Novel Approach for Juxtarenal Aortic Occlusion Treatment: The Y-Guidewire Configuration for Aortic Bifurcation Reconstruction Gian Franco Fadda, Holta Kasemi, Costantino Luca Di Angelo, Raffaello Borghesi & Mario Marino CardioVascular and Interventional Radiology ISSN 0174-1551 Cardiovasc Intervent Radiol DOI 10.1007/s00270-013-0730-z
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Author's personal copy Cardiovasc Intervent Radiol DOI 10.1007/s00270-013-0730-z
LETTER TO THE EDITOR
Novel Approach for Juxtarenal Aortic Occlusion Treatment: The Y-Guidewire Configuration for Aortic Bifurcation Reconstruction Gian Franco Fadda • Holta Kasemi • Costantino Luca Di Angelo • Raffaello Borghesi Mario Marino
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Received: 26 June 2013 / Accepted: 20 August 2013 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2013
Infrarenal aortic occlusion accounts for 3–8.5 % of aortoiliac occlusive disease with the juxtarenal form affecting [50 % of patients [1, 2]. TASC II guidelines recommend reconstructive surgery as the best treatment for juxtarenal aortic occlusion (JAO) [3]. Endovascular therapies, widely used for less complex lesions, actually are becoming an attractive option for JAO treatment, especially in patients considered at high risk for open surgery. Antegrade recanalization from the brachial access and retrograde angioplasty and stenting using bare stents from bilateral femoral accesses is the treatment strategy reported [4, 5]. Protective measures for the renal arteries, such as guidewires, filters, or balloons, become necessary when the distance between the ostium of the lower renal artery and the aortic occlusion is \2 cm [1, 4]. Goverde et al. [6] performed the covered endovascular reconstruction of aortic bifurcation (CERAB) technique for extensive aortoiliac occlusive disease with balloonexpandable covered stents to limit complications, such as
G. F. Fadda C. L. Di Angelo R. Borghesi M. Marino Vascular Surgery Unit, Department of Surgery, San Francesco Hospital, Via Mannironi 1, 08100 Nuoro, Italy e-mail:
[email protected] C. L. Di Angelo e-mail:
[email protected] R. Borghesi e-mail:
[email protected] M. Marino e-mail:
[email protected] H. Kasemi (&) Vascular Surgery Unit, Department ‘‘Paride Stefanini’’, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 165, 00161 Rome, Italy e-mail:
[email protected]
dissection, arterial rupture, or embolization, and to prevent late intrastent restenosis. Antegrade recanalization and retrograde stenting were performed. We report a new approach to reconstruct the aortoiliac bifurcation using self-expandable covered stents: antegrade aortic and retrograde iliac recanalization and stenting with the Y-guidewire configuration. A 58-year-old man presented to our department with lower-limb rest pain. The patient was classified as American Society of Anesthesiology category III and New York Heart Association category III. The ankle–brachial index was 0.32 (right) and 0.28 (left). Computed tomography (CT) scan showed the JAO up to the iliac artery bifurcation, two right and one left renal arteries. The distance between the lower right renal artery (2.5-mm diameter) and the occluded aorta was 3 mm. To avoid open reconstruction, the patient was offered a less invasive endovascular procedure. Written informed consent was obtained before the procedure. Institutional Review Board approval was obtained before data collection. With the patient under local anesthesia, and after systemic heparinization was achieved, a 12F, 45 cm-long sheath (Flexor RB-RAABE; Cook Medical, Bloomington, IN) was placed through an open surgical brachial access. A 7F, 90 cm-long sheath (Destination Straight CCV; Terumo, Tokyo, Japan) was introduced into the suprarenal aorta, and preliminary angiography was performed (Fig. 1). Transbrachial recanalization was obtained using a 0.03500 hydrophilic, angled guidewire (Radiofocus Guide Wire, Terumo). Once the wire crossed the proximal cap, the Destination sheath was placed inside the proximal level of the occlusion to obtain a more stable position, thus decreasing the risk of thrombus mobilization. After successful recanalization, each femoral artery was punctured under fluoroscopic guidance. After placing the 7F,
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7 cm-long sheath (Boston Scientific, Natick, MA, USA) into both femoral arteries, the Terumo wires were snared using a goose-neck catheter (Amplatz GooseNeck Snare Kit, ev3, Plymouth, MN) and pulled out. Subsequently, the Terumo guidewires were exchanged for two 0.01400 Pilot guidewires (Abbott Vascular Devices, Abbott Park, IL, USA), and another 0.01400 guidewire was placed into the lower renal artery. To prevent thrombus squeezing and artery rupture, suboptimal aortic angioplasty from the brachial access and iliac angioplasty from both femoral
Fig. 1 Intraoperative angiography
accesses was performed. An 8 9 60-mm balloon catheter (FoxCross; Abbott) for the aorta and a 6 9 80-mm balloon catheter (FoxCross; Abbott) for the common iliac arteries (‘‘kissing’’ fashion) were used. Through the brachial access, a 13 9 50-mm covered stent (Viabahn Stent Grafts; W. L. Gore, Flagstaff, AZ) was deployed in the juxtarenal aorta using the two 0.01400 guidewires as singular one (Figs. 2A, B). Unfortunately the renal guidewire was displaced, and vessel cannulation was not possible. Through the femoral accesses, two 8 9 100-mm selfexpandable covered stents were deployed in the common iliac arteries (Viabahn; W. L. Gore) in a kissing fashion and extended with two 7 9 80-mm self–expandable bare stents (Absolute Pro; Abbott) with distal landing zone at the proximal portion of the external iliac artery (Fig. 2C). Completion angiography showed that the lower renal occlusion and the 1/5 right lower renal portion were not perfused (Fig. 3A). Brachial access was sutured in layers, whereas the femoral accesses were closed using a percutaneous suture device (Femoseal; St. Jude Medical, St. Paul, MN, USA). The procedure lasted 83 min, and 65 ml of contrast medium was administered; the fluoroscopy time was 38 min. Postoperative serum creatinine level increased from 0.7 to 1.8 mg/dl and returned to 0.8 mg/dl before discharge. The ankle–brachial index increased to 0.9 bilaterally, and the Duplex scan showed patency of the stents. The patient was discharged on postoperative day 4 with oral doubleantiplatelet therapy (aspirin 100 mg/day indefinitely and
Fig. 2 A Intraoperative angiography: antegrade aortic (over both guidewires) stenting. B Covered stent deployment with the Y-configuration guidewire. C Aortic covered stent and iliac covered and bare stents (right oblique view)
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Fig. 3 A Completion angiography. B Thirteen-month follow-up CT scan: stents and vessel patency. Ischemia in the one-fifth right renal lower portion (arrow). C Thirteen-month follow-up CT scan: stents, internal, and external iliac artery patency (right oblique view)
clopidogrel 75 mg/day for 3 months). Thirteen-month follow-up CT scan confirmed stents and vessel patency (Fig. 3B, C). Grimme et al. [7], in a review of 51 articles, found that covered stents improve the results of kissing stents and are related to excellent results in isolated aortic lesions. Use of covered stents was related with better outcome both clinically and hemodynamically. We used bare stents only at the distal part of the occlusion to extend the treatment to the healthy external iliac artery and preserve the hypogastric artery, the most important collateral in the iliac axis. The authors also reported patency rates of kissing stent configuration affected by radial mismatch and stent overlaps in the distal aorta. In a small series of patients, the use of Excluder endografts (W. L. Gore) was also related to better outcomes; however, in case of the occluded aorta, contralateral limb cannulation was not always possible. The CERAB technique was then developed by the authors to simulate a neo-bifurcation or flow divider in combination with the benefits of covered stents [6]. Nevertheless, aortic covered-stent retrograde cannulation from the femoral access may not be feasible as it was for the bifurcated endograft. We performed antegrade aortic recanalization with two guidewires in a Y-configuration pulled out from the femoral accesses. The aortic covered stent was inserted from above over both guidewires, and there was no need to cannulate from below the aortic stent. Crossing the occluded lesion may be responsible for technical failure or embolic events in renal or distal arteries. Renal-protective measures were mandatory in our patient, even though the procedure was unsuccessful.
Furthermore, juxtarenal singular stent-graft deployment allowed better sealing with thrombus entrapment between the stent-graft and the aorta. The continuous thrombus wash-out into the outer stent lumen, which was still perfused in the kissing-stent configuration, was not possible anymore. This approach may further decrease the renal and distal embolization rate. Moreover, in our opinion, self-expandable covered stents may be the best option in cases of thrombotic aortoiliac occlusion, whereas the balloon-expandable stents, with high radial force, are more indicated in case of heavy calcification of the occluding lesion. In conclusion, in young patients with high risk of late surgery complications, such as aorto-enteric fistulae, or in patients considered to be at high risk for open reconstruction, endovascular treatment of JAO may be considered as the first line therapy. Endovascular treatment does not preclude an eventual, delayed surgical option if necessary. Aortic bifurcation reconstruction with the Y-guidewire configuration technique in patients with JAO is safe and feasible. It may render easier the endovascular procedure. More case reports of series of patients are needed. Longer follow-up remains mandatory. Conflict of interest
None.
References 1. Marrocco Trichitta MM, Bertoglio L, Tshomba Y et al (2012) The best treatment of juxtarenal aortic occlusion is and will be open surgery. J Cardiovasc Surg 53:307–312
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5. Kashyap VS, Pavkov ML, Bena JF et al (2008) The management of severe aort-iliac occlusive disease: endovascular therapy rivals open reconstruction. J Vasc Surg 48:1451–1457 6. Goverde PC, Lauwers K, Verbruggen P et al (2013) Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: A new approach in treating aortoiliac occlusive disease. J Cardiovasc Surg (Torino) 54(3):383–387 7. Grimme FAB, Goverde PA, Van Oostayen JA et al (2012) Covered stents for aortoiliac reconstruction of chronic occlusive lesions. J Cardiovasc Surg 53:279–289
