Teaching Case

Male patient, 65-years-old with multiple comorbidities. Thoracic-Endo-Vascular-Aorta-Repair in 2009 for type-B aortic dissection. Regular follow-up until January 2012 when a CT-scan done for abdominal pain showed a large type 1b endoleak(EL) (Fig.1). We decided to solve the problem with a distal aortic tube and a combination of snorkel and chimney technique for SMA and renal arteries.

Through a left surgical femoral access a straight tapered aortic tube (Valiant-Captivia-Medtronic) was deployed in the descending aorta in order to reduce the diameter of the distal aorta. From the groin two 7F-35cm-long introducer-sheaths were advanced in both renal arteries and two covered stent-grafts (Advanta-Atrium) were positioned at the origin of renal arteries (Fig.2a, b). By a cranial approach, after deployment of 2 coils (MWCE-Cook) at the origin ot the coeliac trunk (Fig.2c) to prevent reperfusion of the EL, the catheterization of superior mesenteric artery (SMA) was obtained and a 7F-90cm introducer-sheath and an Advanta stent was positioned at the origin of SMA. After this first phase another straight short aortic tube (Endurant-Medtronic) was deployed at the level of renal arteries and SMA. Simultaneous deployment of the three stents during ballooning of the aortic tube was done (Fig.2d, e). CT scan after 2 months shows the resolution of the distal endoleak and patency of all treated arteries (Fig.3).

Thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms remain challenging pathologies either for surgical and endovascular therapy treatment. Endovascular repair is represented by fenestrated and branched stent-grafts or as part of hybrid procedures with the combination of debranching and stent-grafting. However, most fenestrated/branched devices must be customized for every case and are not available for patients with acute pathologies, such as ruptured or symptomatic aneurysms. Recently, some papers and case reports have described endovascular revascularization of aortic branch vessels and visceral and renal arteries by using the ‘‘chimney and periscope’’ graft technique [1]. However this technique is mainly used for renal revascularization in infrarenal and/or juxtarenal abdominal aneurysm with hostile neck anatomies [2]. In 2010 the group from Zurich demonstrated the possibility to apply a cranial ‘‘chimney’’ approach to the visceral arteries and a caudal ‘‘periscope’’ approach to the renal arteries in a couple of case reports of TAAAs [3,4].
We decided to apply the same technique in this case of distal type 1 endoleak in a patient previously treated in our center with a thoracic stent-graft. An original aspect of our case is that there was a significant difference between the diameter of the thoracic stent-graft and the diameter of the aorta at the level of the renal artery. For this reason we decided to deploy a first stent-graft with a tapered shape to reduce the diameter of the distal thoracic aorta (Fig.4). Concerning the covered stents we decided to use the balloon-expandable covered stents because we have a positive experience with them in previous cases of advanced EVAR treatments. As shown in Fig.3 one of the two renal stents shows a mild degree of kinking suggesting that a more flexible stent could be preferable.