Endovascular Repair of Disclosure: Cook, Inc. Juxtarenal, Pararenal, and • Patents Thoracoabdominal Aneurysms • Consulting • Research Support Tim Chuter, DM UCSF Vascular Surgery And we can all have our favourite way There's more than one way to skin a cat 1
Practical Considerations And the Choices Are…. • CHIMPS • Device Choice • Fenestrations • Operative Planning • Branches Snorkel Snorkel: Where is the Seal? • Where is the seal? • How many branches? • The ideal patient • The ideal technique 2
How Many Snorkels? • More snorkels, more gutters • More snorkels, more access • More snorkels, more arteries at risk 3
Best Case for Snorkel • Single low renal artery • Renal arteries well below the SMA • Good renal function Type I • No renal stenosis Endoleak 25% • More sophisticated alternatives are unavailable Mario Lachat, Frank J. Veith, Thomas Pfammatter, Michael Glenck, Dominique Bettex, Dieter Mayer, Zoran Rancic, Steffen Gloekler, and Felice Pecoraro ( 2013 ) Chimney and Periscope Grafts Observed Over 2 Years After Their Use to Revascularize 169 Renovisceral Branches in 77 Patients With Complex Aortic Aneurysms. Journal of Endovascular Therapy: October 2013, Vol. 20, No. 5, pp. 597-605. Preemptive Coil Embolization Endovascular Ironing 4
Fenestration Fundamentals • Balloon expandable stents – Straight – Fragile • Perpendicular branches – Accurate positioning – Shuttering – Migration SNORKEL FENESTRATION Patient/Device Selection Technical Issues • Single low renal artery • Covered stents • Renal arteries well below the SMA • SMA • No tortuosity • Access through a contralateral sheath • Good renal function • Indwelling catheters • No renal stenosis • Narrow aorta at level of renal arteries • More sophisticated alternatives unavailable 5
Axially-Oriented Cuffs 6
Off-The-Shelf Branched Technical Limitations • Multiple renal arteries • Narrow aorta at level of renal arteries • Coverage of SC aorta, even in type IV Conclusion • Anatomy • Geography • Expense 7
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