Liao Jane L, Rossi Matthew J, Fatima Javairiah
Department of Vascular Surgery, Goergetown University School of Medicine, Washington, DC.
J Vasc Surg Cases Innov Tech. 2024 Aug 28;10(6):101616. doi: 10.1016/j.jvscit.2024.101616. eCollection 2024 Dec.
For high-risk patients with complex aortic aneurysms and post-dissection aneurysms, fenestrated and branched endovascular aortic repair (F/BEVAR) offers minimally invasive options customized to each individual's anatomy. Company-manufactured devices or physician-modified endovascular grafts performed under the purview of an investigational device exemption are two United States Food and Drug Administration-approved avenues to perform fenestrated and branched endovascular aortic repair. This case report describes a creative use of physician-modified endograft to salvage renal function in a solitary kidney with a near immediate bifurcation of the renal artery in a patient with post-dissection extent II thoracoabdominal aortic aneurysm. In our patient, the immediate bifurcation (2 mm distal to the common left renal artery orifice) of the left renal artery in the setting of a known long-standing occlusion of a remotely placed right renal stent presented a clinical and technical challenge to maintaining this patient's kidney function without sacrificing a significant portion of his remaining solitary kidney. Additionally, each branch was sizeable (5 and 7 mm), perfusing the cranial and caudal half of the kidney, respectively. Early bifurcation of renal arteries often results in sacrifice of the smaller branch to obtain adequate target vessel seal. Although some analyses have shown no change in glomerular filtration rate from coverage of accessory renal arteries, more recent studies have indicated clinically significant drops in both glomerular filtration rate and kidney length at 2-year follow-up. Herein, we describe use of a combination of an inner and external branch modification to stent both branches to preserve renal parenchyma and function. The patient has provided written informed consent for publication of this case report and their associated imaging studies.
对于患有复杂主动脉瘤和夹层后动脉瘤的高危患者，开窗和分支型血管腔内主动脉修复术（F/BEVAR）提供了根据个体解剖结构定制的微创选择。公司制造的器械或在研究器械豁免范围内由医生改良的血管内移植物是美国食品药品监督管理局批准的两种进行开窗和分支型血管腔内主动脉修复术的途径。本病例报告描述了在一名患有II型胸腹主动脉夹层动脉瘤且肾动脉几乎立即分叉的单肾患者中，创造性地使用医生改良的血管内移植物来挽救肾功能。在我们的患者中，已知远端放置的右肾支架长期闭塞，左肾动脉在左肾动脉共同开口远端2毫米处立即分叉，这对在不牺牲其剩余单肾大部分组织的情况下维持该患者的肾功能构成了临床和技术挑战。此外，每个分支都相当大（5毫米和7毫米），分别灌注肾脏的上半部分和下半部分。肾动脉早期分叉通常会导致牺牲较小的分支以获得足够的靶血管密封。尽管一些分析表明，覆盖副肾动脉对肾小球滤过率没有影响，但最近的研究表明，在2年随访时，肾小球滤过率和肾长度均出现了具有临床意义的下降。在此，我们描述了使用内部和外部分支改良相结合的方法对两个分支进行支架置入，以保留肾实质和功能。患者已书面同意发表本病例报告及其相关影像学研究。
