Endovascular management of juxtarenal aneurysms with fenestrated endovascular grafting Roy K Greenberg, MD, Stephan Haulon, MD, Sean P Lyden, MD, Sunita.

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Presentation transcript:

Endovascular management of juxtarenal aneurysms with fenestrated endovascular grafting Roy K Greenberg, MD, Stephan Haulon, MD, Sean P Lyden, MD, Sunita D Srivastava, MD, Adrian Turc, MD, Matthew J Eagleton, MD, Timur P Sarac, MD, Kenneth Ouriel, MD Journal of Vascular Surgery Volume 39, Issue 2, Pages 279-287 (February 2004) DOI: 10.1016/j.jvs.2003.09.050

Fig 1 The device pictured is representative of the majority (18) of implants that were placed in these 22 patients. A three-piece modular design (A), using a proximal tube graft (B) that included the customized fenestrations, was coupled with a bifurcation segment. The intended overlap was quite long (usually in excess of 4 cm), and then mated with an iliac limb of variable length and diameter. Journal of Vascular Surgery 2004 39, 279-287DOI: (10.1016/j.jvs.2003.09.050)

Fig 2 A, The posterior sutures tether the graft, providing the ability to partially expand the prosthesis to allow for cannulation of fenestrated vessels, which serves to ensure proper rotation of the device as it fully expands. B, Renal fenestrations with four gold markers oriented in a circular manner 90 degrees apart. These markers, in conjunction with a set of anterior vertically oriented linear markers that are oblique to the set of posterior horizontal markers, are used to help orient the device prior to deployment (C). Journal of Vascular Surgery 2004 39, 279-287DOI: (10.1016/j.jvs.2003.09.050)

Fig 3 The standard technique for ensuring the proper orientation of the device after deployment consists of the placement of guiding catheters or balloons into two vessels (A) prior to removal of the wire maintaining the posterior tethering sutures. Alternatively, in the setting of an early renal branch or two adjacent renal arteries, the use of kissing stents can be accomplished with 0.014-inch systems in conjunction with 6F guiding catheters (B-C). Simultaneous stent (Herculink plus 6.5 × 18 mm; Guidant, Menlo Park, Calif) inflation and caution when manipulating device or ballooning the proximal neck will help to ensure preservation of renal blood flow. Journal of Vascular Surgery 2004 39, 279-287DOI: (10.1016/j.jvs.2003.09.050)

Fig 4 This 67-year-old woman is on home oxygen secondary to chronic obstructive pulmonary disease, and she is a Jehovah's Witness. Her preoperative angiogram is demonstrative of a very short neck below the right renal with the aneurysm incorporating the left renal (A). This represents a complex fenestrated repair, as the fabric must be lodged into the left renal artery to achieve a complete seal. She was treated with a fenestrated graft with two renal fenestrations and a scallop for the SMA. She had complete exclusion of the 5.5-cm aneurysm on her completion angiogram (B) and discharge CT scan. The size of her aneurysm has subsequently decreased to 4.5-cm maximum diameter after 1 year of follow-up. Journal of Vascular Surgery 2004 39, 279-287DOI: (10.1016/j.jvs.2003.09.050)

Fig 5 This expanded axis view demonstrates the primary and assisted patency of any visceral vessels incorporated into a fenestrated repair, as calculated with the Kaplan-Meier method. Journal of Vascular Surgery 2004 39, 279-287DOI: (10.1016/j.jvs.2003.09.050)