Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair Rajendra Patel, MD, Mark F. Conrad,

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Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair Rajendra Patel, MD, Mark F. Conrad, MD, Vikram Paruchuri, MD, Christopher J. Kwolek, MD, Richard P. Cambria, MD Journal of Vascular Surgery Volume 51, Issue 2, Pages 310-315 (February 2010) DOI: 10.1016/j.jvs.2009.04.079 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Schematic representation of opened visceral aortic segment (patient head to right) during thoracoabdominal (TAA) repair. Origins of (from right to left) celiac, superior mesenteric, right, and left renal arteries are displayed. Dashed lines indicate the right renal artery wherein circumferential external exposure is not possible. Inset: hemostat gently dilates right renal artery orificial stenosis. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 Inclusion button reconstruction of celiac, superior mesenteric, and right renal artery ostia. The left renal artery origin is detached from the aorta, and cold renal preservation solution is instilled. Note the attached side-arm graft for the subsequent left renal artery reconstruction. The visceral inclusion button anastomosis is begun just cephalad to the celiac axis origin and coursing close to the visceral and right renal origins. Note the suture bites into the right renal artery; a perfusion catheter (not shown) is typically placed within the right renal artery orifice to allow the instillation of cold renal preservation solution and to interrogate the course of the right renal artery as it courses around the aneurysm. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 Following completion of the posterior/inferior aspect suture line, a balloon expandable stent is inserted into the right renal artery with a small portion overriding into the aorta. The stent is then rapidly expanded under direct vision. Note that no guidewire or fluoroscopic imaging is utilized. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 The anterior aspect of the visceral button anastomosis is now completed, with no further bites near or into the stented right renal artery. Inset: the balloon-expandable stent is seen within the right renal artery in a coronal plane. Note how the stent overrides into the aorta and protects it from suture line impingement or plaque shift. The left renal bypass using a sidearm polytetrafluoroethylene (PTFE) graft is now performed after completion of the visceral inclusion button anastomosis. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 Cummlative survival. Patients post-right renal artery stenting during open complex aortic aneurysm repair.Months01122436At risk676041164Cum events3491011Cum survival0.950.940.850.800.74St error0.030.030.050.060.08 Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 6 Reintervention or stent occlusion.Months01122436At risk674430101Cum events01112Freedom from occlusion/reintervention10.980.980.980.86St error00.020.020.020.12 Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 7 Figure depicts a cross-sectional computed tomography (CT) image with a balloon expandable renal stent within the right renal artery, slightly overriding into the aorta. A dissection flap is noted immediately distal to the stent, however, contrast is noted to fill the right kidney without any appreciable delay when compared to the left kidney. Note the orificial plaque at the right renal artery origin. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 8 A, Depicts a preoperative cross-sectional computed tomography (CT) image demonstrating an aortic aneurysm in proximity to a tortuous right renal artery. Note the small area of calcification along the inferior aspect of the right renal artery origin. B, demonstrates a similar cross-sectional image upon postoperative CT imaging. Note the stent migration into the renal artery without appropriate overriding into the aorta with kinking of the renal artery proximal to the stent near the orificial calcification. Journal of Vascular Surgery 2010 51, 310-315DOI: (10.1016/j.jvs.2009.04.079) Copyright © 2010 Society for Vascular Surgery Terms and Conditions