Enlarging Perivisceral Aortic Aneurysm With Prior Open Repair of Infrarenal Aortic Aneurysm Treated With In Situ Laser Fenestration of Physician-Modified Stent Graft for Preservation of Accessory Renal Arteries
Adam Brown, Matthew Wooster
Medical University of South Carolina, Mount Pleasant, SC
INTRODUCTION: Physician-modified stent grafts (PMEG) have become a safe and effective tool to treat complicated abdominal aortic aneurysm (AAA) that is otherwise not amenable to open aortic repair. Even with proper planning prior to surgery, vessel architecture can vary intraoperatively requiring adjustments to be made. In situ laser fenestration (LISF) provides a useful intraoperative tool to preserve perfusion to vital visceral organs.
METHODS: A 69-year-old male with past medical history of hypertension, hyperlipidemia, hypothyroidism, and previous repair of AAA with infrarenal tube graft with chief complaint of lower back pain. Aneurysm was found during MRI for lower back pain. Subsequent CT imaging showed an enlarging, 6-cm, perivisceral aortic aneurysm. Patient was otherwise asymptomatic and had no follow-up imaging since previous AAA repair. Given previous open aortic repair and high risk of complications for redo open repair, endovascular treatment was planned with a 5-vessel fenestrated PMEG with placement of stent to celiac, SMA, right renal artery, and the larger two out of three left renal arteries through fenestration. A 30x155mm Cook Zenith AlphaTM thoracic endovascular graft was modified using heat cautery to create fenestrations and fenestrations were reinforced/marked using gooseneck snares. Using percutaneous bilateral femoral access, the fenestrated device was advanced into position and deployed using aortogram and AP and lateral views to configure 3D overlay. Initial angiography raised concerns that the accessory renal arteries were larger than anticipated and potentially requiring preservation. Selective cannulation of the three branches suggested that the branch planned for sacrifice in fact perfused a large portion of the kidney. Once all other visceral branches had been cannulated to protect against device rotation, a 2.3mm Spectranetics Turbo EliteTM laser catheter was used to create an in-situ fenestration and cannulate the third renal artery for which a premade fenestration had not been planned. Repair was then completed as previously planned. Completion aortogram demonstrated wide patency of all renal visceral vessels with no evidence of endoleak (Figure 1). Patient recovered from surgery without complication and discharged post-operation day 1.
RESULTS: Patient was last seen 3 months following the intervention and continues to have uncomplicated recovery. He remains on dual antiplatelet therapy with aspirin and Plavix. Follow-up CT angiogram demonstrated aortic graft with 6 patent visceral stents and a 7.3cm residual aneurysm sac (Figure 2).
CONCLUSIONS: Planning is a hallmark for successful treatment of complex aortic disease, but the ability to make changes intraoperatively remains vital. PMEG and in situ laser fenestration (LISF) have each been established as safe and effective techniques. In the event that pre-made devices are not able to be properly aligned (or when additional large branches are identified intraoperatively), LISF can provide an alternative to successfully complete repair.
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