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Hybrid-Fenestrated Aortic Aneurysm Repair: A Novel Technique for Treating Patients With Para-Anastomotic Juxtarenal Aneurysms
Hybrid-Fenestrated Aortic Aneurysm Repair: A Novel Technique for Treating Patients With Para-Anastomotic Juxtarenal Aneurysms Benjamin W. Starnes, and Elina Quiroga, Seattle, Washington
This article describes a novel technique that combines off-label endovascular methods with an open surgical debranching procedure to facilitate repair of a para-anastomotic juxtarenal aortic aneurysm. We present a case of recurrent aortic aneurysmal disease 10 years after infrarenal tube graft repair. The aneurysm was treated in two stages; first by retrograde aortobirenal bypass with a bifurcated graft. Subsequently, fenestrated endografting was performed with a customaltered TX-2 thoracic stent graft (COOK, Bloomington, IN), with fenestrations for both the celiac and superior mesenteric arteries. As compared with a purely open approach, this technique offers an alternative for managing juxtarenal aneurysms with less physiologic insult.
Exciting new endovascular technologies have afforded the opportunity to manage patients with increasingly complex aortic aneurysmal disease. Although fenestrated techniques have certain requirements for success, they have not been proven in the United States and therefore currently remain investigational.1,2 Hybrid techniques of relocating vital aortic branches to alternate or remote locations to make patients meet the criteria as candidates for endovascular repair have been well described, but are not without risk of significant morbidity and even mortality.3-5 We describe a technique of a combination of these methods for successful repair of a para-anastomotic juxtarenal aortic aneurysm in an elderly patient.
CASE REPORT An 80-year-old man presented 10 years after uncomplicated infrarenal aneurysm repair with a 7.4-cm para-anastomotic juxtarenal aortic aneurysm (Fig. 1A). The aneurysm extended to within 3 mm of the superior mesenteric artery (SMA) and single, bilateral renal arteries Correspondence to: Benjamin W. Starnes, MD, Division of Vascular Surgery, University of Washington, Box 359796, 325 Ninth Avenue, Seattle, WA, E-mail: [email protected] Ann Vasc Surg 2010; 24: 1150-1153 DOI: 10.1016/j.avsg.2010.03.024 Ó Annals of Vascular Surgery Inc.
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were found to directly emanate from the aneurysm sac. The region of aorta where the celiac and SMAs originated was free of aneurysmal disease (Fig. 1B). The patient underwent a two-stage procedure. The first stage consisted of laparotomy and aortobirenal bypass with a 12 7 mm bifurcated dacron graft (Hemashield Gold; Boston Scientific, Natick, MA). The surgery took 246 minutes, and ischemic time was 14 minutes to the right renal artery and 11 minutes to the left renal artery. Estimated blood loss was 450 mL. Consideration was given to a single-stage procedure, but was not possible because of the unavailability of high quality biplanar imaging in the operative suite; therefore, a completion second-stage procedure was planned. The patient made an uneventful recovery with no evidence of any renal impairment and the length of stay in the hospital was 6 days. Follow-up imaging demonstrated a successful revascularization and aided in the planned second stage of the procedure (Fig. 2). After 8 weeks, the patient underwent an off-label fenestrated stent-graft procedure using a custom-made 36 152 mm TX-2 (COOK, Bloomington, IN) thoracic aortic stent graft. The second procedure was delayed because of a bout of Clostridium difficile colitis which required a 2-week course of antibiotics. Fenestrations were created precisely for both the celiac and SMA with measurements taken from the caudal end of the aortic stent graft on the basis of reconstructed images, using TeraRecon reconstruction software (TeraRecon Inc., San Mateo, CA). Subsequently, after deployment of the graft using biplanar imaging to precisely orient the graft, the SMA was selected with a SOS catheter (COOK) and
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Hybrid-fenestrated aortic aneurysm repair 1151
Fig. 1. Axial computed tomography angiography (CTA) images depicting a large para-anastomotic juxtarenal aneurysm A and a relatively normal healthy aorta in the region of the SMA B.
technical result (Fig. 4). The patient recovered fully and is 18 months out of this procedure without evidence of endoleak and an aneurysm sac size that has diminished to 4.7 cm.
DISCUSSION
Fig. 2. Reconstructed CTA depicting retrograde aortobirenal bypass before second-stage fenestrated aneurysm repair.
replaced with a 7F Ansel Sheath (COOK). A 7 22 mm covered stent (iCAST; Atrium, Hudson, NH) was then deployed into the SMA and flared into the aorta with a 9-mm balloon (Fig. 3A-D). Unlike the SMA fenestration, the celiac fenestration was allowed to have crossing stent struts and was therefore left unstented. The stent graft was deployed down to the origin of the aortobirenal bypass. Follow-up imaging performed several weeks later demonstrated no evidence of endoleak and, an excellent
Management of aneurysmal disease affecting the paravisceral segment of the aorta has undergone an evolution over the past several years. Fenestrated techniques were introduced in 1998 to increase the landing zone for conventional aortic stent graft repair and thereby offer this minimally invasive alternative to a larger number of patients with challenging aortic anatomy.6 In an attempt to combine open and endovascular techniques and subsequently ‘‘debranch’’ the entire paravisceral aorta before stent grafting across this entire segment of aorta, hybrid operative and endovascular techniques were developed.4,7,8 The results of these techniques have been variable and most authorities have recognized that the operative stages of these procedures involve surgical procedures that are as great or greater in physiologic insult to the patient, often taking more than 5 hours to perform, and not without substantial morbidity. Some patients do not survive to undergo the second, more minimally invasive procedure.3 In our patient, the addition of bypass grafts to the healthy celiac and SMA would have added additional time to this reoperative surgery and would have based all four visceral vessels off a single graft. When dealing with aneurysms such as the one described in this technical note, conventional options for repair would include standard open repair, a four vessel debranching procedure before aortic stent grafting across the visceral segment or nonoperative management.
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Annals of Vascular Surgery
Fig. 3. A series of fluoroscopic images depicting selection of the SMA fenestration A, placement of a 7 22 mm covered stent B, deployment of the stent C, and finally flaring of the 7-mm stent into the stent graft with a 9-mm balloon D.
Fig. 4. Follow-up CTA reconstructions in coronal A and sagittal B planes demonstrating a successful hybrid-fenestrated repair.
Combining fenestrated stent grafting with aortic debranching for those segments of normal aorta that may serve as seal zones for endovascular repair has many advantages. Ischemic time to the viscera is substantially minimized and does not all take place in a cumulative manner as it would with supraceliac cross-clamping. For conventional bifurcated stent grafts, most of the graft migration forces are exerted on the aortic bifurcation. With fenestrations placed in a tube graft, the migration forces on the graft and the stented fenestrations are minimized. Additionally, stented fenestrations
into this ‘‘normal’’ segment of aorta allow for better fixation of the stent graft. Some authors have suggested that at least one fenestration should be stented to help secure fixation of the graft and prevent migration.9 Finally, and probably most importantly, the physiologic insult to the patient is minimized and outcomes may theoretically be improved. On the horizon are custom-made fenestrated grafts that are currently approved in countries outside the United States but only performed in a few centers in an ‘‘off-label’’ manner or under
Vol. 24, No. 8, November 2010
an Investigational Device Exemption. The hybridfenestrated technique of aneurysmal repair represents a novel approach for managing patients presenting in this manner with minimal physiologic insult. REFERENCES 1. Anderson JL, Adam DJ, Berce M, Hartley DE. Repair of thoracoabdominal aortic aneurysms with fenestrated and branched endovascular stent grafts. J Vasc Surg 2005;42:600-607. 2. Chuter TA. Fenestrated and branched stent-grafts for thoracoabdominal, pararenal and juxtarenal aortic aneurysm repair. Semin Vasc Surg 2007;20:90-96. 3. Bockler D, Kotelis D, Geisbusch P, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissectionsda single center experience in 28 patients. J Vasc Surg 2008;47:724-732.
Hybrid-fenestrated aortic aneurysm repair 1153
4. Starnes BW, Tran NT, McDonald JM. Hybrid approaches to repair of complex aortic aneurysmal disease. Surg Clin North Am 2007;87:1087-1098, ix. 5. van de Mortel RH, Vahl AC, Balm R, et al. Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms. Vascular 2008;16:140-146. 6. Anderson JL, Berce M, Hartley DE. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001;8:3-15. 7. Quinones-Baldrich WJ, Panetta TF, Vescera CL, Kashyap VS. Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach. J Vasc Surg 1999;30: 555-560. 8. Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg 2006;43:1081-1089. 9. Muhs BE, Verhoeven EL, Zeebregts CJ, et al. Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg 2006;44:9-15.
This article describes a novel technique that combines off-label endovascular methods with an open surgical debranching procedure to facilitate repair of a para-anastomotic juxtarenal aortic aneurysm. We present a case of recurrent aortic aneurysmal disease 10 years after infrarenal tube graft repair. The aneurysm was treated in two stages; first by retrograde aortobirenal bypass with a bifurcated graft. Subsequently, fenestrated endografting was performed with a customaltered TX-2 thoracic stent graft (COOK, Bloomington, IN), with fenestrations for both the celiac and superior mesenteric arteries. As compared with a purely open approach, this technique offers an alternative for managing juxtarenal aneurysms with less physiologic insult.
Exciting new endovascular technologies have afforded the opportunity to manage patients with increasingly complex aortic aneurysmal disease. Although fenestrated techniques have certain requirements for success, they have not been proven in the United States and therefore currently remain investigational.1,2 Hybrid techniques of relocating vital aortic branches to alternate or remote locations to make patients meet the criteria as candidates for endovascular repair have been well described, but are not without risk of significant morbidity and even mortality.3-5 We describe a technique of a combination of these methods for successful repair of a para-anastomotic juxtarenal aortic aneurysm in an elderly patient.
CASE REPORT An 80-year-old man presented 10 years after uncomplicated infrarenal aneurysm repair with a 7.4-cm para-anastomotic juxtarenal aortic aneurysm (Fig. 1A). The aneurysm extended to within 3 mm of the superior mesenteric artery (SMA) and single, bilateral renal arteries Correspondence to: Benjamin W. Starnes, MD, Division of Vascular Surgery, University of Washington, Box 359796, 325 Ninth Avenue, Seattle, WA, E-mail: [email protected] Ann Vasc Surg 2010; 24: 1150-1153 DOI: 10.1016/j.avsg.2010.03.024 Ó Annals of Vascular Surgery Inc.
1150
were found to directly emanate from the aneurysm sac. The region of aorta where the celiac and SMAs originated was free of aneurysmal disease (Fig. 1B). The patient underwent a two-stage procedure. The first stage consisted of laparotomy and aortobirenal bypass with a 12 7 mm bifurcated dacron graft (Hemashield Gold; Boston Scientific, Natick, MA). The surgery took 246 minutes, and ischemic time was 14 minutes to the right renal artery and 11 minutes to the left renal artery. Estimated blood loss was 450 mL. Consideration was given to a single-stage procedure, but was not possible because of the unavailability of high quality biplanar imaging in the operative suite; therefore, a completion second-stage procedure was planned. The patient made an uneventful recovery with no evidence of any renal impairment and the length of stay in the hospital was 6 days. Follow-up imaging demonstrated a successful revascularization and aided in the planned second stage of the procedure (Fig. 2). After 8 weeks, the patient underwent an off-label fenestrated stent-graft procedure using a custom-made 36 152 mm TX-2 (COOK, Bloomington, IN) thoracic aortic stent graft. The second procedure was delayed because of a bout of Clostridium difficile colitis which required a 2-week course of antibiotics. Fenestrations were created precisely for both the celiac and SMA with measurements taken from the caudal end of the aortic stent graft on the basis of reconstructed images, using TeraRecon reconstruction software (TeraRecon Inc., San Mateo, CA). Subsequently, after deployment of the graft using biplanar imaging to precisely orient the graft, the SMA was selected with a SOS catheter (COOK) and
Vol. 24, No. 8, November 2010
Hybrid-fenestrated aortic aneurysm repair 1151
Fig. 1. Axial computed tomography angiography (CTA) images depicting a large para-anastomotic juxtarenal aneurysm A and a relatively normal healthy aorta in the region of the SMA B.
technical result (Fig. 4). The patient recovered fully and is 18 months out of this procedure without evidence of endoleak and an aneurysm sac size that has diminished to 4.7 cm.
DISCUSSION
Fig. 2. Reconstructed CTA depicting retrograde aortobirenal bypass before second-stage fenestrated aneurysm repair.
replaced with a 7F Ansel Sheath (COOK). A 7 22 mm covered stent (iCAST; Atrium, Hudson, NH) was then deployed into the SMA and flared into the aorta with a 9-mm balloon (Fig. 3A-D). Unlike the SMA fenestration, the celiac fenestration was allowed to have crossing stent struts and was therefore left unstented. The stent graft was deployed down to the origin of the aortobirenal bypass. Follow-up imaging performed several weeks later demonstrated no evidence of endoleak and, an excellent
Management of aneurysmal disease affecting the paravisceral segment of the aorta has undergone an evolution over the past several years. Fenestrated techniques were introduced in 1998 to increase the landing zone for conventional aortic stent graft repair and thereby offer this minimally invasive alternative to a larger number of patients with challenging aortic anatomy.6 In an attempt to combine open and endovascular techniques and subsequently ‘‘debranch’’ the entire paravisceral aorta before stent grafting across this entire segment of aorta, hybrid operative and endovascular techniques were developed.4,7,8 The results of these techniques have been variable and most authorities have recognized that the operative stages of these procedures involve surgical procedures that are as great or greater in physiologic insult to the patient, often taking more than 5 hours to perform, and not without substantial morbidity. Some patients do not survive to undergo the second, more minimally invasive procedure.3 In our patient, the addition of bypass grafts to the healthy celiac and SMA would have added additional time to this reoperative surgery and would have based all four visceral vessels off a single graft. When dealing with aneurysms such as the one described in this technical note, conventional options for repair would include standard open repair, a four vessel debranching procedure before aortic stent grafting across the visceral segment or nonoperative management.
1152 Starnes and Quiroga
Annals of Vascular Surgery
Fig. 3. A series of fluoroscopic images depicting selection of the SMA fenestration A, placement of a 7 22 mm covered stent B, deployment of the stent C, and finally flaring of the 7-mm stent into the stent graft with a 9-mm balloon D.
Fig. 4. Follow-up CTA reconstructions in coronal A and sagittal B planes demonstrating a successful hybrid-fenestrated repair.
Combining fenestrated stent grafting with aortic debranching for those segments of normal aorta that may serve as seal zones for endovascular repair has many advantages. Ischemic time to the viscera is substantially minimized and does not all take place in a cumulative manner as it would with supraceliac cross-clamping. For conventional bifurcated stent grafts, most of the graft migration forces are exerted on the aortic bifurcation. With fenestrations placed in a tube graft, the migration forces on the graft and the stented fenestrations are minimized. Additionally, stented fenestrations
into this ‘‘normal’’ segment of aorta allow for better fixation of the stent graft. Some authors have suggested that at least one fenestration should be stented to help secure fixation of the graft and prevent migration.9 Finally, and probably most importantly, the physiologic insult to the patient is minimized and outcomes may theoretically be improved. On the horizon are custom-made fenestrated grafts that are currently approved in countries outside the United States but only performed in a few centers in an ‘‘off-label’’ manner or under
Vol. 24, No. 8, November 2010
an Investigational Device Exemption. The hybridfenestrated technique of aneurysmal repair represents a novel approach for managing patients presenting in this manner with minimal physiologic insult. REFERENCES 1. Anderson JL, Adam DJ, Berce M, Hartley DE. Repair of thoracoabdominal aortic aneurysms with fenestrated and branched endovascular stent grafts. J Vasc Surg 2005;42:600-607. 2. Chuter TA. Fenestrated and branched stent-grafts for thoracoabdominal, pararenal and juxtarenal aortic aneurysm repair. Semin Vasc Surg 2007;20:90-96. 3. Bockler D, Kotelis D, Geisbusch P, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissectionsda single center experience in 28 patients. J Vasc Surg 2008;47:724-732.
Hybrid-fenestrated aortic aneurysm repair 1153
4. Starnes BW, Tran NT, McDonald JM. Hybrid approaches to repair of complex aortic aneurysmal disease. Surg Clin North Am 2007;87:1087-1098, ix. 5. van de Mortel RH, Vahl AC, Balm R, et al. Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms. Vascular 2008;16:140-146. 6. Anderson JL, Berce M, Hartley DE. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001;8:3-15. 7. Quinones-Baldrich WJ, Panetta TF, Vescera CL, Kashyap VS. Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach. J Vasc Surg 1999;30: 555-560. 8. Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg 2006;43:1081-1089. 9. Muhs BE, Verhoeven EL, Zeebregts CJ, et al. Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg 2006;44:9-15.