The Endovascular Management of a Ruptured Suprarenal Abdominal Aortic Aneurysm (SAAA) Utilizing Antegrade In-Situ Laser Fenestration at a Community Hospital
Lauren B Gammel1, Richard Yoon2, Robert C Allen3
1East Tennessee State University, Johnson City, TN;2Ballad Health, Johnson City, TN;3Ballad Health Holston Valley Medical Center, Kingsport, TN
Introduction:We present a unique case and successful technique for emergent 4-vessel laser fenestrated endovascular repair of a ruptured suprarenal abdominal aortic aneurysm (SAAA) in a community hospital setting. Endovascular techniques utilizing laser fenestration have emerged as a potential solution to this complex pathology in the acute setting and are relatively accessible in community hospital settings.Methods:A 59-year-old male with history of hypertension and tobacco abuse presented to the emergency department of a community hospital with severe abdominal pain. He was hypotensive, tachycardic, and tachypneic. A noncontrasted computed tomography scan revealed a ruptured 9cm suprarenal aortic aneurysm. He was booked emergently for the hybrid operating theatre. Bilateral, retrograde, ultrasound guided access was obtained. Two proglide perclose devices were deployed bilaterally (Abbott, IL). A TourGuide (Medtronic) steerable sheath was used to deploy balloon expandable, uncovered stents (Vis-Pro, Medtronic) in the visceral and renal vessels to serve as target markers for completing in-situ fenestration. Concomitantly, the 0.18 OTW, 1.7 mm laser (Spectranetics, Phillips), pre and post dilatation balloons, and covered bridging stents were prepared and organized for rapid, sequential use. A endovascular extent 4 TAAA repair was performed, requiring four fenestrations. Our proximal endograft (Valiant 32-32-200, Medtronic) was deployed approximately 5cm above the celiac, followed by infrarenal main body (Endurant 36-16-166, Medtronic). The contralateral limb (16-24-124) was deployed and molded to complete the aneurysm exclusion. An Aptus SG (12fr, Medtronic) was utilized to direct our fenestrations. After reviewing both a parallax corrected anterior view, and lateral “barrel shot”, the laser catheter was aligned in the center towards the pre-existing marker stent, pulsed, and directed with gentle forward force to create a fenestration Subsequently, we delivered a 0.18 precurved, Thruway wire (Boston Scientific) into the target vessel. The fenestration was dilated with a 0.18, 6 X 2mm RX (Sterling, Boston Scientific) balloon. Subsequently, a bridging balloon expandable covered stent (iCast, Getinge, or VBX, Gore) was deployed and flared with a 10 X 2 Armada (Abbott) balloon. Target vessel fenestration was performed on the SMA first, then the renal vessels, and the celiac artery last. Completion angiogram revealed an excellent technical result with no obvious endoleak detected.$$MISSING OR BAD GRAPHIC SPECIFICATION (?) $$ Results:The patient was extubated in the ICU shortly after the procedure. He did well and was discharged home on hospital day two. Two month follow up imaging revealed no endoleak and patent viscerorenal stents.Conclusions:Endovascular repair of a ruptured SAAA in a community hospital setting is feasible with antegrade in situ laser fenestration of an off-the-shelf device. This technique provides rapid aneurysm exclusion and limited viscerorenal ischemia time. Prospective studies and long term follow up are necessary for further safety and efficacy determinations. 
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