Mycotic Pararenal Double Chimney

University of ColoradoRulon Hardman, MD

Rajan Gupta, MD

60 yo male, 3.9 cm AAA

• Gets a PNA• 3 weeks later..

At celiac

At SMA

R renal

L renal

3.9 7 cm in 3 weeks

AAA goes to level of SMA/L renal

Coronal

Course

• Initially thought no endo solution• Taken to OR• Can’t resect due to inflammation and

adherence to renal veins• Closed and told there are no options, hospice

consulted

Following week

• Endo team finds out about patient from IR fellow• Patient alive and still in hospital• Plan

– Embolize R kidney– Double chimney (SMA/L renal)– L axillary conduit for access– Endologix stent chosen

• Easy to build up• Iliacs not an issue – both will seal with 16 mm limbs• Easier to focus on top seal• Endoleak less of a concern (unibody will seal on IMA/low lumbars and

leave less lumbars in the circuit for potential type IIs)

Plan• Axillary conduit (10 mm)• Perc access/preclose• All graft components soaked in Rifampin• Place main body on bifucation• Embolize R kidney (unable to salvage with stent)• Axillary access into conduit

– 6Fr– Cath desc aorta with kumpe/glide xchange for stiff wire– Upsize to 9 Fr into desc aorta– Select L renal, sheath into L renal

• 2nd Axillary access (same conduit)– Same process put 2nd 9 Fr sheath into SMA

• First place infrarenal stent up to lowest renal (secondary snorkel)– Maximize any infrarenal seal– May help with guttering/graft stability

• Place stents in respective sheaths– 7mm x 5 cm Viabahn L renal– 9mm x 5 cm Viabahn SMA

• In lateral deploy suprarenal cuff just below celiac (after all parallax corrected)• Balloon Endologix stent seal zones including proximally (Viabahns not yet

deployed)– Maximize main stent seal/minimize guttering

• Unsheath each viabahn keeping stent 2-4 mm above top of main body graft material

• Deploy both Viabahns– Don’t balloon unless needed– If needed, kissing balloon

Initial Angio

IVUS at SMAArrows show aneurysm. Actually about 4 mm neck to SMA but

not healthy aorta, this was aneurysm projecting up

IVUS at L renalPosterior chunk of Ca causing shadowing (renal not that big)

Stents in SMA/L renal, getting ready to deploy infrarenal cuff

No seal

Lateral with stents in place

Lateral before deploying suprarenalIncidental celiac stenosis

Post angio – sealed. Both stents patent.

• Took about 4 hours (including ax conduit)• < 3 Gy radiation• ~ 200 cc contrast• Bilateral groin perc closures (2 proglides each side)• Pt up in chair walking next day• Long term plan:– Lifelong antibiotics

• Follow up– Patient alive 18 months post intervention, doing well