title: Antegrade in situ stent-graft fenestration for the renal artery following inadvertent coverage during EVAR.
abstract: OBJECTIVE
  To report the use of antegrade in situ fenestration as a bailout technique to rescue a renal artery after inadvertent coverage during endovascular aneurysm repair (EVAR).
  
  
  METHODS
  The technique is demonstrated in a patient with a 6-cm infrarenal abdominal aortic aneurysm (AAA) and a short, angulated proximal neck. A type I endoleak persisted on completion angiography after implantation of a bifurcated Zenith stent-graft despite dilation with a compliant balloon. A Giant Palmaz stent mounted on a large compliant balloon successfully resolved the endoleak. After placing the stent, the left renal artery was covered completely by the main aortic graft material, leading to only marginal opacification on angiography. To preserve flow to the renal artery, a transseptal sheath and transseptal needle were introduced from the right femoral artery and used to puncture the abdominal stent-graft antegrade at the site of the left renal artery. A 0.018-inch guidewire could then be introduced into the left renal artery; following a number of maneuvers, a balloon-expandable stent was placed through the fenestration into the target vessel. On computed tomographic angiography 4 days postoperatively, the AAA remained excluded and both renal arteries were patent, with all side branches fully preserved. Renal function was completely restored.
  
  
  CONCLUSIONS
  Antegrade in situ fenestration can facilitate immediate revascularization of inadvertently covered side branches in EVAR using a transseptal sheath and needle. If the anatomical features are supportive, antegrade in situ fenestration can be a useful bailout technique.
authors.affiliation: Department for Vascular Medicine, University Heart Center Hamburg Eppendorf, Hamburg, Germany. tilokoelbel@googlemail.com
authors.forename: Tilo
authors.initials: T
authors.lastname: Kölbel
authors.forename: Sebastian William
authors.initials: SW
authors.lastname: Carpenter
authors.forename: Holger
authors.initials: H
authors.lastname: Diener
authors.forename: Sabine
authors.initials: S
authors.lastname: Wipper
authors.forename: Eike Sebastian
authors.initials: ES
authors.lastname: Debus
authors.forename: Axel
authors.initials: A
authors.lastname: Larena-Avellaneda
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D057510:Endovascular Procedures / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012077:Renal Artery / Q000601:surgery*; D015607:Stents