title: Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction.
abstract: OBJECTIVE
  Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm.
  
  
  METHODS
  Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records.
  
  
  RESULTS
  Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff.
  
  
  CONCLUSIONS
  These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill 27599, USA. j_fulton@med.unc.edu
authors.forename: Joseph John
authors.initials: JJ
authors.lastname: Fulton
authors.forename: Mark A
authors.initials: MA
authors.lastname: Farber
authors.forename: William A
authors.initials: WA
authors.lastname: Marston
authors.forename: Robert
authors.initials: R
authors.lastname: Mendes
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Mauro
authors.forename: Blair A
authors.initials: BA
authors.lastname: Keagy
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012079:Renal Circulation / Q000502:physiology*; D013152:Splanchnic Circulation / Q000502:physiology*; D015607:Stents; D016896:Treatment Outcome