Fenestrate what you can't snorkel?
BACKGROUND
Although challenging proximal necks have limited the utility of standard endovascular aneurysm repair (EVAR) devices, sophisticated endovascular techniques have evolved in recent years for the repair of juxtarenal abdominal aortic aneurysms (AAAs). Among these techniques, snorkel or chimney EVAR (sn-EVAR) and fenestrated EVAR (f-EVAR) have emerged as options for repairing anatomic high-risk AAAs. Unfortunately, in the United States, except in the context of a clinical trial or physician-sponsored device exemption, limited long-term data exist on the treatment of juxta- and suprarenal AAAs with either sn-EVAR or f-EVAR. Owing to these limitations, comparison of these two techniques is challenging, and we sought to describe a case when one was favored over the other.


RESULTS
A 72-year-old man presented with an enlarging, asymptomatic, juxtarenal fusiform AAA (5.9 cm), a moderately enlarged right common iliac artery (2.8 cm), a history of oxygen-dependent chronic obstructive pulmonary disease, and a previous right nephrectomy. An initial sn-EVAR was attempted but was unsuccessful owing to the inability to deliver the "snorkel" covered stent via a brachial approach because of renal ostial stenosis and cephalad angulation of the patient's left renal artery. A subsequent f-EVAR approach was successfully used to repair the juxtarenal AAA while preserving adequate renal artery blood flow. Two-year postoperative follow-up demonstrated a stable endovascular repair without endoleaks, a shrinking aneurysm sac, and stable renal function.


CONCLUSIONS
The sn-EVAR configuration in this case report was precluded by cephalad renal angulation, and the AAA was instead repaired using an f-EVAR approach, with good 2-year follow-up outcomes. The sn-EVAR strategy requires downward pointing renal arteries in addition to adequate brachial/axillary artery access dimensions to facilitate successful repair. With improving techniques and technology for either approach, anatomic specifications and indications for these advanced EVAR strategies will need to be delineated.
Department of Surgery, Stanford University Medical Center, Stanford, CA 94305, USA.
Mohamed A
MA
Zayed
Mohammed
M
Chowdhury
Kevin
K
Casey
Ronald L
RL
Dalman
Jason T
JT
Lee
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods*; D057510:Endovascular Procedures / Q000295:instrumentation; D006801:Humans; D008297:Male; D011474:Prosthesis Design; D012077:Renal Artery / Q000000981:diagnostic imaging / Q000601:surgery; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome