Chimney technique combined with aortoiliac stenting for the treatment. disease. of juxtarenal aortoiliac occlusive
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1 Chimney technique combined with aortoiliac stenting for the treatment of juxtarenal aortoiliac occlusive disease Suwanruangsri Veera,MD Kaviros Pruesttipong,MD Department of Surgery, Maharat Nakhon Ratchasima Hospital, Thailand
2 Disclosure Speaker name: Suwanruangsri Veera I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
3 A 50-year-old male presented with severe thigh claudication and absent both femoral pulses. The past medical problem was arterial hypertension. ABI of right and left leg were 0.48 and 0.54, respectively.
4 CT angiography showed an juxtarenal aortoiliac occlusion from the level of left renal artery to both external iliac arteries, occlusion of right renal artery and stenosis of left renal artery.
5 Open bypass or Endovas Tx What are the problems of open bypass? 1. Suprarenal aortic clamping 2. Renal ischemic time 3. Longer hospital stay 4. Longer recovery time 5. Inferior patency rate of extraanatomical bypass
6 Open bypass or Endovas Tx What are the problems of EVT? 1. Visceral embolization 2. Renal artery protection 3. Inferior patency rate 4. Higher reintervention rate
7 Stenting a juxtarenal aortic occlusion without applying the chimney technique carries a risk of visceral occlusion.
8 How to approach? Proximal brachial artery cutdown, 12 Fr. sheath Bilateral femoral access, 6 Fr. sheath
9 Left renal artery stenting with the Viabahn stent-graft was initially performed. 7Fr sheath 7Fr sheath stenosis Viabahn, 6mm
10 The inch Advantage guidewire was advanced from left brachial access into right iliac artery. Retrograde guidewire was advanced from right femoral access and CART technique was performed. 7Fr sheath 4Fr sheath 7Fr sheath Advantage guidewire
11 The inch Advantage guidewire was advanced and the Epic stent was deployed just below the origin of the superior mesenteric artery from right femoral access. Epic 14mm Armada 12mm Viabahn 6mm Post stenting angioplasty
12 Another guidewire was advanced from left brachial access through the Epic stent and into right iliac artery. Crossover and snare technique was performed from left femoral access.
13 Crossover and snare technique
14 Crossover and snare technique
15 Another inch Advantage guidewire was advanced into the Epic stent from left femoral access. Advantage guidewire
16 The Astron stents were deployed at both external iliac arteries. The Dynamic stents were deployed at both common iliac arteries and infrarenal aorta (kissing stents).
17 Dynamic 7mm Epic 14mm Astron 7mm Dynamic 7mm
18 Viabahn Epic 14mm Epic 14mm Dynamic 7mm Dynamic 7mm
19 Anterior View
20 LAO view
21
22 Operative time : 4 hr. 30 min. Flu-time : 1 hr. 13 min. Contrast used : 102 ml. At eight months follow-up, the patient was in good condition. ABI of right and left leg were 1.01 and 1.07, respectively.
23 When crossover and snare technique should be performed?? Failure to enter into the aorta (true lumen) from bilateral femoral approach. Only unilateral iliac artery cannulation can be performed from brachial approach. Two options 1. Crossover and snare technique 2. Aortouniiliac stenting with fem-fem crossover bypass
24 231 AUI-EVAR patients yr : 91% Patency@5 yr : 83% Wound complications : 11% (groin hematoma4%, seroma3%, superficial wound infection3%) J Vas Surg2003;38:
25 Crossover Crossover and and snare snare technique technique
26 Crossover Crossover and and snare snare technique technique
27 Crossover and snare technique
28 Conclusions Chimney technique combined with aortoiliac stenting can be performed for the treatment of juxtarenal aortoiliac occlusive disease with acceptable short-term outcomes. Crossover and snare technique is a good option when only unilateral iliac artery cannulation can be performed.
29 Thank you for your attention
30 Chimney technique combined with aortoiliac stenting for the treatment of juxtarenal aortoiliac occlusive disease Suwanruangsri Veera,MD Kaviros Pruesttipong,MD Department of Surgery, Maharat Nakhon Ratchasima Hospital, Thailand
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