Side branch preservation during endovascular aortic aneurysm repair

Retrograde Fenestration of Endoluminal Grafts from Target Vessels: Feasibility, Technique, and Potential Usage

Purpose:

To report initial experiments involving a new method for percutaneous intraprocedural stent-graft fenestration from the target vessel.

Technique:

In bench and canine models, the fabric of an implanted Zenith endograft was punctured easily using the stiff end of a coronary 0.014-inch guidewire delivered through the target vessel (e.g., renal or iliac artery). A 20-G cutting needle was passed over the coronary wire to enlarge the puncture site, followed by a cutting balloon to create a fenestration that was of sufficient size to allow deployment of a stent.

Conclusions:

In vivo endograft fenestration of a Zenith endograft is feasible. In addition to providing a percutaneous means of intentionally fenestrating a stent-graft from the artery to be perfused, the technique has potential application as a bailout maneuver after inadvertent side branch occlusion. Although the time to achieve successful fenestration in the experimental model was long, refinement may achieve performance times adequate to maintain viability of the end organ.

Open Repair of Pararenal Aortic Aneurysms: Operative Management, Early Results, and Risk Factor Analysis

Surgical treatment of pararenal aortic aneurysms, if compared to open surgical repair of infrarenal aneurysms, is technically more demanding and characterized by problems related to organ ischemia. To better define challenges, risks, and results, we analyzed our experience with the treatment of pararenal aortic aneurysms. Between January 1993 and March 2005, 119 consecutive patients underwent surgery for pararenal aneurysms at our institution. A prospective analysis of results was performed. According to their localization, we treated 85 juxtarenal aneurysms and 34 suprarenal aneurysms. One hundred and three patients underwent primary repair of an atherosclerotic aneurysm, four patients underwent surgical repair of an anastomotic pseudoaneurysm, and eight patients underwent correction of an aneurysm of the pararenal aorta proximal to a previous infrarenal anastomosis. Four patients underwent emergency operation for a ruptured aneurysm. In the juxtarenal aneurysm group, the 30-day mortality rate was 4.7% (4/85) including three patients with ruptured aneurysm. In the suprarenal aneurysm group, the 30-day mortality rate was 2.9% (1/34). Preoperative renal insufficiency was present in 16 patients, respectively in 7 patients with juxtarenal aneurysms and in 9 patients with suprarenal ones. In 22 patients, we registered a transient increase in creatinine levels with return to baseline levels by discharge. Four patients required long-term dialysis. In three patients, a short period of dialysis was required. Clamping time longer than 30 min was associated with a higher risk of transient postoperative deterioration of renal function (p = 0.0073). Preoperative renal insufficiency was associated with a higher risk of persistent postoperative deterioration of renal function (p < 0.0001). Morbidity and mortality of elective surgery for pararenal aneurysms is acceptable. One of the main risks of this surgery is renal morbidity. Preoperative renal insufficiency and long periods of renal ischemia are associated with a higher risk of postoperative deterioration of renal function that is often, but not always, reversible. Nowadays, pararenal aneurysm repair is a safe procedure, especially if performed electively.