Pararenal abdominal aortic aneurysms (PAAA) are challenging to treat. The necessity for a suprarenal (and sometimes higher level) clamp site increases the risk of developing dialysis-dependent renal failure after open repair. In addition, many older patients (over 80) and patients with significant cardiac disease will not tolerate this type of repair very well.
IDE-sponsored trials at a limited number of medical centers treat this problem with branched/fenestrated devices. Some sites also use an approach that incorporates physician-modification of devices to treat aneurysms with this type of challenging anatomy. Another approach is the use of parallel grafts or snorkels.
I recently treated an 84-year-old man with a pararenal aneurysm. I had a long discussion with the patient and his son about the risks of open repair. I also explained to them the off-label use of technology to treat this aneurysm in an endovascular fashion. Despite a negative stress test, the patient was adamant that he did not want an open operation. Therefore, we proceeded with an endovascular approach.
I prefer to use an axillary conduit (Figure 1) when multiple sheaths are necessary from the axillary approach, which allows us to place two 7 Fr sheaths and one diagnostic 5 Fr sheath. I chose two 6 mm x 5 cm Viabahn stents (W.L. Gore and Associates, Flagstaff, Arizona) for the renal arteries (Figure 2) and a 31 mm C3 Excluder device (W.L. Gore). The SMA was the proximal target. There was no endoleak and the renal artery stents were widely patent at the end of the procedure.
I was happy with the result, but was even happier with the decision to proceed with an endovascular solution when the patient had a postoperative myocardial infarction. He recovered without incident, but had an 8-day hospital stay. I feel that an open approach would have been life threatening given his course after an endovascular approach.
How would you have handled this case and patient?
ROSS MILNER, MD, FACS
Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.
Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.