Branched EVAR

Journal Pre-proof An Original Bailout Solution For Renal Artery Dissection After Fenestrated / Branched Evar Alice Lopes, Miguel Lemos Gomes, Ryan Melo, Pedro Amorim, Gonçalo Sobrinho, Luís Mendes Pedro PII:

S0890-5096(19)30964-1

DOI:

https://doi.org/10.1016/j.avsg.2019.11.006

Reference:

AVSG 4767

To appear in:

Annals of Vascular Surgery

Received Date: 18 September 2019 Revised Date:

1 November 2019

Accepted Date: 1 November 2019

Please cite this article as: Lopes A, Gomes ML, Melo R, Amorim P, Sobrinho G, Pedro LM, An Original Bailout Solution For Renal Artery Dissection After Fenestrated / Branched Evar, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.11.006. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.

1

AN ORIGINAL BAILOUT SOLUTION FOR RENAL ARTERY DISSECTION AFTER

2

FENESTRATED / BRANCHED EVAR

3

Alice Lopes1, 3, Miguel Lemos Gomes1, 3, Ryan Melo1, 3, Pedro Amorim1, 2, 3, Gonçalo Sobrinho1,

4

2, 3

and Luís Mendes Pedro1, 2, 3

5 6

1

7

(CHULN), Lisbon

8

2

Faculty of Medicine, University of Lisbon

9

3

Lisbon Academic Medical Center

Vascular Surgery Department - Heart and Vessels Division, Hospital de Santa Maria

10 11

Corresponding author: Alice Lopes

12

[email protected]

13

Avenida Professor Egas Moniz, Lisboa - Portugal 1649-035

14 15

Keywords: thoraco-abdominal aneurysm; bEVAR; fEVAR; renal artery dissection; renal

16

kissing sent

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

Total word count: 1080

38

Abstract

39

Purpose: Renal artery (RA) dissection may occur during endovascular treatment of thoraco-

40

abdominal aneurysms. The aim of this paper is to report the use of kissing coronary stents in the

41

renal bifurcation as a bailout solution for dissection after F/B-EVAR.

42

Case report: A 73-year-old male with an asymptomatic Crawford type 4 thoraco-abdominal

43

aneurysm and a concomitant right common iliac artery aneurysm was proposed for

44

endovascular repair, consisting in TEVAR plus CMD F/B-EVAR, followed by staged

45

bifurcated EVAR plus right-sided IBD. In the control angiogram of the first procedure, a distal

46

occlusion of the left renal artery was observed and attributed to iatrogenic dissection. The 6F

47

sheath was reintroduced and the two main branches of the RA were catheterized with 0.014

48

wires. Then, two coronary drug-eluting stents were used for a kissing stenting technique with

49

good angiographic and clinical results. As planned, one week later the patient underwent an

50

uneventful second stage procedure. Follow-up CTA at 1 year showed normal patency of the

51

renal stents as well as aneurysm shrinking and no signs of endoleak.

52

Conclusion: In the reported case, the use of coronary stents was a safe and long-lasting solution

53

to rescue an iatrogenic renal artery dissection during F/B-EVAR.

54 55

Keywords: thoraco-abdominal aneurysm; bEVAR; fEVAR; renal artery dissection; renal

56

kissing sent

57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74

75

Introduction

76

Dissection is a potential complication of target vessels cannulation and stenting during

77

endovascular treatment of thoraco-abdominal aneurysms using either fenestrated or branched

78

endografts.

79

The iatrogenic dissection of the main trunk of the renal arteries is usually treated by stent

80

placement. However, if the dissection extends to its bifurcation, with stenosis or occlusion of

81

the side branches, the treatment is far more complex not only due to the small caliber of renal

82

bifurcation vessels but also to the unavailability of adequate stents for its management.

83

The purpose of this paper is to report the use of kissing coronary stents as a bailout solution for

84

distal iatrogenic dissection of the renal artery and its efficacy at a 1-year follow-up.

85 86

Case report

87

A 73-year-old male patient with a past medical history of coronary disease, type 2 diabetes

88

mellitus, hypertension and past smoking habits, was admitted due to an 5cm asymptomatic

89

Crawford type 4 thoraco-abdominal aneurysm and a concomitant 5cm right common iliac artery

90

aneurysm. The patient was proposed for endovascular repair, consisting in TEVAR plus CMD

91

F/B-EVAR with 3 fenestrations for the superior mesenteric artery (SMA) and both renal arteries

92

and a branch for the celiac trunk (CT), followed by staged EVAR plus right-sided iliac branch

93

device (Figure 1).

94

The first procedure was performed under general anesthesia and drainage of the cerebrospinal

95

fluid using bilateral femoral and left axillary surgical accesses. All fenestrations and branch

96

were cannulated with a 0.035’’ hydrophylic guidewire which was then replaced by a stiffer

97

guidewire (Rosen®, Cook Medical®, Bloomington, Ind) allowing the introduction of a 6F

98

sheath. After selective angiogram balloon-expandable covered stents (Advanta V12®, Getinge,

99

Sweden) were placed in the visceral arteries. The left RA (LRA) was cannulated in the same

100

fashion. After selective LRA angiogram, a balloon-expandable covered stent (Advanta V12®-

101

5x22mm, Getinge, Sweden) was placed in the LRA. Control angiogram revealed the stent

102

ending just after the ostium so a second stent of the same dimensions was placed distally. The

103

procedure on the LRA was otherwise uneventful and the final control showed no defects (Figure

104

2).

105

Nevertheless, in the final control angiogram, a distal occlusion of the left renal artery was

106

observed and attributed to an iatrogenic dissection (Figure 3). The 6F sheath was reintroduced

107

inside the renal stentgrafts and the two main branches of the renal artery were catheterized with

108

0.014” wires (Figure 4). Then, two coronary drug eluting stents (DES) (XIENCE Alpine®-

109

3x38+3.5x38mm, Abbott, CA, USA) were deployed for a kissing stenting technique with good

110

final angiographic result (Figure 4).

111

As planned, one week later the patient underwent an uneventful second stage procedure, being

112

discharged home on the 5th day of the postoperative period with no acute renal injury (creatinine

113

1.10 mg/dL) and no neurologic complications.

114

The follow-up with computerized tomography angiography (CTA) at 1 month and at 1 year

115

showed the normal patency of the renal stents as well as aneurysm shrinking and no signs of

116

endoleak (Figure 5). At 1 year of follow-up the patient maintained his normal renal function.

117 118

Discussion

119

We report the case of an after F/B-EVAR iatrogenic distal dissection of the left RA and its

120

bifurcation branches successfully treated with “kissing stent” technique. This complication is

121

described in the literature but, to the best of the author’s knowledge, its incidence has not been

122

quantified neither has its treatment been described.

123

Renal artery stenting has become a well-accepted procedure for the treatment of atherosclerotic

124

RAS, which usually involves the proximal segments of the artery.2,3,4 However, when the renal

125

bifurcation is involved the treatment becomes more challenging and the use of stents in a

126

kissing fashion may be necessary as previously described. The first reports of this approach in

127

atherosclerosis used bare metal stents and, consequently, were associated with a high restenosis

128

rate, especially in small arteries with 4mm or less.4,5,6 Therefore, in our case, as the branches of

129

the RA were small sized we used a "coronary-like" approach 2,4 as, currently, there are no

130

specific renal medicated stents available and coronary DES have been used with good safety

131

and efficacy.2,6,7

132

Given the good technical results of this procedure in atherosclerotic disease, we applied this

133

technique to a case of iatrogenic dissection of the distal RA. The medium-term result (1 year

134

follow-up) was very good without evidence of restenosis or occlusion. However, as mentioned

135

before, to the best of our knowledge, the use of this approach as bailout after iatrogenic

136

dissection has not been previously reported in the literature and so further studies are needed to

137

ascertain its safety, efficacy and patency rates in these clinical setting.

138 139

Conclusion

140

The clinical and technical success in the reported case as well as the maintenance of normal

141

patency of the renal stents at 1-year follow-up supports its use as a safe and effective solution to

142

manage iatrogenic dissection of the distal renal artery.

143 144 145 146 147

148

Images

149 150 151 152

Figure 1 – Plan of the procedure

153

expandable covered stents.

Figure 2 – Control angiogram showing normal patency of the left renal artery with two balloon-

154 155

Figure 3 – Distal occlusion of the left renal artery

156 157

Figure 4 – a) Re-catheterization of the two main branches of the renal artery with 0.014 wires;

158

b) kissing stenting technique; c) good angiographic result

159 160

Figure 5 – Follow-up CTA at 1 month (a and b) and 1 year (c)

161 162

References

163

1 - Avula S, Dorros G. Juxtaposed “Kissing” Stents as a Technique to Preserve Both Limbs of a

164

Bifurcating Renal Artery. Catheterization and Cardiovascular Diagnosis. 1995; 36(2): 143-5.

165

2 - Hasija P, Chadha D, Kalra R. Kissing stenting of aorto-ostial lesions in juxtaposed renal

166

arteries. BMJ Case Rep. 2014; doi:10.1136/bcr-2014-205373.

167

3 - Leonardou P, Pappas P. Stents in renal artery bifurcation stenosis: a case report. Case Rep

168

Med. 2011; doi:10.1155/2011/653143.

169

4- Misra S, Sturludottir M, Verghese M et al. Treatment of Complex Stenoses Involving Renal

170

Artery Bifurcations with Use of Drug-eluting Stents. J Vasc Interv Radiol. 2008; 19(2): 272 –

171

278.

172

5- Lederman R, Mendelsohn F, Santos R et al. Primary renal artery stenting: Characteristics and

173

outcomes after 363 procedures. Am Heart J. 2001; 142(2): 314-23.

174

6- Yan H, Zheng B, Wu Z et al. Two-stent strategy for renal artery stenosis with bifurcation

175

lesion. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2010; 11(8): 561-567.

176

7- Li C, WU Z, YAN H et al. Safety and efficacy of coronary drug eluting stent for

177

atherosclerotic stenosis of the small renal artery. Chinese Medical Journal. 2009; 122(10): 1223-

178

1226.