mycotic pararenal double chimney university of colorado rulon hardman, md rajan gupta, md
Post on 31-Dec-2015
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• Initially thought no endo solution• Taken to OR• Can’t resect due to inflammation and
adherence to renal veins• Closed and told there are no options, hospice
consulted
Following week
• Endo team finds out about patient from IR fellow• Patient alive and still in hospital• Plan
– Embolize R kidney– Double chimney (SMA/L renal)– L axillary conduit for access– Endologix stent chosen
• Easy to build up• Iliacs not an issue – both will seal with 16 mm limbs• Easier to focus on top seal• Endoleak less of a concern (unibody will seal on IMA/low lumbars and
leave less lumbars in the circuit for potential type IIs)
Plan• Axillary conduit (10 mm)• Perc access/preclose• All graft components soaked in Rifampin• Place main body on bifucation• Embolize R kidney (unable to salvage with stent)• Axillary access into conduit
– 6Fr– Cath desc aorta with kumpe/glide xchange for stiff wire– Upsize to 9 Fr into desc aorta– Select L renal, sheath into L renal
• 2nd Axillary access (same conduit)– Same process put 2nd 9 Fr sheath into SMA
• First place infrarenal stent up to lowest renal (secondary snorkel)– Maximize any infrarenal seal– May help with guttering/graft stability
• Place stents in respective sheaths– 7mm x 5 cm Viabahn L renal– 9mm x 5 cm Viabahn SMA
• In lateral deploy suprarenal cuff just below celiac (after all parallax corrected)• Balloon Endologix stent seal zones including proximally (Viabahns not yet
deployed)– Maximize main stent seal/minimize guttering
• Unsheath each viabahn keeping stent 2-4 mm above top of main body graft material
• Deploy both Viabahns– Don’t balloon unless needed– If needed, kissing balloon
IVUS at SMAArrows show aneurysm. Actually about 4 mm neck to SMA but
not healthy aorta, this was aneurysm projecting up
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