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In Vivo Fenestration During Endovascular Aneurysm Repair 

In Vivo Fenestration During Endovascular Aneurysm Repair
Chapter:
In Vivo Fenestration During Endovascular Aneurysm Repair
Author(s):

Abdulrahman Masrani

, and Bulent Arslan

DOI:
10.1093/med/9780199986071.003.0008
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Brief Description

Endovascular management of abdominal aortic aneurysms has become the standard of care during the past 10–15 years. Anatomical constraints are the main limitations in our ability to treat patients endovascularly. The two most important factors are aortic neck and iliofemoral access anatomy. This chapter describes a technique to overcome a hostile neck with a renal artery originating from the aneurysm that does not allow enough proximal landing zone for stent grafting. Several techniques were developed to overcome this obstacle, including custom-made grafts with fenestrations, back table fenestration, and parallel graft placement. In this chapter, we describe an in vivo graft fenestration technique to preserve the renal artery lumen during the endovascular repair of an abdominal aortic aneurysm.

Applications of the Technique

  1. 1. Endovascular repair of abdominal aneurysms with a renal artery origin that does not allow sufficient aortic length/proximal seal zone for deployment of the stent graft.

Challenges of the Procedure

  1. 1. The technique requires utilization of several steps that are all challenging, such as creating a fenestration in the graft material with a re-entry needle, dilation of the fenestration with high-pressure and/or scoring balloons (most graft materials are very resistant to dilation), and catheterizing the renal artery through the fenestration. Failure of any of these steps may result in the loss of blood flow to the renal artery.

Potential Pitfalls/Complications

  1. 1. Loss of flow to the kidney due to inability to fenestrate.

  2. 2. Dissection and/or thrombosis of the renal artery during the fenestration process.

  3. 3. Inability to catheterize the renal artery through the fenestration, which would result in a type III endoleak and possible loss of flow to the kidney.

Steps of the Procedure

  1. 1. From a femoral access, advance an 8 Fr Flexor (Cook Medical Inc., Bloomington, IN) sheath to the level of the renal artery to be targeted for the fenestration.

  2. 2. Catheterize the renal artery, and place a 0.014-in. guidewire in the renal artery for support as well as to use as a target later in the procedure.

  3. 3. Advance an OUTBACK® LTD® Re-Entry Catheter (Cordis Corp., Milpitas, CA), and park it at the level of the renal artery origin, within the sheath.

  4. 4. Deploy the stent graft covering the renal artery orifice.

  5. 5. Perform the graft fenestration using the re-entry device that is positioned between the stent graft and the aortic wall by turning and advancing the tip of the needle medially into the lumen of the graft.

  6. 6. Capture the 0.014-in. wire that was advanced into the lumen of the stent graft via the re-entry catheter using a large-diameter snare.

  7. 7. Establish a through-and-through access from inside the lumen of the stent graft to the space between the aortic wall and stent graft.

  8. 8. Using the through-and-through guidewire, use a low-profile (3- or 4-mm diameter) balloon to dilate the graft material.

  9. 9. After dilation of the stent graft material, a 5 Fr Berenstein catheter (AngioDynamics Inc., Latham, NY) is advanced over the 0.014-in. wire from inside the stent graft lumen to the space between the graft and the aortic wall.

  10. 10. Advance a 0.018-in. V18 guidewire (Boston Scientific Inc., Marlborough, MA) through the Berenstein catheter next to the through-and-through 0.014-in. wire to select the renal artery.

  11. 11. Once the V18 wire selectively catheterizes the renal artery, remove the 0.014-in. wire and advance the 5 Fr catheter into the renal artery over the V18 guidewire.

  12. 12. Exchange the V18 wire to a 0.035-in. Rosen wire.

  13. 13. If necessary, further dilate the graft fenestration up to 5- or 6-mm diameter.

  14. 14. Place a covered balloon expandable stent from the renal artery to the lumen of the stent graft through the fenestration, providing flow to the kidney and sealing the aneurysm sac.

Example

A 70-year-old female with a past medical history of chronic obstructive pulmonary disease, hypertension, and abdominal aortic aneurysm was found to have a bilobed abdominal aortic aneurysm measuring 5.1 cm in largest diameter with interval growth. Due to the low origin of the right renal artery, in vivo fenestration was performed to maintain perfusion of the right kidney (Figure 8.1).

Figure 8.1 (A) Abdominal aortogram demonstrating a high origin for the left renal artery, but the right renal artery origin (arrow) is very low coming from the aneurysmal segment. (B) A 0.014-in. guidewire in the right renal artery with an 8-Fr Flexor sheath positioned at the origin of the renal artery. Over a separate 0.014-in. wire, the re-entry device (arrow) is also positioned in the sheath. (C) Bifurcated main body is deployed over the sheath, positioning the sheath between the aortic wall and the graft. (D) After puncturing through the graft wall into the lumen of the stent graft using the OUTBACK® LTD® Re-entry Catheter, the guidewire is snared from the contralateral access, and through-and-through access is achieved. A 4-mm, 0.014-in. balloon (arrow) is advanced over the 0.014-in. wire, and the graft material is dilated. (E) After initial dilation, a larger high-pressure balloon is utilized to further dilate the fenestration to accommodate the covered stents. (F) A 6-mm Viabahn and two 6-mm covered balloon-expandable stents are placed and angioplastied bridging the right renal artery with the stent graft lumen. (G) A larger 8-mm balloon is used to flair the proximal end of the covered stent graft to seal the fenestration. (H) Completion aortogram shows no evidence of endoleak and good flow to the right kidney through the in vivo fenestration. (I) Three-month CT angiogram showing patent right renal artery without any flow limitation to the right kidney.

Figure 8.1 (A) Abdominal aortogram demonstrating a high origin for the left renal artery, but the right renal artery origin (arrow) is very low coming from the aneurysmal segment. (B) A 0.014-in. guidewire in the right renal artery with an 8-Fr Flexor sheath positioned at the origin of the renal artery. Over a separate 0.014-in. wire, the re-entry device (arrow) is also positioned in the sheath. (C) Bifurcated main body is deployed over the sheath, positioning the sheath between the aortic wall and the graft. (D) After puncturing through the graft wall into the lumen of the stent graft using the OUTBACK® LTD® Re-entry Catheter, the guidewire is snared from the contralateral access, and through-and-through access is achieved. A 4-mm, 0.014-in. balloon (arrow) is advanced over the 0.014-in. wire, and the graft material is dilated. (E) After initial dilation, a larger high-pressure balloon is utilized to further dilate the fenestration to accommodate the covered stents. (F) A 6-mm Viabahn and two 6-mm covered balloon-expandable stents are placed and angioplastied bridging the right renal artery with the stent graft lumen. (G) A larger 8-mm balloon is used to flair the proximal end of the covered stent graft to seal the fenestration. (H) Completion aortogram shows no evidence of endoleak and good flow to the right kidney through the in vivo fenestration. (I) Three-month CT angiogram showing patent right renal artery without any flow limitation to the right kidney.

References and Suggested Readings

1. Deng GY, Zhou J, Lu QS, et al. A novel pressure difference-induced perforation aortic stent-grafts system: An experimental study. Chin Med J (Engl). 2013;126(7):1264–1268.Find this resource:

2. Ahanchi SS, Almaroof B, Stout CL, Panneton JM. In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair. J Endovasc Ther. 2012;19(2):226–230.Find this resource:

3. Kolbel T, Carpenter SW, Diener H, Wipper S, Debus ES, Larena-Avellaneda A. Antegrade in situ stent-graft fenestration for the renal artery following inadvertent coverage during EVAR. J Endovasc Ther. 2013;20(3):289–294.Find this resource:

4. McWilliams RG, Murphy M, Hartley D, Lawrence-Brown MM, Harris PL. In situ stent-graft fenestration to preserve the left subclavian artery. J Endovasc Ther. 2004;11(2): 170–174.Find this resource:

5. Wheatley GH 3rd. In situ fenestration of the internal iliac artery as a bailout technique associated with endovascular repair of an abdominal aortic aneurysm: Long-term follow-up. J Endovasc Ther. 2012;19(6):716–720.Find this resource: