A Case of Abdominal Aortic Aneurysm with Short Angulated Proximal Neck Treated with the Chimney Graft Technique
A 78-year-old male with a known infrarenal AAA presented with recent left flank pain at the Urology Department of Severance Hospital. The patient had previously undergone a percutaneous transluminal coronary angioplasty at the mid right coronary artery (RCA) due to inferior wall myocardial infarction 22 years ago and had been regularly followed up. In addition, he also had a past history of hypercholesterolemia and benign prostate hyperplasia. He reported being a non-smoker without hypertension or diabetes. The AAA was incidentally discovered on coronary computed tomography (CT) taken six years ago and had a maximal diameter of 33 mm.\nThe CT taken prior to admission demonstrated a thrombosed infrarenal aortic aneurysm with an increased maximum diameter of 63 mm, which prompted a referral to Cardiology (). The proximal aortic neck had an angulation of approximately 45° to the suprarenal aorta, and the length of the aortic neck to the right renal artery orifice was 16 mm. However, the left renal artery orifice was adjacent to the aneurysm, and there was practically no neck. Therefore, if the conventional EVAR technique were to be used, the blood flow to the left renal artery would be compromised due to the stent, inevitably resulting in decreased renal function.\nBased on the patient's advancing age and history of myocardial infarction, a preprocedural coronary evaluation was performed. An electrocardiogram showed normal sinus rhythm with ischemic changes in inferior leads, and echocardiography showed reduced left ventricular systolic function with an ejection fraction of 48% and akinesia of the RCA territory. The coronary angiography showed significant tandem stenotic lesions of the proximal and distal left anterior descending artery, which were subsequently treated with drug-eluting stents (Endeavor Sprint 3.0×24 mm and 2.5×18 mm, Medtronic, Santa Rosa, CA, USA).\nConsidering the patient's age and history of significant coronary artery disease, we decided to perform EVAR using the chimney technique for AAA during his hospital stay.\nVascular access in both femoral arteries was obtained percutaneously and was preclosed using two suture type closure devices (ProGlide, Abbott, Abbott Park, IL, USA) on each side. A 7 Fr Shuttle Sheath was inserted into the suprarenal aorta through the left brachial artery access. The left renal artery was cannulated using a 5 Fr Multi-purpose catheter through the Shuttle Sheath. A 0.035" wire (Amplatz stiff wire Cook Medical Inc., Bloomington, IN, USA) was inserted into the left renal artery, and a 6×50 mm graft stent (Viabahn, Gore, Flagstaff, AZ, USA) was placed into the left renal artery along the wire.\nA 36×70 mm aortic extension stent graft (Endurant, Medtronic) was inserted into the abdominal aorta through the right femoral artery and deployed so that the upper end of the graft of the aortic extension is positioned just below the right renal artery. The ostium of the left renal artery was covered by the graft (). Subsequently, the Viabahn stent graft (Gore Viabahn Endoprothesis, W.L. Gore and Associates, Flagstaff, AZ, USA) placed in the left renal artery was deployed. Thereafter, a 36-20-166 mm bifurcated Endurant main body stent was inserted into the abdominal aorta through the left femoral artery and deployed in overlap with the aortic extension (). Also, a 16-24-93 mm contralateral limb piece (Endurant, Medtronic) was inserted through the right femoral artery and deployed.\nThe apposition of the aortic extension and the Viabahn stent graft to the aortic wall was achieved by a kissing balloon method using a 46 mm Reliant balloon and a 6×40 mm peripheral angioplasty balloon (). Immediate post-procedure angiography showed no significant endoleak and patent left renal artery (). The left brachial artery access site was manually compressed and the femoral puncture sites were closed by tightening the prepared sutures.\nNo endoleaks or other complications were noted on routine postprocedural follow-up CT (). The laboratory results showed the patient's creatinine level at 1.14 mg/dL, which had no interval change of creatinine (baseline creatine 1.2 to 1.4 mg/dL) and estimated glomerular filtration rate.\nThe patient developed a fever after the procedure, but with no evident leukocytosis and negative blood culture, it was considered as a post-implant syndrome. The patient was discharged without other significant complications.