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Parallel Endograft Repair Of An Aortic Anastomotic Pseudoaneurysm In A Patient With Middle Aortic Syndrome
Arash Fereydooni, Marcos Kuroki, MD, PhD, Jason T. Lee, MD.
Stanford University, Stanford, CA, USA.
Demographics: A 66-year-old female with congenital Middle Aortic Syndrome (MAS) and morbid obesity (BMI=41) presented with a pulsatile abdominal mass.
History: The patient was diagnosed with MAS at age 6, after a failed exploratory thoracotomy. She had worsening renovascular hypertension and claudication and age 19, she underwent a supraceliac aorta to left common iliac artery bypass with jump-graft to celiac artery and bypass from right common iliac artery to bilateral renal arteries. Forty-seven years later, she was found to have a 7.4 cm pseudoaneurysm at the distal anastomosis of aorto-iliac bypass. Imaging also revealed a dominant lumbar artery, critical for spinal cord perfusion, and no other spinal arteries in the atretic aortic segment.
Plan: Given the complexity of the redo field, morbid obesity, and need to preserve the single large lumbar artery, an endovascular approach involving parallel grafting to preserve the dominant lumbar artery was offered. A 3D printed anatomical model was used for enhanced visualization. The procedure was done via bilateral percutaneous femoral access. After deploying a 20mmx12mmx12cm Excluder Active Control Endograft in the mid portion of the prior bypass graft, a periscope 6mm x 75mm Viabahn was deployed in the lumbar artery over the pre-wired platform. This was then distally extended with 6mm x 79mm VBX to the area of overlap with the ipsilateral limb. A 16 x 120mm contralateral limb was deployed to the right CIA, ensuring not to cover the origin of the renal artery bypass. The VBX was then crushed by dilation of the ipsilateral limb with a molding balloon and re-expanded with 4mm balloon to create an “eye of the tiger” configuration of the parallel graft. Completion angiogram showed full exclusion of the pseudoaneurysm, successful preservation of lumbar artery perfusion, and no evidence of type 1 or 3 endoleak. On 1-year follow up imaging, patient had full thrombosis of the pseudoaneurysm (Figure).
Discussion: Aortic pseudoaneurysms in patients with MAS present unique challenges due to complex anatomy and prior surgical interventions. This case illustrates the utility of parallel grafting for preserving critical vascular structures, such as the lumbar artery, during complex endovascular repairs.
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