Novel Endovascular Technique for Repair of a Ruptured Abdominal Aortic Aneurysm with a Narrow Distal Aorta
Cynthia Xu, Desmond Khor, MD, Hakan Orbay, MD, Gregory Steiner, MD, Khanjan H. Nagarsheth, MD, Shahab A. Toursavadkohi, MD.
University of Maryland School of Medicine, Baltimore, MD, USA.
Objectives:
Endovascular repair of ruptured abdominal aortic aneurysms (rAAA) has been shown to have a survival benefit over open repair, but the narrow distal aorta poses a unique difficulty in endovascular repair of rAAA. Herein we present a novel technique for repairing such an aneurysm.
Methods:
Case report and review of the literature.
Results:
This is a 69-year-old male with multiple medical comorbidities who presented as a transfer from an outside facility following myocardial infarction. During cardiac catheterization he complained of abdominal pain and a computerized tomography scan was obtained identifying a rAAA. He was taken emergently to the operating room as he was hemodynamically labile. Balloon occlusion of the aorta was performed just cephalad to the renal arteries and his vital signs stabilized. A bifurcated graft was used to get a proximal seal, but upon trying to cannulate the contra-gate, it was found that the gate was only partially opened due to the narrow distal aorta. A second bifurcated graft was deployed with the contralateral gate in reverse configuration and the ipsilateral limb deployed at the aortic bifurcation, resulting in an aorto-uni-graft that ended at the aortic bifurcation. Next, the limb was cannulated from the contralateral side and kissing covered stent grafts were placed into the limb to obtain a seal. At the end of the procedure, the patient stabilized and had no evidence of endoleak (Figure 1). He was discharged from the hospital several days later and was doing well at six-month follow-up without evidence of endoleak.
Conclusions:
The technique described to manage a very narrow distal aorta in the setting of rAAA prevents the need for extra-anatomic bypass and can quickly seal a ruptured aortic aneurysm. To our knowledge, this is the first reported case of creating a bifurcated stent using the ipsilateral limb of a main body aortic graft. 
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