INTRODUCTION
Juxtarenal or pararenal aneurysms begin at the level of the renal arteries and do not
afford a large enough neck for conventional endovascular treatment11. Sarac TP, Clair DG, Hertzer NR, et al. Contemporary results of
juxtarenal aneurysm repair. J Vasc Surg. 2002;36(6):1104-11. PMid:12469040.
http://dx.doi.org/10.1067/mva.2002.129638
http://dx.doi.org/10.1067/mva.2002.12963...
,
22. Jongkind V, Yeung KK, Akkersdijk GJ, et al. Juxtarenal aortic
aneurysm repair. J Vasc Surg. 2010;52(3):760-7. PMid:20382492.
http://dx.doi.org/10.1016/j.jvs.2010.01.049
http://dx.doi.org/10.1016/j.jvs.2010.01....
. Unfavorable anatomy is responsible for a large proportion of technical
failures, such as mal-positioned or dislodged stents, leading to type I endoleaks33. Coscas F, Becquemin JP, Majewski M, et al. Management of
Perioperative Endoleaks During Endovascular Treatment of Juxta-Renal Aneurysms. Ann
Vasc Surg. 2012;26(2):175-84. PMid:22078306.
http://dx.doi.org/10.1016/j.avsg.2010.10.021
http://dx.doi.org/10.1016/j.avsg.2010.10...
. In such cases special strategies are needed to ensure endovascular treatment
success44. Mendonça CT, Carvalho CA, Wein J. The Use of a Self-expandable Aortic
Stent to Incarcerate Microcoils and to Create a Favourable Infrarenal Neck in an
Unusual Case of Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc
Surg. 2013 May;45(5):465-7. PMid:23473782.
http://dx.doi.org/10.1016/j.ejvs.2013.01.040
http://dx.doi.org/10.1016/j.ejvs.2013.01...
.
PART I - CLINICAL SITUATION
The patient was a 64-year-old sedentary male smoker with hypertension, diabetes and chronic obstructive pulmonary disease (COPD) with a forced expiratory volume in 1 second (VEF1.0), less than 60% of predicted capacity. An infrarenal abdominal aortic aneurysm with a 4.8 cm diameter was diagnosed by Doppler ultrasound. On physical examination, the patient's general condition was regular, the abdominal aorta was hyperpulsatile and the left pedal pulse was absent, although all other pulses were present and symmetrical. Since the AAA diameter was less than 5.5 cm at this consultation, the patient was given advice on lifestyle habit changes, such as walking and giving up smoking. The medication he was already on was maintained (atenolol, enalapril and metformin) and a return appointment for ultrasound examination was scheduled for 6 months later.
At the return consultation, Doppler ultrasound showed that the aneurysm had increased in size by 6 mm in five and a half months, and had a 5.4 cm diameter. Angiotomography (Angio-TC) was requested and showed a secondary aneurysm sac in a pararenal position (Figure 1). This second aneurysm sac, located 7 mm from the right renal artery, introduced an additional difficulty since there was now a risk of the stent becoming dislodged into it.
PART II - WHAT WAS DONE
The decision was taken to repair the aneurysm using endovascular methods in view of the patients' pulmonary capacity and the fact that he did not consent to conventional surgery. An Apolo(r) 25×12×12×150 branched stent (Nano Endoluminal, Florianópolis, Brazil) with double proximal free flow and a 12×12×110 straight-line length was implanted via a right femoral access. The pararenal saccular aneurysm was embolized with 12×14 and 10×14 Nester(r) coils (Cook Medical Inc. Bloomington, IN, USA) after the main body of the stent had been released. However, the coils had been placed in advanced, using a Vertebral 5F catheter via a left femoral access and left ready in the sac of the pararenal aneurysm before release of the main body of the stent (Figure 2). After the secondary pararenal aneurysm had been completely filled with coils, the procedure was completed with placement of the left iliac branch and fixation with a 20-50×100 Coda balloon (Cook Medical Inc. Bloomington, IN, USA) (Figure 3).
Intraoperative angiography showing the pararenal sac (A). In (B), the released main body of the stent can be seen compressing the vertebral catheter against the aorta wall. The catheter tip is inside the pararenal aneurysm sac.
Control angiographs showed that the procedures had been successful, with excellent patency of the system and obliteration of both aneurysms, with no evidence of endoleaks (Figure 4).
The patient coursed progressed with no intercurrent conditions and an angio-CT performed eighth months after the procedure showed that exclusion of the primary and secondary aneurysmal sacs had been maintained, and the primary sac diameter had reduced to 4.4 cm (Figure 5).
Angio-TC demonstrating that exclusion of primary and secondary aneurysmal sac exclusion has been maintained and showing coils inside the pararenal sac.
DISCUSSION
Treatment of abdominal aorta aneurysms with endovascular methods, described in 1991 for
the first time by Parodi55. Parodi JC, Palmaz JC, Barone HD. Transfemoral Intraluminal Graft
Implantation for Abdominal Aortic Aneurysms. Ann Vasc Surg. 1991;5(6):491-9.
PMid:1837729. http://dx.doi.org/10.1007/BF02015271
http://dx.doi.org/10.1007/BF02015271...
, is becoming ever more common. Despite the complexity of the procedure, the
dependence on favorable anatomy and the need for a highly trained technical team, the
minimally invasive character of the procedure and its advantages for postoperative
recovery have promoted it to the treatment of first choice, wherever indicated.
In the case described here, the secondary pararenal aneurysm sac created an additional
therapeutic challenge. Another challenge was to avoid a type I endoleak, in view of the
short neck. These difficulties were surmounted by customizing an stent with double
proximal free flow, in order to provide better support for fixation, and by filling the
proximal aneurysm sac with coils. This was achieved using the strategy of placing the
tip of a vertebral 5F diagnosis catheter inside the sac before the main body of the
stent was released. After the main body had been released into its pararenal position
and the right common iliac artery branch had been placed, the coils were released inside
the secondary sac until it was entirely filled. Next the catheter was removed and the
left common iliac artery branch of the stent was placed conventionally and the procedure
finished off. We used the main body of the stent to retain the coils inside the
secondary sac, since it had a wide neck. In one recently reported case11. Sarac TP, Clair DG, Hertzer NR, et al. Contemporary results of
juxtarenal aneurysm repair. J Vasc Surg. 2002;36(6):1104-11. PMid:12469040.
http://dx.doi.org/10.1067/mva.2002.129638
http://dx.doi.org/10.1067/mva.2002.12963...
, the author used a self-expanding stent accomplish this function, followed by
placement of a stent, which made the proximal neck into a 'sandwich' comprising
stent and stent. Among other possibilities, a multilayer stent66. Pieper CC, Meyer C, Verrel F, et al. Using the Multilayer Stent as a
Supplement to EVAR in Combined Abdominal Aortic Aneurysm and Iliac Artery Aneurysm
With Inadequate Distal Landing Zone-A Case Report. Vasc Endovasc Surg.
2012;46(7):565-9. http://dx.doi.org/10.1177/1538574412456306
http://dx.doi.org/10.1177/15385744124563...
,
77. Henry M, Polydorou A, Frid N, et al.. Treatment of renal artery
aneurysm with the multilayer stent. J Endovasc Ther. 2008;15(2):231-6. PMid:18426265.
http://dx.doi.org/10.1583/07-2222.1
http://dx.doi.org/10.1583/07-2222.1...
or fenestrated stents88. Verhoeven EL, Vourliotakis G, Tielliu IF, et al. Fenestrated Stent
grafting for short-necked and justarenal abdominal aortic aneurysm: An 8-year
single-centre experience. Eur J Vasc Endovasc Surg. 2010;39(5):529-36. PMid:20202868.
http://dx.doi.org/10.1016/j.ejvs.2010.01.004
http://dx.doi.org/10.1016/j.ejvs.2010.01...
could have been used, but at the time we did not feel sufficiently familiarized
with these techniques.
The patient is asymptomatic with renal function spared and a recent tomographic study showed that the treatment employed achieved and maintained the stated objectives, namely to exclude both aneurysm sacs with no endoleaks and with shrinkage of the primary sac diameter.
REFERENCES
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1Sarac TP, Clair DG, Hertzer NR, et al. Contemporary results of juxtarenal aneurysm repair. J Vasc Surg. 2002;36(6):1104-11. PMid:12469040. http://dx.doi.org/10.1067/mva.2002.129638
» http://dx.doi.org/10.1067/mva.2002.129638 -
2Jongkind V, Yeung KK, Akkersdijk GJ, et al. Juxtarenal aortic aneurysm repair. J Vasc Surg. 2010;52(3):760-7. PMid:20382492. http://dx.doi.org/10.1016/j.jvs.2010.01.049
» http://dx.doi.org/10.1016/j.jvs.2010.01.049 -
3Coscas F, Becquemin JP, Majewski M, et al. Management of Perioperative Endoleaks During Endovascular Treatment of Juxta-Renal Aneurysms. Ann Vasc Surg. 2012;26(2):175-84. PMid:22078306. http://dx.doi.org/10.1016/j.avsg.2010.10.021
» http://dx.doi.org/10.1016/j.avsg.2010.10.021 -
4Mendonça CT, Carvalho CA, Wein J. The Use of a Self-expandable Aortic Stent to Incarcerate Microcoils and to Create a Favourable Infrarenal Neck in an Unusual Case of Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg. 2013 May;45(5):465-7. PMid:23473782. http://dx.doi.org/10.1016/j.ejvs.2013.01.040
» http://dx.doi.org/10.1016/j.ejvs.2013.01.040 -
5Parodi JC, Palmaz JC, Barone HD. Transfemoral Intraluminal Graft Implantation for Abdominal Aortic Aneurysms. Ann Vasc Surg. 1991;5(6):491-9. PMid:1837729. http://dx.doi.org/10.1007/BF02015271
» http://dx.doi.org/10.1007/BF02015271 -
6Pieper CC, Meyer C, Verrel F, et al. Using the Multilayer Stent as a Supplement to EVAR in Combined Abdominal Aortic Aneurysm and Iliac Artery Aneurysm With Inadequate Distal Landing Zone-A Case Report. Vasc Endovasc Surg. 2012;46(7):565-9. http://dx.doi.org/10.1177/1538574412456306
» http://dx.doi.org/10.1177/1538574412456306 -
7Henry M, Polydorou A, Frid N, et al.. Treatment of renal artery aneurysm with the multilayer stent. J Endovasc Ther. 2008;15(2):231-6. PMid:18426265. http://dx.doi.org/10.1583/07-2222.1
» http://dx.doi.org/10.1583/07-2222.1 -
8Verhoeven EL, Vourliotakis G, Tielliu IF, et al. Fenestrated Stent grafting for short-necked and justarenal abdominal aortic aneurysm: An 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39(5):529-36. PMid:20202868. http://dx.doi.org/10.1016/j.ejvs.2010.01.004
» http://dx.doi.org/10.1016/j.ejvs.2010.01.004
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*All authors have read and approved of the final version of the article submitted to J Vasc Bras.
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Study carried out at Hospital do Coração de Natal.
Publication Dates
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Publication in this collection
15 Dec 2013 -
Date of issue
Oct-Dec 2013
History
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Received
31 July 2013 -
Accepted
13 Aug 2013