case report accidental coverage of both renal arteries...

Case ReportAccidental Coverage of Both Renal Arteries during InfrarenalAortic Stent-Graft Implantation Cause and Treatment

Umberto Marcello Bracale1 Anna Maria Giribono1 Gaetano Vitale1 Donatella Narese1

Gianpaolo Santini2 and Luca del Guercio1

1Department of Vascular and Endovascular Surgery University Federico II of Naples Naples Italy2Department of Diagnostic Imaging Section of General and Emergency Radiology Cardarelli Hospital of Naples 80131 Naples Italy

Correspondence should be addressed to Umberto Marcello Bracale palumbetinit

Received 29 May 2014 Accepted 17 November 2014 Published 3 December 2014

Academic Editor Konstantinos A Filis

Copyright copy 2014 Umberto Marcello Bracale et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

The purpose of this paper is to report a salvage maneuver for accidental coverage of both renal arteries during endovascularaneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA) A 72-year-old female with a 6 cm infrarenalabdominal aortic aneurysm was treated by endovascular means with a standard bifurcated graft Upon completing an angiogramboth renal arteries were found to be accidentally occluded Through a left percutaneous brachial approach the right renal arterywas catheterized and a chimney stent was deployed however this was not possible for the left renal artery A retroperitoneal surgicalapproach was therefore carried out with a retrograde chimney stent implanted to restore blood flow After three months both renalarteries were patent and renal function was not different from the baseline Both endovascular with percutaneous access via thebrachial artery and open retroperitoneal approaches with retrograde catheterization are feasible rescue techniques to recanalize theaccidentally occluded renal arteries during EVAR

1 Introduction

Unintentional coverage of both renal arteries after endo-vascular aneurysm repair (EVAR) for abdominal aorticaneurysm (AAA) remains one of the most undesirablecomplications for the vascular surgeon Several endovasculartechniques found in the literature describe adjusting themalpositioned stent-graft or revascularizing the occludedartery [1ndash3] however to date no consensus exists as to thebest approach to resolving this occurrence Herein we reporton accidental ostial coverage of both renal arteries duringEVARandpresent an alternate combined openendovascularapproach used to salvage one of the occluded renal arteries

2 Case Report

A 72-year-old female with a 6 cm diameter asymptomaticinfrarenal abdominal aortic aneurysm as revealed by

previous computed tomography angiography (CTA) meas-urements (Figure 1) was evaluated for standard EVAR Thepatientrsquos clinical history was remarkable for hypertensionhyperlipidemia and low renal insufficiency (creatinine levelof 12mgdL and BUN 72mgdL)

A 28mm times 14mm E-vita abdominal stent-graft (JOTECHechingen Germany) was selected for repairing the aneu-rysm In the operating theatre the patient was put undergeneral anesthesia at her choice and both common femoralarteries were surgically exposedThe stent-graftwas deployedand the completion angiogram showed a type 1a endoleakwhich was treated with a proximal aortic extension cuff(Figure 2(a)) Insertion and deployment of the aortic cuffsystem proved tricky with much friction due perhapsto severe angulation of the calcified iliac vessels and thepresence of the previously implanted prosthesis A subse-quent angiogram revealed coverage of both renal arteries(Figure 2(b)) Selective catheterization of the right renal

Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2014 Article ID 710742 4 pageshttpdxdoiorg1011552014710742

2 Case Reports in Vascular Medicine

Figure 1 Preoperative angio-CT scan showing a 6 cm abdominalaortic aneurysm suitable for EVAR

artery was achieved through left percutaneous brachial accessand a 6mm times 18mm balloon-expandable stent (Express SDBoston Scientific NatickMAUSA) deployed in a ldquochimneyrdquofashion (Figures 3(a) and 3(b)) Attempts to catheterize theleft renal artery failed requiring an open exposure through aleft retroperitoneal surgical approach (Figures 4(a) 4(b) and4(c)) A retrograde puncture of the occluded renal artery wascarried out and a 5 Fr sheath positioned inWith a 003510158401015840 wire(Zip Guidewire Boston Scientific Natick MA USA) and aJR 4 Fr catheter (Cordis Johnson and Johnson Miami USA)retrograde catheterization of the occluded renal artery wasperformed (Figure 5(a)) and another 6mm times 18mmballoon-expandable stent (Express SD Boston Scientific Natick MAUSA) was implanted (Figure 5(b)) Completion angiogramconfirmed patency of both renal arteries stentsThe puncturehole in the renal artery was closed with prolene 6-0 (EthiconLtd Edinburg UK) Total operative time of both procedureswas 310min and blood loss was 700mL Fluoroscopy timewas 98min and total contrast volume used was 380mL(Visipaque 270mgmL GE Healthcare BV Eindhoven TheNetherlands)

After 24 hours a transient decline of renal functionwas noted with an increase of serum creatinine (21mgdL)The patientrsquos postoperative course was uneventful and renalfunction returned to baseline within four days (creatinine12mgdL) The patient was discharged home on postopera-tive day 8 and at three months both duplex examination andCT scan revealed patency of renal arteries with no evidenceof any types of endoleaks nor recurrent migration of anypart of the stent-graft material (Figure 6) and stable serumcreatinine

3 Discussion

Inadvertent occlusion of one or both renal arteries to treatinfrarenal AAA following stent-graft implantation is one ofthe severest EVAR complications and its treatment strategy

particularly in large trials is not well documented leadingto the currently unknown incidence rate Though this phe-nomenon is extremely rare if not identified and treated earlyacute tubular necrosis and permanent renal failure requiringhemodialysis can occur

Katzen et al first described the case of a patient whounderwent infrarenal stent-graft procedure and postoper-atively developed dialysis-dependent renal failure due toa retrograde migration of the device which occluded thepatientrsquos bilateral renal arteries Considering the patientrsquoscomorbidities and the length of time since the kidneys hadbeen perfused the decision was made to continue with dialy-sis and leave the stent-graft in place [4] Several techniques arebeing found in the current published literature that attempt toavoid such an undesirable complication In 2010Hamish et alpublished a literature review and the results of a questionnaireon the incidence andmanagement of both renal artery occlu-sions following stent-graftmalpositioningThe questionnairewas sent to all listed members of the Vascular Society ofGreat Britain and Ireland Forty percent (2768) of therespondents had almost experienced a case of bilateral renalartery occlusion during EVAR Two-thirds (67 1827) of thesurgeons stated a preference for revascularizing the kidneysendovascularly 7 preferred to convert to open repair and1 surgeon favored iliorenal bypass while another suggestedsplenorenal bypass Following intervention 15 (56) out of27 surgeons reported achieving revascularization resultingin a return to baseline serum creatinine 7 (26) achievedpartial recovery of the patientrsquos serum creatinine 3 (11) hada patient on permanent dialysis and 2 (7) had patientswho had died (following open repair and endovascularprocedure resp) [5] More recently Adu et al [1] present agood overview of all endovascular and surgical proceduresfor renal artery salvage following unintentional coverageAmongst these the antegrade renal artery chimney stent alsodescribed by Inan et al [3] is considered a well-documentedand effective endovascular rescue technique however itsfeasibility depends on a leak or some space between the aortaand the main body of the stent-graft in order to advance aguidewire into the renal artery

Such was the case of the right renal artery revascular-ization we performed on our patient which was cannulatedthrough left brachial access a preferred route in most casesEndovascular techniques provide an effective strategy andshould be used as the initial therapy to restoring renalperfusion and salvage renal function while open surgicalbypass should be considered in those patients for whomendovascular therapy has failed [6] Typically risk of failureincreases with a difficult anatomy such as an angulation ofthe iliac vessels and aortic neck or sharp take-off of the renalarteries Hamish et al [7] reported a case of a successfulhepatorenal bypass performed on the right kidney usingthe origin of the gastroduodenal artery as inflow while theleft kidney was revascularized through a splenorenal bypassProcedures such as these as well as open conversion aretechnically demanding and require large vessel dissectionandor supraceliac aortic clamping

Case Reports in Vascular Medicine 3

(a) (b)

Figure 2 Completion angiogram after stent-graft deployment showing type 1a endoleak (a) After aortic cuff extension placement both renalarteries were covered (arrows) (b)

(a) (b)

Figure 3 Successful recanalization (a) and stent placement (b) into right renal artery from left brachial approach

(a) (b) (c)

Figure 4 Left retroperitoneal approach abdominal incision for left retroperitoneal approach to the renal artery (a) Surgical exposure of themain trunk of the left renal artery (b) Retrograde insertion of a 5 Fr short sheath and subsequent 6mm times 18mm balloon expandable stentdeployment (c)


(a) (b)

Figure 5 Retrograde cannulation of the left renal artery with a4 Fr JR catheter injection of contrast medium through the catheterconfirming the successful reentering into the aorta (a) Completionangiogram after retrograde bare metal stent placement confirmingpatency of the renal artery (b)

Figure 6 The angio-CT scan at the 3-month follow-up showingpatency of renal stents and nice perfusion of both kidneys with noevidence of any endoleak

Alternately retrograde access catheterization though aless invasive retroperitoneal open approach is a relativelyeasy technique allowing for assessment of renal ischemiaand permitting full control of distal outflow to preventembolization A similar technique was adopted by Vourlio-takis et al [8] to reopen an accidentally crushed covered stentduring implantation of a fenestrated stent-graft Aswith otherendovascular procedures certain limitations related to thestenting of renal arteries exist as the rate of restenosis is morecommon in stented arteries than in open procedures Withbypass surgery however in most cases it is relatively easy toretreat the target vessel with a percutaneous approach underlocal anesthesia and the risk of graft kinking is also avoided

4 Conclusion

Combined openendovascular technique used for renalartery salvage as an emergency maneuver for patients under-going EVAR is a useful and an alternative technique whena surgeon finds it difficult to cannulate an occluded vesselantegradely or when bypass surgical revascularization andopen conversion are not the preferred approaches

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgment

The authors would like to thank Mrs Juliet Ippolito forreviewing the English text of this paper

References

[1] J AduN J Cheshire C V RigaMHamady andCD BicknellldquoStrategies to tackle unrecognized bilateral renal artery occlu-sion after endovascular aneurysm repairrdquo Annals of VascularSurgery vol 26 no 8 pp 1127e1ndash1127e7 2012

[2] Z Rancic T Pfammatter M Lachat et al ldquoPull-down tech-nique to allow complete endovascular relining of failed AAAVanguard endografts with Excluder bifurcated endograftsrdquoEuropean Journal of Vascular and Endovascular Surgery vol 38no 1 pp 54ndash60 2009

[3] K Inan A Ucak B Onan V Temizkan M Ugur and A TYilmaz ldquoBilateral renal artery occlusion due to intraoperativeretrograde migration of an abdominal aortic aneurysm endo-graftrdquo Journal of Vascular Surgery vol 51 no 3 pp 720ndash7242010

[4] B T Katzen A A MacLean and H E Katzman ldquoRetrogrademigration of an abdominal aortic aneurysm endograft leadingto postoperative renal failurerdquo Journal of Vascular Surgery vol42 no 4 pp 784ndash787 2005

[5] T Ohrlander B Sonesson K Ivancev T Resch N Dias andMMalina ldquoThe chimney graft a technique for preserving or res-cuing aortic branch vessels in stent-graft sealing zonesrdquo Journalof Endovascular Therapy vol 15 no 4 pp 427ndash432 2008

[6] NHedayati P H Lin A B Lumsden andW Zhou ldquoProlongedrenal artery occlusion after endovascular aneurysm repairendovascular rescue and renal function salvagerdquo Journal ofVascular Surgery vol 47 no 2 pp 446ndash449 2008

[7] M Hamish G Geroulakos D A Hughes S Moser A Shep-herd and A D Salama ldquoDelayed hepato-spleno-renal bypassfor renal salvage following malposition of an infrarenal aorticstent-graftrdquo Journal of Endovascular Therapy vol 17 no 3 pp326ndash331 2010

[8] GVourliotakisM BlanchC J Zeebregts T Cohen T R Prinsand E L G Verhoeven ldquoIntraoperative salvage of a renal arteryocclusion during fenestrated stent graftingrdquo Journal of VascularSurgery vol 50 no 6 pp 1481ndash1483 2009

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Figure 1 Preoperative angio-CT scan showing a 6 cm abdominalaortic aneurysm suitable for EVAR

artery was achieved through left percutaneous brachial accessand a 6mm times 18mm balloon-expandable stent (Express SDBoston Scientific NatickMAUSA) deployed in a ldquochimneyrdquofashion (Figures 3(a) and 3(b)) Attempts to catheterize theleft renal artery failed requiring an open exposure through aleft retroperitoneal surgical approach (Figures 4(a) 4(b) and4(c)) A retrograde puncture of the occluded renal artery wascarried out and a 5 Fr sheath positioned inWith a 003510158401015840 wire(Zip Guidewire Boston Scientific Natick MA USA) and aJR 4 Fr catheter (Cordis Johnson and Johnson Miami USA)retrograde catheterization of the occluded renal artery wasperformed (Figure 5(a)) and another 6mm times 18mmballoon-expandable stent (Express SD Boston Scientific Natick MAUSA) was implanted (Figure 5(b)) Completion angiogramconfirmed patency of both renal arteries stentsThe puncturehole in the renal artery was closed with prolene 6-0 (EthiconLtd Edinburg UK) Total operative time of both procedureswas 310min and blood loss was 700mL Fluoroscopy timewas 98min and total contrast volume used was 380mL(Visipaque 270mgmL GE Healthcare BV Eindhoven TheNetherlands)

After 24 hours a transient decline of renal functionwas noted with an increase of serum creatinine (21mgdL)The patientrsquos postoperative course was uneventful and renalfunction returned to baseline within four days (creatinine12mgdL) The patient was discharged home on postopera-tive day 8 and at three months both duplex examination andCT scan revealed patency of renal arteries with no evidenceof any types of endoleaks nor recurrent migration of anypart of the stent-graft material (Figure 6) and stable serumcreatinine

3 Discussion

Inadvertent occlusion of one or both renal arteries to treatinfrarenal AAA following stent-graft implantation is one ofthe severest EVAR complications and its treatment strategy

particularly in large trials is not well documented leadingto the currently unknown incidence rate Though this phe-nomenon is extremely rare if not identified and treated earlyacute tubular necrosis and permanent renal failure requiringhemodialysis can occur

Katzen et al first described the case of a patient whounderwent infrarenal stent-graft procedure and postoper-atively developed dialysis-dependent renal failure due toa retrograde migration of the device which occluded thepatientrsquos bilateral renal arteries Considering the patientrsquoscomorbidities and the length of time since the kidneys hadbeen perfused the decision was made to continue with dialy-sis and leave the stent-graft in place [4] Several techniques arebeing found in the current published literature that attempt toavoid such an undesirable complication In 2010Hamish et alpublished a literature review and the results of a questionnaireon the incidence andmanagement of both renal artery occlu-sions following stent-graftmalpositioningThe questionnairewas sent to all listed members of the Vascular Society ofGreat Britain and Ireland Forty percent (2768) of therespondents had almost experienced a case of bilateral renalartery occlusion during EVAR Two-thirds (67 1827) of thesurgeons stated a preference for revascularizing the kidneysendovascularly 7 preferred to convert to open repair and1 surgeon favored iliorenal bypass while another suggestedsplenorenal bypass Following intervention 15 (56) out of27 surgeons reported achieving revascularization resultingin a return to baseline serum creatinine 7 (26) achievedpartial recovery of the patientrsquos serum creatinine 3 (11) hada patient on permanent dialysis and 2 (7) had patientswho had died (following open repair and endovascularprocedure resp) [5] More recently Adu et al [1] present agood overview of all endovascular and surgical proceduresfor renal artery salvage following unintentional coverageAmongst these the antegrade renal artery chimney stent alsodescribed by Inan et al [3] is considered a well-documentedand effective endovascular rescue technique however itsfeasibility depends on a leak or some space between the aortaand the main body of the stent-graft in order to advance aguidewire into the renal artery

Such was the case of the right renal artery revascular-ization we performed on our patient which was cannulatedthrough left brachial access a preferred route in most casesEndovascular techniques provide an effective strategy andshould be used as the initial therapy to restoring renalperfusion and salvage renal function while open surgicalbypass should be considered in those patients for whomendovascular therapy has failed [6] Typically risk of failureincreases with a difficult anatomy such as an angulation ofthe iliac vessels and aortic neck or sharp take-off of the renalarteries Hamish et al [7] reported a case of a successfulhepatorenal bypass performed on the right kidney usingthe origin of the gastroduodenal artery as inflow while theleft kidney was revascularized through a splenorenal bypassProcedures such as these as well as open conversion aretechnically demanding and require large vessel dissectionandor supraceliac aortic clamping


(a) (b)


(a) (b)


(a) (b) (c)



(a) (b)




4 Conclusion




Acknowledgment


References














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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)


(a) (b)


(a) (b) (c)



(a) (b)




4 Conclusion




Acknowledgment


References














of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)




4 Conclusion




Acknowledgment


References














of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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