Contributors: Gregory Westin and Paresh Shah
Endovascular stent grafting (EVAR) is now the preferred approach to repair of abdominal aortic aneurysms for many patients. One of the most common complications associated with EVAR is the development of an endoleak, or continued flow of blood into the aneurysm sac outside the graft. Type II endoleaks, those due to retrograde flow through a branch vessel such as the inferior mesenteric artery (IMA) or a lumbar artery, are the most common. Options for treatment include transarterial embolization, translumbar embolization, and laparoscopic ligation. Embolization techniques require reintervention in approximately 20%, with less than half free from aneurysm sac growth at five years, though current evidence is insufficient to determine a clear threshold for intervention or optimal technique.[1,2]
The use of renal stents in atherosclerotic renal artery stenosis has been mired in controversy secondary to poorly designed randomized clinical trials which demonstrated minimal benefit over medical management. This publication illustrates the deployment of an isolated renal stent as an ancillary procedure for a patient with a 5.5cm juxtarenal AAA in need of fenestrated endovascular repair.
Under general anesthesia, the patient was prepped with the left arm tucked. Access via the right common femoral artery over the femoral head was obtained under ultrasound guidance. Using the Seldinger technique, a long sheath (Ansell) was inserted to the level of the infrarenal aorta. A Glidewire (Terumo) was used to enter the right renal ostia with the assistance of an Omniflush (Angiodynamics) catheter after an initial aortogram. A Rosen (Cook) wire was exchanged and the sheath was advanced past the stenosis over the dilator. The balloon mounted iCAST (Atrium) stent was positioned and the sheath pulled back. The stent was deployed and flared using a Flash ostial balloon (Cordis). Completion angiography demonstrated excellent flow through the right renal artery and into the terminal renal branches.
The patient recovered uneventfully overnight with a stable Cr the next morning. Four weeks after his renal intervention, the patient was taken to the operating theatre for a successful 3-vessel fenestrated aortic repair. At the most recent 6-month follow-up, the patient had a stable Cr and residual aortic sac diameter.
While the use of renal stenting in hypertension related to atherosclerotic renal artery disease continues to remain controversial, this intervention can still be performed as an adjunctive procedure in select cases with excellent technical success and low morbidity.
Raghu L. Motaganahalli
This patient is a 9-month-old with a macrocystic lymphatic malformation (LM) of the left neck. LMs, the second most common type of head and neck vascular malformation, are composed of dilated, abnormal lymphatic vessels thought to occur due to abnormal development of the lymphatic system. A complete resection was performed, and LM was confirmed by pathology. Soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process.
The patient was then nasotracheally intubated, prepped and draped in sterile fashion and the tongue injected with 2 cc lidocaine with epi. Bovie was used to incise lesion in ellipse down to its base which was sent for pathology. A tongue stitch was used for traction. Hemostasis was also achieved with Bovie. The site was closed primarily with vicryl, deep and superficial. Bipolar was used to treat small surface lesions. All instrumentation was then removed and the patient was turned back over to anesthesia, awakened, and transferred to the recovery room extubated in stable condition.