Postoperative “Chimney” for Unintentional Renal Artery Occlusion after EVAR

Case ReportPostoperative lsquolsquoChimneyrsquorsquo for Unintentional Renal ArteryOcclusion after EVAR

Marco Franchin1 Federico Fontana2 Filippo Piacentino2

Matteo Tozzi1 and Gabriele Piffaretti1

1 Vascular Surgery Department of Surgery and Morphological Sciences Circolo University HospitalUniversity of Insubria School of Medicine Via Guicciardini 9 21100 Varese Italy

2 Interventional Radiology Department of Surgery and Morphological Sciences Circolo University HospitalUniversity of Insubria School of Medicine Via Guicciardini 9 21100 Varese Italy

Correspondence should be addressed to Gabriele Piffaretti gabrielepiffarettiuninsubriait

Received 11 August 2014 Accepted 27 October 2014 Published 16 November 2014

Academic Editor Atila Iyisoy

Copyright copy 2014 Marco Franchin et alThis is an open access article distributed under theCreative CommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Renal artery obstruction during endovascular repair of abdominal aortic aneurysm using standard device is a rare but life-threatening complication and should be recognized and repaired rapidly in order to maintain renal function Both conventionalsurgery and endovascular stenting have been reportedWe report a case of late postoperative bilateral ldquochimneyrdquo to resolve a bilateralthrombosis of the renal artery following an uncomplicated endovascular aortic repair

1 Introduction

Acute kidney injury (AKI) remains a known complica-tion after endovascular abdominal aortic aneurysm repair(EVAR) multiple factors may be involved in postoperativeAKI including contrast-induced nephropathy atheroem-bolism occlusion of accessory renal arteries or unintentionaloverstenting of the renal arteries [1 2]

Generally renal artery occlusion due to endograft (EG)overstenting is recognized rapidly and could be treatedimmediately during the procedure in contrast unexpectedrenal artery occlusion may lead to prolonged ischemic dam-age and potential permanent injury requiring hemodialysis[3 4]

In this report we describe the occurrence of an unin-tentional and unexpected bilateral renal artery overstentingsuccessfully managed with a bilateral renal artery ldquochimneyrdquostenting in the late postoperative course

2 Case Report

A 73-year-old man was admitted to our department witha diagnosis of an asymptomatic 57mm fusiform abdominal

aortic aneurysm (AAA) Medical history was notable forobesity hypertension chronic depressed (lt30) left heartdysfunction and chronic obstructive pulmonary diseasePreoperative computed tomography angiography (CT-A)highlighted the presence of a hostile proximal aortic neckcharacterized by a reversed tapered shape (Figures 1(a) and1(b)) plus an acute 120573-angle gt 60∘ (Figure 1(c)) In the oper-ating room a 28mm transrenal bifurcated EG (Endurant-Medtronic Santa Rosa-CA USA) was implanted throughconventional bilateral groin cut-down Final angiographyconfirmed the complete exclusion of the AAA with no evi-dence of proximal or distal endoleak as well as the visualiza-tion of the renal arteries (Figures 2(a) and 2(b)) The imme-diate postoperative serum creatinine level was 148mgdL(range 06ndash13mgdL preoperative level 136mgdL) Twelvehours later a progressive reduction of urine output wasnoted at that time serum creatinine level increased to326mgdL configuring a grade 4 AKI according to theAneurysm Renal Injury Score (ARISe) [5] Angiography wasperformed immediately thereafter it showed the occlusionof the renal artery bilaterally During the same procedurewe attempted an endovascular revascularization of the renal

Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2014 Article ID 170198 5 pageshttpdxdoiorg1011552014170198

2 Case Reports in Vascular Medicine

(b) (c)

(a)

120573 gt 60∘

Figure 1 Preliminary CT-A showing (a b) the reversed tapered shape of the proximal neck (arrows renal arteries origin) and the severe120573-angle (c)

RT renal

(a)

RT renalSMA LT renal

(b)

Figure 2 Predeployment preliminary angiography (a) Final con-trol (b) showed the patency of both the renal arteries (arrows)

arteries which failed because of the acute onset of a high-response atrial fibrillation causing hemodynamic instabilityand acute respiratory distress The patient was transferred inthe intensive care unit and started a temporary renal replace-ment therapy and amiodarone (Cordarone-Sanofi-AventisMilano-Italy) intravenously Four days later hemodynamicstability was recovered at that time a percutaneous lefttransbrachial approach was used to catheterize selectivelythe renal arteries (Figure 3(a)) with a 001410158401015840 guidewire(Stabilizer-Cordis Miami Lakes FL USA) coupled with a4F vertebral catheter (Cordis Miami Lakes-FL USA) A 5times 15mm bare metal stent (Genesis-Cordis Miami Lakes-FL USA) was used bilaterally with the complete restora-tion of renal flow into the parenchyma (Figure 3(b)) Thesubsequent postoperative course was uneventful the urineoutput improved progressively He was discharged on day 6postoperatively on acetylsalicylic acid (Cardioaspirin-BayerMilano-Italy) 100mgdie ad infinitum He was last seeneighteen months later the patient is still alive asymptomaticand the follow-up CT-A confirmed the complete exclusionof the aneurysm without endoleaks and the patency of therenal stents with preservation of visceral flow (Figures 3(c)and 3(d)) At that time serum creatinine level was 138mgdL

Case Reports in Vascular Medicine 3

(d )

(a)

(b)

(c)

Figure 3 Selective angiography at the proximal extremity of the EG (a) showed the overstenting (arrows) of the origin of both the renalarteries Complete revascularization after bilateral stenting (b) Follow-up CT-A complete reperfusion of the parenchyma (c) as well aspersistent exclusion of the aneurysm and absence of endoleak (d)

3 Discussion

The starting points for discussion of our case are either tech-nical or clinical they concern the underhanded pathogenesisof the renal artery occlusion the feasibility of a postoperativeldquochimneyrdquo technique to overcome the renal artery ostiaoverstenting and the recovery of the renal function 96 hoursafter the onset of the acute kidney injury

As all the innovative techniques even EVAR has broughtnew complications such as endoleaks and migration someothers are shared with conventional aortic repair such asrenal artery occlusion [6] Acute kidney injury is a seriouscomplication and harbinger of poor prognosis after EVAR[7 8] despite renal artery occlusion during EVAR remainingan uncommon complication as EVAR gains popularity theincidence of EVAR-associated renal artery obstruction mayincrease

EVAR-related renal artery occlusion is generally foundintraoperatively following an EG maldeployment howeverit has been suggested that also those occlusions detectedduring the follow-up could be considered occluded sincethe initial operation [9ndash11] Inan et al [12] described acase of intraoperative bilateral renal artery occlusion the

cause was a proximal migration of a bifurcated EG anevent that is anecdotal and mainly due to an iatrogenicupward thrust of the device during contralateral cannulationWhen suprarenal stents were first introduced there wasconcern that they would induce hyperplasia and narrow therenal orifices up to date insufficient high-level evidence hasdecreed for or against proximal transrenal fixation on EVAR-related renal occlusion [13ndash15] In our case as probably occursin most of the cases the mechanism that caused the renalartery thrombosis was an underhanded partial obstructionthat can be difficult to identify on intraoperative angiogramsWe had an uncomplicated deployment with visualizationof the renal arteries at completion angiography the reasonthat may explain the delayed onset of the thrombosis of therenal arteries can be ascribed to the imperceptible fillingdefect in the renal artery profile even when the EG coversmuch of the orifice so that the renal artery lumen oftenfills with contrast-enhanced blood Furthermore the partialobstructions of renal arteries by the graft material or thestruts of the suprarenal hooks were potentially masked byintraoperative anticoagulation

Currently there is no consensus about the treatmentstrategy of operative treatment and outcomes after prolonged


renal artery occlusionWe believe that an attempt to revascu-larize the overstented renal arteries should have beenmanda-tory in our case Twine and Boyle [5] reported the occlusionof both renal arteries in the early postoperative period ofan ordinary infrarenal EVAR resulting in dialysis-dependentkidney injury Our case shows that urgent revascularizationcould be effective for this type of complication Maybe thefavorable outcome was facilitated by the early developmentof a rich collateral circulation that has been studied to comeup most commonly from the periureteral peripelvic andadrenal vessels and that can maintain viability of nephronsat sub-filtration arterial pressures furthermore it providesthe rationale for rescue intervention after total renal arteryocclusion even when the diagnosis has been delayed [16 17]

Both open and endovascular techniques may be used asprocedures to treat this uncommon but important especiallyif we consider the rapid and steady increase of EVARs eitherto treat conventional anatomies or complex aortic necks [18]Open conversion still remains an option when they coveredthe renal arteries for a number of weeks Adu et al [18]proposed a flowchart with specific vascular bypasses depend-ing on the patency status of the celiac trunk In contrastendovascular revascularization is primarily determined byaccessibility of the renal orifices [4 10 12] Similar to ourcase Hedayati et al [11] reported two cases of renal arteryocclusion treated oneweek after a transrenal EVARwith renalartery stenting using a transfemoral approach which led tosymptom resolution and recovery of renal function In thepresent case the femoral approach has not been successfulin contrast the second attempt using a brachial approach hasled to an easier and more rapid catheterization of both renalarteries perhaps more so for the presence of the transrenalbare fixation and despite the greater length of the shaftaffecting its maneuverability

4 Conclusion

Lessons learned from our case are never settled on thecontrast effect into renal arteries at the time of completionangiography and revascularization is still an option evenwhen EVAR-related occlusion of the renal arteries has adelayed onset Postoperative ldquochimneyrdquo might be considereda viable alternative if the renal artery overstenting is notcompletely occlusive also because it does not preclude asubsequent conventional bypass attempt

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] RWald S SWaikar O Liangos B J G Pereira GMChertowand B L Jaber ldquoAcute renal failure after endovascular vsopen repair of abdominal aortic aneurysmrdquo Journal of VascularSurgery vol 43 no 3 pp 460ndash466 2006

[2] M Antonello M Menegolo M Piazza L Bonfante F Gregoand P Frigatti ldquoOutcomes of endovascular aneurysm repair on

renal function compared with open repairrdquo Journal of VascularSurgery vol 58 no 4 pp 886ndash893 2013

[3] P Cao F Verzini S Zannetti et al ldquoDevice migration afterendoluminal abdominal aortic aneurysm repair analysis of 113cases with a minimum follow-up period of 2 yearsrdquo Journal ofVascular Surgery vol 35 no 2 pp 229ndash235 2002

[4] B T Katzen A A MacLean and H E Katzman ldquoRetrogrademigration of an abdominal aortic aneurysm endograft leadingto postoperative renal failurerdquo Journal of Vascular Surgery vol42 no 4 pp 784ndash787 2005

[5] C P Twine and J R Boyle ldquoRenal dysfunction after EVAR timefor a standard definitionrdquo Journal of Endovascular Therapy vol20 no 3 pp 331ndash333 2013

[6] WGrande and SW Stavropoulos ldquoTreatment of complicationsfollowing endovascular repair of abdominal aortic aneurysmsrdquoSeminars in Interventional Radiology vol 23 no 2 pp 156ndash1642006

[7] B Wisniowski M Barnes J Jenkins N Boyne A Kruger andP J Walker ldquoPredictors of outcome after elective endovascularabdominal aortic aneurysm repair and external validation of arisk prediction modelrdquo Journal of Vascular Surgery vol 54 no3 pp 644ndash653 2011

[8] G T Pisimisis C F Bechara N R Barshes P H Lin W S Laiand P Kougias ldquoRisk factors and impact of proximal fixationon acute and chronic renal dysfunction after endovascularaortic aneurysm repair using glomerular filtration rate criteriardquoAnnals of Vascular Surgery vol 27 no 1 pp 16ndash22 2013

[9] B Thomas and L Sanchez ldquoProximal migration and endoleakimpact of endograft design and deployment techniquesrdquo Semi-nars in Vascular Surgery vol 22 no 3 pp 201ndash206 2009

[10] P H Lin R L Bush and A B Lumsden ldquoEndovascular rescueof a maldeployed aortic stent-graft causing renal artery occlu-sion technical considerationsrdquo Vascular and Endovascular Sur-gery vol 38 no 1 pp 69ndash73 2004

[11] NHedayati P H Lin A B Lumsden andW Zhou ldquoProlongedrenal artery occlusion after endovascular aneurysm repairendovascular rescue and renal function salvagerdquo Journal ofVascular Surgery vol 47 no 2 pp 446ndash449 2008

[12] K Inan A Ucak B Onan V Temizkan M Ugur and A TYilmaz ldquoBilateral renal artery occlusion due to intraoperativeretrograde migration of an abdominal aortic aneurysm endo-graftrdquo Journal of Vascular Surgery vol 51 no 3 pp 720ndash7242010

[13] S K Subedi A M Lee and G S Landis ldquoSuprarenal fixationbarbs can induce renal artery occlusion in endovascular aorticaneurysm repairrdquo Annals of Vascular Surgery vol 24 no 1 pp113e7ndash113e10 2010

[14] A Saratzis P Sarafidis NMelas et al ldquoSuprarenal graft fixationin endovascular abdominal aortic aneurysm repair is associatedwith a decrease in renal functionrdquo Journal of Vascular Surgeryvol 56 no 3 pp 594ndash600 2012

[15] G N Kouvelos I Boletis N Papa A Kallinteri M Peroulisand M I Matsagkas ldquoAnalysis of effects of fixation type onrenal function after endovascular aneurysm repairrdquo Journal ofEndovascular Therapy vol 20 no 3 pp 334ndash344 2013

[16] M Hamish G Geroulakos D A Hughes S Moser A Shep-herd and A D Salama ldquoDelayed hepato-spleno-renal bypassfor renal salvage following malposition of an infrarenal aorticstent-graftrdquo Journal of Endovascular Therapy vol 17 no 3 pp326ndash331 2010


[17] BWilliams J Feehally A R Attard and P R F Bell ldquoRecoveryof renal function after delayed revascularisation of acute occlu-sion of the renal arteryrdquo The British Medical Journal vol 296no 6636 pp 1591ndash1592 1988

[18] J AduN J Cheshire C V RigaMHamady andCD BicknellldquoStrategies to tackle unrecognized bilateral renal artery occlu-sion after endovascular aneurysm repairrdquo Annals of VascularSurgery vol 26 no 8 pp 1127e1ndash1127e7 2012

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


(b) (c)

(a)

120573 gt 60∘

Figure 1 Preliminary CT-A showing (a b) the reversed tapered shape of the proximal neck (arrows renal arteries origin) and the severe120573-angle (c)

RT renal

(a)

RT renalSMA LT renal

(b)

Figure 2 Predeployment preliminary angiography (a) Final con-trol (b) showed the patency of both the renal arteries (arrows)

arteries which failed because of the acute onset of a high-response atrial fibrillation causing hemodynamic instabilityand acute respiratory distress The patient was transferred inthe intensive care unit and started a temporary renal replace-ment therapy and amiodarone (Cordarone-Sanofi-AventisMilano-Italy) intravenously Four days later hemodynamicstability was recovered at that time a percutaneous lefttransbrachial approach was used to catheterize selectivelythe renal arteries (Figure 3(a)) with a 001410158401015840 guidewire(Stabilizer-Cordis Miami Lakes FL USA) coupled with a4F vertebral catheter (Cordis Miami Lakes-FL USA) A 5times 15mm bare metal stent (Genesis-Cordis Miami Lakes-FL USA) was used bilaterally with the complete restora-tion of renal flow into the parenchyma (Figure 3(b)) Thesubsequent postoperative course was uneventful the urineoutput improved progressively He was discharged on day 6postoperatively on acetylsalicylic acid (Cardioaspirin-BayerMilano-Italy) 100mgdie ad infinitum He was last seeneighteen months later the patient is still alive asymptomaticand the follow-up CT-A confirmed the complete exclusionof the aneurysm without endoleaks and the patency of therenal stents with preservation of visceral flow (Figures 3(c)and 3(d)) At that time serum creatinine level was 138mgdL


(d )

(a)

(b)

(c)


3 Discussion









4 Conclusion




References


























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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(d )

(a)

(b)

(c)


3 Discussion









4 Conclusion




References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















4 Conclusion




References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Documents

Postoperative “Chimney” for Unintentional Renal Artery Occlusion after EVAR