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Rapid endovascular bailout revascularization of the renal arteries with a steerable guiding sheath after endovascular abdominal aortic aneurysm repair

  • Ningzhi Gu
    Affiliations
    Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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  • Jeffery G. Grab
    Affiliations
    Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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  • Randy D. Moore
    Correspondence
    Correspondence: Randy D. Moore, MD, Division of Vascular Surgery, Department of Surgery, University of Calgary, 3500 26 Avenue NE, Calgary, AB T1Y 6J4, Canada
    Affiliations
    Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Open AccessPublished:May 04, 2021DOI:https://doi.org/10.1016/j.jvscit.2021.04.015

      Abstract

      Advancements in endovascular therapy have made it increasingly available for patients with complex cases but not without complications. Unintentional coverage of the renal arteries is a rare occurrence during endovascular aortic aneurysm repair. Given the potentially devastating repercussions, it is important that surgeons understand the suitability and the risks and benefits of the available revascularization options. We have described two cases of unintentional renal coverage, with subsequent successful bailout via direct manipulation of the stent-graft with a steerable sheath. We also conducted a review of the reported data, discussed the breadth of management options and their technical aspects, and provided several distinct solutions.

      Keywords

      Renal dysfunction occurs in ∼3.3% of endovascular abdominal aortic aneurysm repairs (EVARs).
      • Zarkowsky D.S.
      • Hicks C.W.
      • Bostock I.C.
      • Stone D.H.
      • Eslami M.
      • Goodney P.P.
      Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair.
      An important and dramatic cause is the unintentional coverage of the renal artery orifices during stent-graft deployment. Although rare, with a modern incidence of <1%,
      • Greenberg R.K.
      • Chuter T.A.
      • Lawrence-Brown M.
      • Haulon S.
      • Nolte L.
      Zenith Investigators
      Analysis of renal function after aneurysm repair with a device using suprarenal fixation (Zenith AAA endovascular graft) in contrast to open surgical repair.
      the consequences are devastating, especially in the setting of bilateral coverage. We present two cases in which we have demonstrated that steerable guiding sheaths can be used to manipulate malpositioned aortic stent-grafts, enabling selective cannulation and the deployment of salvage stents in inadvertently covered renal arteries. The patients have provided written informed consent for the report of their case details and imaging studies.

      Case report

       Patient 1

      Patient 1, a 76-year-old man, underwent elective EVAR for a fusiform infrarenal abdominal aortic aneurysm with expansion to 60 mm in the maximal axial diameter. Computed tomography angiography revealed a mildly calcific aortic neck that was 24.6 mm wide and 12.0 mm in length as measured from the slightly downward coursing left and right renal arteries to the proximal aneurysm sac.
      Intraoperatively, the procedure went accordingly with placement of a bifurcated C3 Excluder and iliac limb devices (W. L. Gore and Associates, Inc, Flagstaff, Ariz) through bilateral percutaneous femoral access. The device was deployed immediately inferior to the left and right renal arteries. Completion angiography, after balloon dilation of the stent-graft, showed that the aneurysmal pathology had been excluded but the graft had migrated ∼10 mm distally (Fig 1, A). A proximal aortic neck extension cuff (W. L. Gore and Associates, Inc) was then deployed, with inadvertent coverage of both the left and the right renal ostia (Fig 1, B). An 8.5F Destino Twist sheath (Oscor Inc, Palm Harbor, Fla) with a 7F renal curved Destination guide sheath (Terumo Medical Canada Inc, Vaughan, Ontario, Canada) was rapidly placed to retract the fabric of the extension cuff inferiorly by flexing the Oscor sheath, providing enough clearance for cannulation of the renal arteries with a Glidewire (Terumo Medical Canada Inc; Fig 1, C and D) followed by placement of 7-mm Advanta V12 covered stents (Atrium Medical Corp, Merrimack, NH) bilaterally. The completion angiogram demonstrated excellent flow to both renal arteries (Fig 1, E). During follow-up, there was no evidence of renal dysfunction or residual endoleak.
      Figure thumbnail gr1
      Fig 1Fluoroscopic images obtained during endovascular abdominal aortic aneurysm repair (EVAR) for patient 1. A, The Gore C3 Excluder stent-graft was fully deployed with some unexpected distal migration and clear visualization of the renal arteries. Images showing a maldeployed Gore proximal extension cuff above the level of the renal arteries (B) with a steerable Oscor sheath used to purposefully retract the cuff fabric (C). Access to the renal arteries was successfully obtained bilaterally with fabric retraction from the renal ostia (C and D). E, Completion angiogram showing bilateral parallel stents placed in each renal artery with excellent patency.

       Patient 2

      Patient 2, a 78-year-old man with a rapidly enlarging (>0.5 cm within 6 months) 51-mm abdominal aortic aneurysm at maximal axial diameter underwent elective EVAR. Computed tomography angiography revealed an aortic neck that measured 21 mm in diameter and a renal artery to aortic sac neck length of 48 mm with slight reverse conicity. Both renal arteries had steep downward going trajectories, with the left renal artery lower by 9 mm.
      A bifurcated C3 Excluder (W. L. Gore and Associates, Inc) was selected and deployed. Completion angiography revealed that the stent-graft was malpositioned over both renal ostia (Fig 2, A). A reverse curve SOS Omni catheter (AngioDynamics Canada Inc, Oakville, Ontario, Canada) and Glidewire (Terumo Medical Canada Inc) were used to cannulate the more superior right renal artery, and an Advanta V12 7-mm covered stent (Atrium Medical Corp) was deployed into the vessel. The more inferior left renal artery had been entirely covered by the stent-graft fabric, rendering direct cannulation impossible (Fig 2, B). An 8.5F renal curved Destino Twist sheath (Oscor Inc) with a 7F renal curved Destination guide sheath (Terumo Medical Canada Inc) placed within provided a stiff system to catch the top of the fabric, and the Oscor sheath (Oscor Inc) was then flexed, folding it inferiorly (Fig 2, C). A noncompliant Coda balloon (Cook Medical, Bloomington, Ind) was advanced through the contralateral groin and placed just superior to the renal ostia and inflated to 2 atm, allowing a buddy Glidewire (Terumo Medical Canada Inc) to deflect off the balloon and into the defect made with the guiding sheath, cannulating the vessel (Fig 2, D and E). An Advanta V12 7-mm covered stent (Atrium Medical Corp) was then deployed in a parallel fashion to reestablish the flow. Completion angiography revealed excellent flow through this aortorenal reconstruction (Fig 2, F). The patient did well postoperatively with no loss of kidney function.
      Figure thumbnail gr2
      Fig 2Fluoroscopic images obtained during endovascular abdominal aortic aneurysm repair (EVAR) for patient 2 of an infrarenal abdominal aortic aneurysm showing bailout bilateral renal artery cannulation. The C3 Excluder stent-graft was fully deployed and overlay both renal arteries (A). B, A wisp of contrast can be seen in the lumen of the left renal artery, which could not be cannulated using conventional methods. C, A steerable Oscor sheath retracting the stent-graft fabric permitted access for cannulation. D, A combination of aortic balloon occlusion and Oscor sheath manipulation allowed the stent-graft fabric to be folded inferiorly, deflecting a wire off the balloon and into the now accessible renal artery (E). F, Completion angiogram showing bilateral parallel renal stents and renal patency.

      Discussion

      Although aortic stent-graft migration at deployment is a well-documented phenomenon, proximal migration is rare and thought to result from the sudden release of the elastic potential energy stored in the stiff wire or delivery device during deployment or fracture of the fixation components of the graft.
      • Inan K.
      • Ucak A.
      • Onan B.
      • Temizkan V.
      • Ugur M.
      • Yilmaz A.T.
      Bilateral renal artery occlusion due to intraoperative retrograde migration of an abdominal aortic aneurysm endograft.
      ,
      • Katzen B.T.
      • MacLean A.A.
      • Katzman H.E.
      Retrograde migration of an abdominal aortic aneurysm endograft leading to postoperative renal failure.
      Technical errors, device defects, extensive calcification, and/or anatomic complexity could also be contributing factors.
      Patients who have undergone urgent repair “off the instructions for use” with short necks have had an increased complication rate, including unintentional renal coverage.
      • Herman C.R.
      • Charbonneau P.
      • Hongku K.
      • Dubois L.
      • Hossain S.
      • Lee K.
      • et al.
      Any nonadherence to instructions for use predicts graft-related adverse events in patients undergoing elective endovascular aneurysm repair.
      We have limited our use of off the instructions for use endovascular applications to those patients deemed medically unfit and those at high risk of open repair, with either abdominal symptoms referable to the aorta (unable to wait 4 weeks for fenestrated repair) or anatomy not suitable to more complicated fenestrated or branched graft repair. In these patients with a neck length measuring 10 to 15 mm long, we will use standard endovascular techniques and attempt to precisely place the device adjacent to the renal arteries with intraoperative hypotension (systolic blood pressure <90 mm Hg) during deployment to minimize the “windsock” effect, with or without subsequent Palmaz stent placement in the aortic neck or endoanchors, depending on the findings from the completion angiogram (type Ia endoleak). For patients requiring urgent endovascular repair with a neck length of 5 to 10 mm, we will plan to use a Palmaz stent or endoanchors, or both, to ensure proximal fixation. We do not routinely offer endovascular repair for patients with a neck length <5 mm at our institution. In our experience, the use of parallel graft or chimney techniques are not routinely used outside the aortic arch owing to the high incidence of chimney stent occlusion and type Ia endoleak seen in the infrarenal segment. Our local strategy has resulted in a persistent type Ia endoleak rate of <2%.
      We have presented two cases of accidental renal coverage due to stent migration. Folding of the proximal stent fabric inferiorly with a stiff steerable sheath provided adequate access for cannulation. Parallel grafting enabled flow into the vessels and preserved an adequate proximal seal on the stent-graft, without the need to access the arm or revert to maximally invasive emergency open surgery. A similar approach is the “encroachment” technique, in which the renal stent is placed to force the encroaching proximal edge of the aortic stent down toward the aneurysm.
      • Hiramoto J.S.
      • Chang C.K.
      • Reilly L.M.
      • Schneider D.B.
      • Rapp J.H.
      • Chuter T.A.M.
      Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair.
      Parallel and encroachment in the context of renal bailout have been well described in the current studies
      • Hiramoto J.S.
      • Chang C.K.
      • Reilly L.M.
      • Schneider D.B.
      • Rapp J.H.
      • Chuter T.A.M.
      Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair.
      • van Dijk L.C.
      • van Sambeek M.R.H.M.
      • Cademartiri F.
      • Pattynama P.M.T.
      Partial blockage of the renal artery ostium after stent-graft placement: detection and treatment.
      • Reed A.B.
      • Mozes G.
      • Carmo M.
      • Andrews J.C.
      • Macedo T.A.
      • Gloviczki P.
      Renal artery coverage during endovascular aortic aneurysm repair: proximal migration or misplacement of the stent-graft?.
      • Hedayati N.
      • Lin P.H.
      • Lumsden A.B.
      • Zhou W.
      Prolonged renal artery occlusion after endovascular aneurysm repair: endovascular rescue and renal function salvage.
      • Adu J.
      • Cheshire N.J.
      • Riga C.V.
      • Hamady M.
      • Bicknell C.D.
      Strategies to tackle unrecognized bilateral renal artery occlusion after endovascular aneurysm repair.
      • Franchin M.
      • Fontana F.
      • Piacentino F.
      • Tozzi M.
      • Piffaretti G.
      Postoperative “chimney” for unintentional renal artery occlusion after EVAR.
      • Bracale U.M.
      • Giribono A.M.
      • Vitale G.
      • Narese D.
      • Santini G.
      • del Guercio L.
      Accidental coverage of both renal arteries during infrarenal aortic stent-graft implantation: cause and treatment.
      • Terauchi Y.
      • Noguchi T.
      • Tanioka K.
      • Kubo T.
      • Kitaoka H.
      • Doi Y.
      A case of percutaneous transluminal renal angioplasty for partial coverage of a renal artery by a stent graft after endovascular aneurysm repair.
      • Stanišić M.G.
      • Majewska N.
      • Romanowski M.
      • Kulesza J.
      • Juszkat R.
      • Makałowski M.
      • et al.
      Endovascular treatment of renal artery occlusion caused by aortic stent-graft migration.
      • Karakaş M.S.
      • Korucuk N.
      • Kemaloğlu C.
      • Altekin R.E.
      • Demir İ.
      Renal artery occlusion in the late postoperative period managed with renal artery stenting after endovascular abdominal aortic aneurysm repair and renal function salvage.
      (Table). Renal access in these cases was attained by direct cannulation of the vessels from either a femoral or brachial approach; none have mechanically altered the main body of the aortic stent-graft after deployment with steerable devices to permit arterial access. This technique might spare patients from time-intensive procedures using traditional catheter techniques that can contribute to further renal impairment, alternative upper extremity vascular access to improve angulation for renal artery cannulation, or even highly morbid emergency open surgical revascularization.
      TableA summary of the described cases of accidental renal coverage during endovascular abdominal aortic aneurysm repair (EVAR)
      InvestigatorStent-graft usedExtent and side of accidental renal coverageIntervention
      Stelter et al,
      • Stelter W.
      • Umscheid T.
      • Ziegler P.
      Three-year experience with modular stent-graft devices for endovascular AAA treatment.
      1997
      UnknownUnknownOpen explantation
      Kalliafas et al,
      • Kalliafas S.
      • Albertini J.-N.
      • Macierewicz J.
      • Yusuf S.W.
      • Whitaker S.C.
      • MacSweeney S.T.
      • et al.
      Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms.
      2000
      NottinghamComplete, unilateralHemodialysis
      NottinghamComplete, unilateralNone
      NottinghamComplete, unilateralNone
      NottinghamComplete, bilateralGraft pulled down with angioplasty balloon
      van Dijk et al,
      • van Dijk L.C.
      • van Sambeek M.R.H.M.
      • Cademartiri F.
      • Pattynama P.M.T.
      Partial blockage of the renal artery ostium after stent-graft placement: detection and treatment.
      2003
      ExcluderPartial, rightEncroachment grafting
      Böckler et al,
      • Böckler D.
      • Krauss M.
      • Mannsmann U.
      • Halawa M.
      • Lange R.
      • Probst T.
      • et al.
      Incidence of renal infarctions after endovascular AAA repair: relationship to infrarenal versus suprarenal fixation.
      2003
      Ancure (12 cases)Bilateral or unilateralNone or hemodialysis
      AneuRx (6 cases)
      PowerLink (4 cases)
      Lifepath (2 cases)
      Stentor (16 cases)
      Zenith (16 cases)
      Greenberg et al,
      • Greenberg R.K.
      • Chuter T.A.
      • Lawrence-Brown M.
      • Haulon S.
      • Nolte L.
      Zenith Investigators
      Analysis of renal function after aneurysm repair with a device using suprarenal fixation (Zenith AAA endovascular graft) in contrast to open surgical repair.
      2004
      ZenithPartial left, complete rightLeft parallel grafting
      ZenithPartial, bilateralNone
      ZenithPartial left, complete rightLeft parallel grafting
      Reed et al,
      • Reed A.B.
      • Mozes G.
      • Carmo M.
      • Andrews J.C.
      • Macedo T.A.
      • Gloviczki P.
      Renal artery coverage during endovascular aortic aneurysm repair: proximal migration or misplacement of the stent-graft?.
      2004
      AneuRxPartial, bilateralEncroachment grafting
      AneuRxPartial, bilateralEncroachment grafting
      Katzen et al,
      • Katzen B.T.
      • MacLean A.A.
      • Katzman H.E.
      Retrograde migration of an abdominal aortic aneurysm endograft leading to postoperative renal failure.
      2005
      AneuRxComplete, bilateralHemodialysis
      Hedayati et al,
      • Hedayati N.
      • Lin P.H.
      • Lumsden A.B.
      • Zhou W.
      Prolonged renal artery occlusion after endovascular aneurysm repair: endovascular rescue and renal function salvage.
      2008
      ZenithComplete, rightEncroachment grafting
      ZenithPartial left, complete rightEncroachment grafting
      Hiramoto et al,
      • Hiramoto J.S.
      • Chang C.K.
      • Reilly L.M.
      • Schneider D.B.
      • Rapp J.H.
      • Chuter T.A.M.
      Outcome of renal stenting for renal artery coverage during endovascular aortic aneurysm repair.
      2009
      Zenith (11 cases)Complete unilateral or partial unilateralEncroachment grafting
      Inan et al,
      • Inan K.
      • Ucak A.
      • Onan B.
      • Temizkan V.
      • Ugur M.
      • Yilmaz A.T.
      Bilateral renal artery occlusion due to intraoperative retrograde migration of an abdominal aortic aneurysm endograft.
      2010
      AnacondaComplete, bilateralOpen aorto-birenal bypass
      Hamish et al,
      • Hamish M.
      • Geroulakos G.
      • Hughes D.A.
      • Moser S.
      • Shepherd A.
      • Salama A.D.
      Delayed hepato-spleno-renal bypass for renal salvage following malposition of an infrarenal aortic stent-graft.
      2010
      EndurantComplete, bilateralOpen splenorenal, hepatorenal bypass
      Adu et al,
      • Adu J.
      • Cheshire N.J.
      • Riga C.V.
      • Hamady M.
      • Bicknell C.D.
      Strategies to tackle unrecognized bilateral renal artery occlusion after endovascular aneurysm repair.
      2012
      EndurantComplete, bilateralLeft parallel grafting
      TalentComplete, bilateralOpen hepatorenal, splenorenal bypass
      TalentComplete, bilateralOpen hepatorenal, splenorenal bypass
      EndurantComplete left, partial rightRight parallel grafting
      Kölbel et al,
      • Kölbel T.
      • Carpenter S.W.
      • Diener H.
      • Wipper S.
      • Debus E.S.
      • Larena-Avellaneda A.
      Antegrade in situ stent-graft fenestration for the renal artery following inadvertent coverage during EVAR.
      2013
      Zenith + proximal Palmaz extension cuffComplete, leftIn situ fenestration with transseptal needle; renal stenting
      Franchin et al,
      • Franchin M.
      • Fontana F.
      • Piacentino F.
      • Tozzi M.
      • Piffaretti G.
      Postoperative “chimney” for unintentional renal artery occlusion after EVAR.
      2014
      EndurantComplete, bilateralBilateral parallel grafting
      Bracale et al,
      • Bracale U.M.
      • Giribono A.M.
      • Vitale G.
      • Narese D.
      • Santini G.
      • del Guercio L.
      Accidental coverage of both renal arteries during infrarenal aortic stent-graft implantation: cause and treatment.
      2014
      E-vitaComplete, bilateralRight parallel grafting; left open exposure, retrograde puncture, catheterization, stent placement
      Terauchi et al,
      • Terauchi Y.
      • Noguchi T.
      • Tanioka K.
      • Kubo T.
      • Kitaoka H.
      • Doi Y.
      A case of percutaneous transluminal renal angioplasty for partial coverage of a renal artery by a stent graft after endovascular aneurysm repair.
      2014
      Zenith FlexPartial, rightRight encroachment grafting
      Stanišić et al,
      • Stanišić M.G.
      • Majewska N.
      • Romanowski M.
      • Kulesza J.
      • Juszkat R.
      • Makałowski M.
      • et al.
      Endovascular treatment of renal artery occlusion caused by aortic stent-graft migration.
      2015
      Zenith FlexPartial, rightRight parallel grafting
      Karakaş et al,
      • Karakaş M.S.
      • Korucuk N.
      • Kemaloğlu C.
      • Altekin R.E.
      • Demir İ.
      Renal artery occlusion in the late postoperative period managed with renal artery stenting after endovascular abdominal aortic aneurysm repair and renal function salvage.
      2017
      AFXComplete, left (congenital solitary kidney)Left encroachment grafting
      Jessula et al,
      • Jessula S.
      • Herman C.R.
      • Lee M.
      • Lightfoot C.B.
      • Casey P.
      Salvage of bilateral renal artery occlusion after endovascular aneurysm repair with open splenorenal bypass.
      2017
      Endurant IIComplete, bilateralOpen spleno-birenal bypass
      Uehara et al,
      • Uehara A.
      • Suzuki T.
      • Hase S.
      • Sumi H.
      • Hachisuka S.
      • Fujimoto E.
      • et al.
      Kidney autotransplantation for the treatment of renal artery occlusion after endovascular aortic repair: a case report.
      2019
      UnknownComplete, right (solitary functioning kidney)Right renal autotransplantation
      Nottingham, in-house custom-made device; Excluder, W. L. Gore and Associates Inc, Flagstaff, Ariz; Ancure, Guidant Corp, Indianapolis, Ind; AneuRx, Medtronic Inc, Santa Rosa, Calif; PowerLink, Endologix, Inc, Irvine, Calif; Lifepath, Baxter SA, Paris, France; Stentor, Boston Scientific, Natick, Mass; Zenith, Cook Medical, Bloomington, Ind; Anaconda, Vascutek/Terumo Inc, Inchinnan, UK; Endurant, Medtronic Inc, Santa Rosa, Calif; Talent, Medtronic Inc, Santa Rosa, Calif; E-vita, Jotec, Hechingen, Germany; Zenith Flex, Cook Medical, Bloomington, Ind; AFX, Endologix Inc, Irvine, Calif; Endurant II, Medtronic Inc, Santa Rosa, Calif; Palmaz, Cordis Corp, Bridgewater, NJ.
      A simple approach for renal salvage would be to begin with a trial of retrograde catheterization via a femoral approach, to then attempt the technique we have described, and to next attempt antegrade catheterization via a transradial/brachial approach, before resorting to open repair. In these cases, the most described approach has been splenorenal and/or hepatorenal bypass with autologous vein or a PTFE graft.
      • Inan K.
      • Ucak A.
      • Onan B.
      • Temizkan V.
      • Ugur M.
      • Yilmaz A.T.
      Bilateral renal artery occlusion due to intraoperative retrograde migration of an abdominal aortic aneurysm endograft.
      ,
      • Adu J.
      • Cheshire N.J.
      • Riga C.V.
      • Hamady M.
      • Bicknell C.D.
      Strategies to tackle unrecognized bilateral renal artery occlusion after endovascular aneurysm repair.
      ,
      • Hamish M.
      • Geroulakos G.
      • Hughes D.A.
      • Moser S.
      • Shepherd A.
      • Salama A.D.
      Delayed hepato-spleno-renal bypass for renal salvage following malposition of an infrarenal aortic stent-graft.
      ,
      • Jessula S.
      • Herman C.R.
      • Lee M.
      • Lightfoot C.B.
      • Casey P.
      Salvage of bilateral renal artery occlusion after endovascular aneurysm repair with open splenorenal bypass.
      It is important to note that this fabric folding approach is also possible in stent-grafts that use suprarenal fixation because it does not entail downward displacement of the fixation struts but the proximal fabric alone. We have used this technique in both the Anaconda (Vascutek/Terumo Inc, Inchinnan, UK) and Cook (Cook Medical) infrarenal devices in cases with partial renal encroachment.

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