1. Mycotic Pararenal Double Chimney University of Colorado Rulon Hardman, MD Rajan Gupta, MD

2. 60 yo male, 3.9 cm AAA

3. Gets a PNA 3 weeks later..

4. At celiac

5. At SMA

6. R renal

7. L renal

8. 3.9  7 cm in 3 weeks

9. AAA goes to level of SMA/L renal

10. Coronal

11. Course Initially thought no endo solution Taken to OR Can’t resect due to inflammation and adherence to renal veins Closed and told there are no options, hospice consulted

12. Following week Endo team finds out about patient from IR fellow Patient alive and still in hospital Plan – Embolize R kidney – Double chimney (SMA/L renal) – L axillary conduit for access – Endologix stent chosen Easy to build up Iliacs not an issue – both will seal with 16 mm limbs Easier to focus on top seal Endoleak less of a concern (unibody will seal on IMA/low lumbars and leave less lumbars in the circuit for potential type IIs)

13. Plan Axillary conduit (10 mm) Perc access/preclose All graft components soaked in Rifampin Place main body on bifucation Embolize R kidney (unable to salvage with stent) Axillary access into conduit – 6Fr – Cath desc aorta with kumpe/glide xchange for stiff wire – Upsize to 9 Fr into desc aorta – Select L renal, sheath into L renal 2 nd Axillary access (same conduit) – Same process put 2 nd 9 Fr sheath into SMA

14. First place infrarenal stent up to lowest renal (secondary snorkel) – Maximize any infrarenal seal – May help with guttering/graft stability Place stents in respective sheaths – 7mm x 5 cm Viabahn L renal – 9mm x 5 cm Viabahn SMA In lateral deploy suprarenal cuff just below celiac (after all parallax corrected) Balloon Endologix stent seal zones including proximally (Viabahns not yet deployed) – Maximize main stent seal/minimize guttering Unsheath each viabahn keeping stent 2-4 mm above top of main body graft material Deploy both Viabahns – Don’t balloon unless needed – If needed, kissing balloon

15. Initial Angio

16. IVUS at SMA Arrows show aneurysm. Actually about 4 mm neck to SMA but not healthy aorta, this was aneurysm projecting up

17. IVUS at L renal Posterior chunk of Ca causing shadowing (renal not that big)

18. Stents in SMA/L renal, getting ready to deploy infrarenal cuff

19. No seal

20. Lateral with stents in place

21. Lateral before deploying suprarenal Incidental celiac stenosis

22. Post angio – sealed. Both stents patent.

23. Took about 4 hours (including ax conduit) < 3 Gy radiation ~ 200 cc contrast Bilateral groin perc closures (2 proglides each side) Pt up in chair walking next day Long term plan: – Lifelong antibiotics Follow up – Patient alive 18 months post intervention, doing well