Endovascular repair of a juxtarenal saccular aneurysm using the Multilayer Flow Modulator: report of the first case performed in a Public Hospital in Brazil

Abstract

Endovascular treatment of abdominal aortic aneurysms (AAA), involving the exits of the renal and visceral arteries still constitutes a considerable challenge. Many different techniques have been developed over the years in attempts to surmount the difficulties presented by these cases. Techniques that have gained prominence include fenestrated or branched stents, methods involving parallel prostheses, such as the chimney, periscope and sandwich techniques, and, more recently, flow modulation with Multilayer stents. We describe a case of a complex juxtarenal saccular AAA with a high surgical risk, both according to cardiological assessment and because the patient had a difficult airway caused by a total laryngectomy for early stage laryngeal neoplasm. In view of the technical simplicity of using Multilayer stents, the presence of chronic obstructive aortoiliac disease, ostial stenosis of the renal artery and a small diameter suprarenal aorta, options involving fenestrated/branched stents and techniques involving parallel prostheses were ruled out, because of the need for multiple accesses. In view of the dilemma it presented, we describe this case as a therapeutic challenge and present the treatment option employed, which has been successful over the short term.Keywords: aorta; aneurysm aortic; endovascular procedures. ResumoO tratamento endovascular de aneurismas de aorta abdominal (AAA), envolvendo a saída das artérias renais e viscerais, constitui ainda um importante desafio. Diversas técnicas foram desenvolvidas ao longo do tempo para contornar as dificuldades oferecidas por esta situação, destacando-se as endopróteses fenestradas ou ramificadas, as técnicas envolvendo próteses paralelas, como Chaminé, Periscópio e Sanduíche, e, mais recentemente, a utilização da modulação de fluxo por stent multicamadas Multilayer. Apresentamos um caso de AAA sacular complexo justarrenal e com alto risco cirúrgico pela avaliação cardiológica e por apresentar via aérea difícil, em decorrência de laringectomia total por antecedente de neoplasia de laringe. Devido à facilidade técnica do uso do Multilayer, à presença de doença obstrutiva crônica aorto-ilíaca, à estenose ostial renal e ao diâmetro limitado da aorta suprarrenal, descartaram-se as opções envolvendo endopróteses fenestradas/ramificadas ou técnicas envolvendo próteses paralelas, pela necessidade de diversos acessos para a execução. Diante do dilema imposto, apresentamos este caso como desafio terapêutico e com uma opção de tratamento bem sucedida, em curto prazo.Palavras-chave: aorta; aneurisma aórtico; procedimentos endovasculares.

Unibody design for aortic disease with a narrow aortic bifurcation: tips and tricks for success

“…Many types of bifurcated endografts (bi/tri-modular or unibody) can be employed to treat NDAAD 32 and each of them has technical and structural characteristics that are more appropriate to certain anatomical profiles and particular patient conditions. 33 Other endovascular devices may also be used, such as Multilayer stents, 34 parallel covered stents, 35 or the endovascular sealing technique (EVAS), 36 but consensus on their use requires further studies. 37,38 The diameters of most other bifurcated devices when fully expanded range from 20 to 26 mm, which may cause collapse of the contralateral gate and prevent successful catheterization with the standard technique.…”