Stutz Jack, Lima Guilherme Baumgardt Barbosa, Huang Ying, Mendes Bernado C, Macedo Thanila A, Oderich Gustavo S
Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
J Endovasc Ther. 2024 Aug 18:15266028241270690. doi: 10.1177/15266028241270690.
To report the use of modified ex vivo renal artery (RA) reconstruction in a patient with 2 small right RAs (RRAs) in anticipation of planned fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysm (TAAA).
A staged hybrid repair was utilized in a patient with Extent II TAAA involving celiac axis (CA), superior mesenteric artery (SMA), single left RA (LRA), and 2 small (<3 mm) RRAs. The first-stage operation consisted of hepato-renal bypass using modified ex vivo renal reconstruction with single end-to-end anastomosis to both RAs using a saphenous vein graft. A second stage FB-EVAR was performed using patient-specific manufactured stent-graft with 3 fenestrations for the CA, SMA, and LRA 6 weeks later. The patient recovered with no complications. At 4 years, the patient had widely patent hepato-renal bypass and target vessels with normal renal function.
The use of adjunctive hybrid procedures may optimize or facilitate FB-EVAR. In this patient, salvage of 2 small RAs was not ideally suited for branch stenting but was possible using modified ex vivo RA reconstruction with preservation of kidney parenchyma and function.
This case report illustrates a hybrid approach to overcome one of the most frequent limitations to total endovascular incorporation of renal arteries, eg small diameter, early bifurcation and multiple vessels. The modified ex vivo technique allows meticulous renal artery reconstruction without the deleterious effect of warm ischemia and without the cumbersome reconstruction of ureter and vein that is needed with traditional on table ex vivo auto transplantation. The technique is used in a minority of cases and adds the morbidity of open approach. Case selection is of paramount importance.
报告在一名患有两根右侧肾动脉（RRA）较细的患者中使用改良的体外肾动脉重建术，该患者计划接受胸腹主动脉瘤（TAAA）的开窗分支型血管腔内主动脉修复术（FB-EVAR）。
一名患有II型TAAA累及腹腔干（CA）、肠系膜上动脉（SMA）、单根左侧肾动脉（LRA）以及两根较细（<3 mm）RRA的患者接受了分期杂交修复术。第一阶段手术包括使用改良的体外肾重建术进行肝-肾旁路移植，采用大隐静脉移植物对两根RRA进行单端对端吻合。六周后进行了第二阶段的FB-EVAR，使用定制的带三个开窗分别对应CA、SMA和LRA的覆膜支架移植物。患者恢复良好，无并发症。四年后，患者的肝-肾旁路移植血管通畅，目标血管肾功能正常。
辅助杂交手术的使用可能会优化或促进FB-EVAR。在该患者中，两根较细的RRA不太适合分支支架置入，但使用改良的体外肾动脉重建术保留肾实质和功能是可行的。
本病例报告展示了一种杂交方法，以克服肾动脉完全血管腔内纳入最常见的限制之一，如直径小、早期分叉和多支血管。改良的体外技术允许进行细致的肾动脉重建，而无热缺血的有害影响，也无需传统的体外自体肾移植手术中所需的输尿管和静脉的繁琐重建。该技术在少数病例中使用，增加了开放手术的发病率。病例选择至关重要。
