Endovascular management of juxtarenal aneurysms with fenestrated endovascular grafting

Abstract

PurposeTo evaluate the technical feasibility and short-term results of juxtarenal aneurysm repair with an endovascular graft that incorporated the visceral aortic segment with graft material. MethodsPatients were studied prospectively after the implantation of an endovascular device with graft material extending proximal to the renal arteries, variably incorporating the superior mesenteric and celiac arteries. All patients were deemed to be high risk with respect to open surgical repair and had compromised proximal neck anatomy. Proximal neck lengths were ≤10 mm, or ≤15 mm with a challenging morphology (funnel shape or extensive thrombus). Fenestrations within the graft material were customized to accommodate visceral and renal vessels on the basis of computerized tomography (CT), angiography, or intravascular ultrasound data. Selected visceral ostia were protected with balloon-expandable stents after partial endograft deployment. All patients were evaluated with CT and kidney, ureters, and bladder x-ray at discharge and at 1, 6, and 12 months. Visceral duplex scan studies were performed at 1, 6, and 12 months. ResultsA total of 22 patients were enrolled in the study. Sixteen patients had short proximal necks (3-10 mm), and six had compromised necks of 10 to 15 mm in length. Endograft design included bifurcated (20) and tube (2) systems. All prostheses were implanted successfully without the acute loss of any visceral arteries. A total of 58 visceral vessels were incorporated (mean, 2.6 per patient) and most commonly included both renal arteries and the superior mesenteric artery. The mean follow-up was 6 months. There were no deaths within 30 days and no aneurysm-related deaths during the follow-up period. Two early (<30 days) and two late secondary interventions were performed, inclusive of two visceral artery stenoses detected with duplex scanning. The 30-day endoleak rate was 4.5%. The aneurysm sac decreased greater than 5 mm in 53 % of patients at 6 months and three of four patients at 12 months. Three patients developed renal insufficiency, only one of which required temporary hemodialysis. ConclusionsThe placement of an endovascular prosthesis with graft material that incorporates the visceral arteries is technically feasible. The occurrence of endoleaks appears to be relatively low. The increased sealing and fixation zones in this patient population should limit the late development of proximal endoleak or migration; however, this situation will require more patients and extended follow-up.