Disclosure: Cook, Inc. Juxtarenal, Pararenal, and Patents - - PowerPoint PPT Presentation

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Disclosure: Cook, Inc. Juxtarenal, Pararenal, and Patents - - PowerPoint PPT Presentation

Sep 07, 2022 276 likes •362 views

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

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Endovascular Repair of Juxtarenal, Pararenal, and Thoracoabdominal Aneurysms

Tim Chuter, DM UCSF Vascular Surgery

Disclosure: Cook, Inc.

  • Patents
  • Consulting
  • Research Support

There's more than one way to skin a cat

And we can all have our favourite way

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Practical Considerations

  • Device Choice
  • Operative Planning

And the Choices Are….

  • CHIMPS
  • Fenestrations
  • Branches

Snorkel

  • Where is the seal?
  • How many branches?
  • The ideal patient
  • The ideal technique

Snorkel: Where is the Seal?

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How Many Snorkels?

  • More snorkels, more gutters
  • More snorkels, more access
  • More snorkels, more arteries

at risk

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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.

Type I Endoleak 25%

Best Case for Snorkel

  • Single low renal artery
  • Renal arteries well below the SMA
  • Good renal function
  • No renal stenosis
  • More sophisticated alternatives are

unavailable

Preemptive Coil Embolization Endovascular Ironing

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FENESTRATION SNORKEL

Fenestration Fundamentals

  • Balloon expandable stents

– Straight – Fragile

  • Perpendicular branches

– Accurate positioning – Shuttering – Migration

Patient/Device Selection

  • Single low renal artery
  • Renal arteries well below the SMA
  • No tortuosity
  • Good renal function
  • No renal stenosis
  • Narrow aorta at level of renal arteries
  • More sophisticated alternatives unavailable

Technical Issues

  • Covered stents
  • SMA
  • Access through a contralateral sheath
  • Indwelling catheters
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Axially-Oriented Cuffs

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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