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Corresponding author. Domenico Palombo, MD, Chairman, Vascular Surgery Unit, Department of Cardiac and Vascular Diseases, Mauriziano Hospital, C.so Turati, 62, I-10128 Turin, Italy
Saccular abdominal aortic aneurysm (SAAA) is a rare condition and it often represents the natural evolution of a penetrating atherosclerotic ulcer. The report of a subcommittee of the Joint Council of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (SVS/ISCVS) recommended that saccular aneurysms should be repaired regardless of the size of the aneurysm.
Recommended indications for operative treatment of abdominal aortic aneurysm. Report of a subcommittee of the Join Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.
We report a unique, successfully managed case of endovascular repair of a saccular aneurysm in a patient with severe renal failure under duplex ultrasound guidance only, without the use of contrast medium.
2. Case Report
A 71-year-old man with a history of smoking, hypertension and severe CRF at risk of dialysis, due to atherosclerosis disease, presented in our outpatient clinic with non characteristic abdominal pain. On examination moderate umbilical and left lumbar tenderness with a palpable pulsatile mass were found. Duplex ultrasound revealed a 4.5 cm infrarenal saccular aortic aneurysm. The communication between the aorta and the SAAA could be seen on the scan. Magnetic resonance imaging (MRI) showed a 4.8 cm isolated SAAA located 4 cm below the level of the renal arteries (Fig. 1(A)) . Taking into account the SAAA length (2 cm), the site, the severe CRF (Creatinine 6.7 mg/dl), the absence of aortic calcification and especially the low body weight of the patient (60 kg Body Mass Index (BMI) 22 kg/m2) we decided that this case was amenable to endovascular repair under duplex ultrasound and fluoroscopic guidance alone, without the use of contrast medium.
Fig. 1(A) SAAA evaluated with MR. (B) MR at 6 months follow-up showed the thrombosis and shrinkage of the aneurismal sac.
The endovascular procedure was performed in the operating room by two experienced vascular surgeons and a vascular radiologist under epidural anaesthesia. The right common femoral artery (CFA) was surgically exposed. A 0.035 in. super stiff Amplatz® guidewire was advanced into the aorta under fluoroscopic guidance (OEC 9600®). The renal arteries and the SAAA were mapped using duplex imaging (ATL HDI 3000®) using a 3.5 MHz convex probe. Systemic heparinization with intravenous (IV) 5000UI was employed. Through a transverse arteriotomy in the CFA a 21F delivery catheter was passed above the communication between the aorta and the SAAA, and an AneuRx® (20–3.75) extender cuff was placed under ultrasound and fluoroscopy guidance.
On-table duplex after the endovascular procedure revealed an image similar to a Type I endoleak (Fig. 2) . We decided to treat this by inserting another endograft overlapping the previous one. A Talent® (20–9.5) cover endograft was implanted using the same technique. On table duplex showed the persistence of the endoleak which disappeared spontaneously after 30 min. The overall procedural time was 60 min.
The post-interventional course was uneventful and the patient was discharged after two days. On discharge the creatinine was 6.4 mg/dl. At 6 months follow-up there was no evidence of an endoleak on duplex imaging. The MRI scan showed thrombosis of the aneurysm sac which had shrunk from 4.8 to 3.7 cm in diameter (Fig. 1(B)). The CRF remained stable (creatinine 6.2 mg/dl).
3. Discussion
The contrast agents employed for vascular imaging and endovascular treatments are an important cause of acute renal failure.
especially in high risk patients with co-morbidities such diabetes, CRF or history of ACE inhibitor treatment. The presence of renal insufficiency that requires dialysis after EVAR has been classified by the reporting standards for endovascular aortic aneurysm repair as a major complication.
Over the past few years several techniques, including intravascular ultrasound (IVUS), carbon dioxide or Gadolinium angiography, have been employed to reduce the rate of renal complications or in patients with a contraindication to iodine contrast injection. A recent report by Lipsitz EC et al.
Evaluation of abdominal aortic aneurysm for stent graft placement: comparison of gadolinium enhanced MR angiography versus helical CT angiography and digital subtraction angiography.
supported Gadolinium enhanced MR angiography as the sole imaging modality for EVAR. Although it is relatively safe and reliable, adverse reaction s can still occur.
Occurrence of adverse reactions to gadolinium based contrast material and management of patients at increased risk: a survey of the American Society of Neuroradiology Fellowship Directors.
showed that the presence of a penetrating atherosclerotic ulcer is more common in the thoracic aorta and the natural history is the development of a progressive saccular or fusiform aneurysm. The aorta above and below such an aneurysm is usually normal and theoretically amenable to endovascular exclusion with a straight tube endograft. York JW et al.
have successfully treated five patients with infrarenal SAAAs using AneurRx® aortic cuff prostheses in a ‘stacked’ configuration. They employed two aortic extender cuffs in three patients and three extender cuffs in two patients to achieve exclusion. They also reported a single intraoperative endoleak which was successfully treated with balloon dilation.
In our case, we knew from the MR scan that the SAAA communication with the abdominal aorta was 8 mm in diameter and that the distance from the renal arteries was greater than 4 cm which made the aneurysm amenable to endovascular exclusion. Because of the severe CRF the use of contrast media was contraindicated. Taking the patient's low patient body weight, the excellent visualization of the SAAA on duplex ultrasound and especially the distance from the renal arteries into consideration, we decided to perform an endovascular exclusion with ultrasound and fluoroscopy alone.
We chose the AneuRx® extender cuff (20–3.75) because the top end of the delivery system was very close to the upper endograft limit. After ultrasound identification, we delivered the extender cuff under fluoroscopic guidance. Intra-operative ultrasound showed an image suggestive of a type I endoleak. We were unable to confirm that this was a true endoleak or an imaging artefact but we nevertheless decided to deploy a cover endograft (Talent® 20–9.5) overlapping and inside the preceding cuff. A further endoleak was demonstrated; whether this was artefactual or not became immaterial since it disappeared after 30 min.
Endovascular exclusion of saccular aneurysms using aortic cuffs seems to be a safe and effective procedure.
No data are currently available in the literature supporting SAAA endovascular exclusion under CDS guidance only.
In conclusion, although our procedure was successful, we believe that endovascular exclusion of SAAA under ultrasound guidance alone should not be considered as a routine alternative to standard endovascular procedures using contrast. This technique can be employed in selected patients with a low body weight, no aortic calcification and with a short SAAA placed far from the renal arteries.
References
Parfrey P.S.
Griffith S.M.
Barrett B.J.
Paul M.D.
Genge M.
Withers J.
Farid N.
et al.
Contrast material induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study.
Recommended indications for operative treatment of abdominal aortic aneurysm. Report of a subcommittee of the Join Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.
Evaluation of abdominal aortic aneurysm for stent graft placement: comparison of gadolinium enhanced MR angiography versus helical CT angiography and digital subtraction angiography.
Occurrence of adverse reactions to gadolinium based contrast material and management of patients at increased risk: a survey of the American Society of Neuroradiology Fellowship Directors.
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