
Conclusion: Endovascular recanalization of chronic juxtarenal aortic occlusions can be performed safely using adjuvant renovisceral angioplasty or stents for protection against atheroembolization. Mid to late outcomes in this small cohort suggests comparable durability to more standard aorto-iliac stent outcomes.