History
A male patient in his 50s had an incidental finding of a large abdominal aortic aneurysm demonstrated on an abdominal duplex ultrasound.
Presentation and Examination
The patient had a 7-cm supra renal abdominal aortic aneurysm. He had heart failure with decreased left ventricular function. He was evaluated by cardiac surgery and underwent a 5-vessel coronary artery bypass grafting. His post-CABG ejection fraction was largely unchanged, and he then underwent implantable cardioverter defibrillator (ICD) placement. He was determined to be a high-risk candidate for open aneurysm repair due to his reduced cardiac function. He was also not a candidate for regular endovascular aneurysm repair as his aneurysm extended above the renal artery.
About abdominal aortic aneurysms
An abdominal aortic aneurysm is caused by a weakening in the wall of the aorta that results in a dilation of the vessel. About 200,000 people are diagnosed with an abdominal aortic aneurysm (AAA) every year in the United States. Ruptured abdominal aortic aneurysm is the 15th leading cause of death in men over the age of 55. Abdominal aortic aneurysm is often diagnosed as an incidental finding noted on ultrasound or computed tomography.
Treatment
The patient underwent a 3-vessel fenestrated endovascular aneurysm repair using a physician-modified endograft. His celiac artery was chronically occluded. Therefore, the superior mesenteric artery (SMA) and bilateral renal arteries required fenestration and target vessel stenting. The graft was opened on the back table and the SMA and bilateral renal artery fenestrations were designed based on the patient’s most recent CT angiography.
I began the procedure by obtaining percutaneous access in both femoral arteries. Then, I advanced a modified Cook Alpha device to the aneurysm site. Through the contralateral femoral artery, a 7 Fr steerable sheath was telescoped into an 18 Fr Dryseal sheath. The 7 Fr sheath was shaped toward the SMA fenestration.
The SMA was selected and a Rosen wire was positioned into the SMA, then both renal arteries were individually selected and wired in the same fashion.
The modified Cook Alpha device was fully deployed, and diameter-reducing ties were removed. I deployed the target vessel stent serially. A 7 x 29 VBX stent graft was placed to the SMA and flared up to 10 mm at the seal.
Right renal fenestration was stented using a 6 x 19 VBX, which was flared to 8 mm. A 5 x 29 VBX was deployed to the left renal fenestration and flared to 8 mm. None of the target vessel stents had a type 3 endoleak on digital subtraction angiography.
I removed the suprarenal fixation of a Cook Zenith Flex stent graft on the back table. This device was deployed and there was more than a two-stent overlap between the devices. The contralateral gate was selected, then the iliac limbs were deployed to the iliac bifurcation.
I performed a completion angiogram, which demonstrated patent SMA and renal arteries. There was no type 1 or 3 endoleak.
Outcome
The patient was seen six months following the procedure and is doing well. He will return in one year for surveillance imaging.
Analysis
Endovascular approach for AAA
Vascular surgeons employing an endovascular approach provide their patients with several benefits. Chiefly, there is less morbidity using an endovascular approach as compared to open surgery. However, patients with aneurysms involving mesenteric or renal arteries are not eligible for commercially available endografts.
Physician-modified fenestrated grafts are an excellent alternative for juxta-renal or higher-level aortic aneurysm with significant comorbidity. I have been using this approach to extend the applicability of endovascular techniques to more patents who would be deemed ineligible for standard endovascular therapy or open aortic repair.
As it was with this case, I believe physician-modified endografts used in the endovascular aortic repair of complex aortic anatomy can be performed with acceptable peri- and post-procedural morbidity and mortality in high-risk patients.
