Parallel Graft Technique in a Complex Aortic Aneurysm: The Value of Intra-operative Flexibility from The Original Operative Plan

Abstract

Introduction: The parallel grafting technique (PGT) is a valuable alternative to prefabricated branched or fenestrated endovascular aortic repair. An often overlooked advantage of PGT is its unique adaptability to different anatomical challenges that might appear intra-operatively.

Report: A 72 year old male patient presented with a 60 mm thoracic aneurysm, 59 mm juxtarenal abdominal aortic aneurysm, and 32 mm common iliac aneurysm (CIAA). Thoracic endovascular aortic repair plus endovascular aortic repair with bilateral renal artery chimneys and CIAA exclusion applying the sandwich technique was proposed. Because of unfavourable angulation it was not possible to achieve selective left renal catheterisation via axillary access. Changing to a femoral approach allowed successful retrograde catheterisation. The procedure ended with a chimney for the right renal artery and a periscope for the left renal artery. The final angiogram showed no endoleaks and renal and hypogastric patency. The patient was discharged three days after the procedure and remains under ultrasound surveillance after 40 months because of a small type two endoleak.

Conclusion: When using a prefabricated branched device, the possibility of selectively catheterising a visceral branch often has no straightforward solution. However, parallel grafting is an extremely flexible technique, which was of paramount importance for the surgical outcome of the present case.

Keywords: Abdominal aortic aneurysm; Parallel graft technique; Periscope graft; Sandwich graft; Thoracic aortic aneurysm; Thoraco-abdominal aneurysm.

Figure 1

Schematic of patient's anatomy and proposed treatment strategy. (A) 60 mm TAA, 59 mm juxtarenal AAA, and 32 mm CIAA. (B) First treatment strategy. TEVAR plus chEVAR with bilateral renal artery chimneys and CIAA exclusion with preservation of the hypogastric artery applying the sandwich technique. (C) TEVAR plus chEVAR, with a chimney for the right renal artery and a periscope for the left renal artery with an additional aortic stent applied in the neck, and CIAA exclusion with preservation of the hypogastric artery applying the sandwich technique.

Figure 2

3D reconstruction of follow up CT scans. (A1 and A2) one year follow up. (B1 and B2) three year follow up. The TEVAR plus chEVAR can be seen with the periscope for the left renal artery, and right common iliac artery aneurysm exclusion with hypogastric artery preservation by the sandwich technique.