Treatment of Renal Artery Stenosis and Fibromuscular Dysplasia
Interventions for renal arterial disease are primarily driven by functional consequences of the disease. These are poorly controlled hypertension, increasing renal dysfunction (often associated with loss of renal mass), and, more recently, control of cong
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Treatment of Suprarenal and Juxtarenal AAA with Fenestrated Grafts and Debranching Procedures Heather P. Park and Mark A. Farber
Abstract
Endovascular aneurysm repair (EVAR) has revolutionized the treatment of infrarenal abdominal aneurysms; however, as many as 45 % of aneurysms are not amenable to standard EVAR due to inadequate sealing zone or involvement of the visceral segment of the aorta. For these patients, advanced endovascular techniques have been developed that allow incorporation of the visceral vessels into the sealing zone while maintaining flow either via stents or with open surgical debranching. Fenestrated techniques are currently available in the USA as part of clinical trial or investigational device protocols or as “surgeon modifications” for urgent or compassionate usage. Successful repair of suprarenal or juxtarenal aneurysms using these techniques requires careful advanced planning based, high-quality intraoperative imaging, and a high level of endovascular expertise. Keywords
Fenestrated endovascular aortic repair • Complex aortic repair • Aortic debranching • Juxtarenal aneurysm • Suprarenal aneurysm
H.P. Park, M.D. Department of Surgery, University of North Carolina Health Care, Chapel Hill, NC, USA M.A. Farber, M.D., FACS (*) Department of Surgery and Radiology, UNC Aortic Center, University of North Carolina Health Care, 3025 Burnett Womack Building, CB# 7212, Chapel Hill, NC, 27599-7212, USA e-mail: [email protected]
Juxtarenal and pararenal abdominal aortic aneurysms pose complex problems for vascular surgeons involved in their management. Development of endovascular repair of aortic aneurysms has been associated with low perioperative morbidity and mortality, even in high-risk patients. However, as many as 45 % of patients have aneurysms that are not amenable to endovascular techniques based on the instructions for use for each device. Exclusion may be because of short, nonexistent, or angulated necks precluding adequate proximal seal [1]. Good surgical candidates may tolerate the complex open procedure necessary to exclude
J.J. Hoballah, A.B. Lumsden (eds.), Vascular Surgery, New Techniques in Surgery Series, DOI 10.1007/978-1-4471-2912-7_2, © Springer-Verlag London 2012
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the aneurysm, but many patients with serious cardiac, pulmonary, or renal comorbidities are unlikely to fully recover from the extensive open procedure. These patients may be best served by a minimally invasive approach to aneurysm exclusion, with the most appropriate treatment determined by an experienced surgeon after consideration of each patient’s risk profile.
History Since the initial reports of endovascular stent grafting for AAA exclusion by Juan Parodi and associates in 1991 [2], there has been significant adoption of endovascular techniques to treat aortic pathology in nearly every subset of patients. However, despite advances in almost all aspects of endovascular technology including preoperative imaging, wires, catheters, balloons, and delivery systems, all
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