Juxtarenal Inflammatory Aneurysm Treated with Bilateral Iliac–Renal Bypass Using the Gore Hybrid Device and Total Sealing of the Aneurysmal Sac with a Nellix Device

doi:10.1016/j.avsg.2016.06.021

Annals of Vascular Surgery

Volume 38, January 2017, Pages 321.e13-321.e18

https://doi.org/10.1016/j.avsg.2016.06.021 Get rights and content

The aim of this study is to present the treatment of a juxtarenal inflammatory aneurysm using a Nellix device (Endologix, Inc., Irvine, CA) to seal the entire aneurysmatic aorta combined with bilateral iliac–renal bypass using the Gore hybrid vascular graft (W. L. Gore & Associates, Inc., Flagstaff, AZ). A 63-year-old man was diagnosed with a 6-cm juxtarenal inflammatory aneurysm. It was initially decided to treat him with an aorto-aortic bypass and to revascularize the 2 renal arteries with “graft to renal artery bypass” using Gore hybrid vascular grafts. Due to the high intraoperative bleeding preparing the proximal neck and the tight adhesion of the aorta to the adjacent structures, we decided to change our plans and to treat the patient using the Nellix system combined with bilateral iliac–renal bypass using the Gore hybrid vascular grafts. Contrast computed tomography control at 1 month showed complete sealing of the aneurysm sac and patent iliac renal bypasses. The reported case demonstrated that the Nellix Endovascular Aneurysm Sealing system combined with Gore hybrid vascular grafts for bilateral iliac–renal bypass showed that it can be an effective modality for the treatment of juxtarenal, inflammatory aortic aneurysm and revascularization of the renal arteries from the distal iliac arteries.

Section snippets

Case Report

A 63-year-old man, suffering from hypertension, diabetes, and dyslipidemia, was diagnosed with a 6 cm × 5.5 cm juxtarenal inflammatory aneurysm.

The preoperative computed tomography angiography (CTA) revealed an atherosclerotic dilated aorta, with bulgings, degenerated walls, and thrombus (Fig. 1) in the proximal neck. The right kidney was perfused by 2 renal arteries (Fig. 1): the proximal artery feeding a really vital part of the kidney and the most distal one, with a stenosis in the origin

Discussion

The management of juxtarenal inflammatory aneurysms may be very challenging especially in the juxtarenal location. Surgery is a well-established treatment modality.12, 13, 14 Notwithstanding, the periaortic inflammation and adhesions involving the aneurysmal sac and the proximal neck and extending above the level of origin of renal arteries may expose to a high risk of iatrogenic injury and severe bleeding. If the retroperitoneal fibrosis is very extensive, both transperitoneal and

Conclusions

The present case suggests that the Nellix system combined with bilateral iliac–renal bypass with Gore hybrid vascular graft appeared to provide a valid alternative for the treatment of juxtarenal and inflammatory aneurysm not suitable for just open surgery.

References (23)

N. Tsilimparis et al.
Results of the Gore Hybrid Vascular Graft in challenging aortic branch revascularization during complex aneurysm repair
Ann Vasc Surg
(2015)
R. Chiesa et al.
Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoracoabdominal aortic aneurysm repair
J Vasc Surg
(2014)
S. Wipper et al.
First implantation of Gore Hybrid Vascular Graft in the right vertebral artery for cerebral debranching in a patient with Loeys-Dietz syndrome
J Vasc Surg
(2015)
J.A. Barrett et al.
Progression of peri-aortic fibrosis despite endovascular repair of an inflammatory aneurysm
Eur J Vasc Endovasc Surg
(2001)
A. Malaj et al.
Treatment of a juxtarenal aneurysm with a parallel graft in the left renal artery and polymer-based technology to seal the entire aneurysmal sac
Ann Vasc Surg
(2015)
J.R. Brownrigg et al.
Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre
Eur J Vasc Endovasc Surg
(2015)
S.C. Paravastu et al.
A systematic review of open versus endovascular repair of inflammatory abdominal aortic aneurysms
Eur J Vasc Endovasc Surg
(2009)
C. Lange et al.
Results of endovascular repair of inflammatory abdominal aortic aneurysms. A report from the EUROSTAR database
Eur J Vasc Endovasc Surg
(2005)
S. Sultan et al.
Fifteen-year experience of transperitoneal management of inflammatory abdominal aortic aneurysms
Eur J Vasc Endovasc Surg
(1999)
G.J. Todd et al.
Retroperitoneal approach for repair of inflammatory aortic aneurysms
Ann Vasc Surg
(1995)

J.L. Crawford et al.

Inflammatory aneurysms of the aorta

J Vasc Surg

(1985)

Cited by (2)

Multidisciplinary diagnosis and management of inflammatory aortic aneurysms
2023, Journal of Vascular Surgery
Citation Excerpt :
Evolving biologic therapies may enhance the role of fenestrated/branched EVAR (FBEVAR), and Chimney EVAR (ChEVAR) especially in high-risk patients 135. Although reports are scarce, FBEVAR, iliac branch devices and ChEVAR have been used in IAAA with juxtarenal and pararenal anatomy or aortoiliac involvement 128,135-139. Although some favor corticosteroids and/or immunosuppressive therapy prior to OSR or EVAR 9,94, there are no controlled trials providing concrete evidence.
Inflammatory abdominal aortic aneurysms (IAAAs) are a variant involving a distinct immunoinflammatory process, with nearly one half believed to be associated with IgG4-related disease (IgG4-RD).
MEDLINE and Google Scholar searches were conducted for English-language publications relevant to inflammatory aortic aneurysms from January 1970 onward. The search terms included inflammatory aortic aneurysms, aortitis, periaortitis, IgG4-related disease, and retroperitoneal fibrosis. Relevant studies were selected for review based on their relevance.
Morphologically, IAAAs are characterized by a thickened aneurysm wall often displaying contrast enhancement and elevated metabolic activity on fluorine-18 fluorodeoxyglucose-positron emission tomography imaging. A strong association exists with perianeurysmal and retroperitoneal fibrosis. Although the rupture risk appears lower with IAAAs than with noninflammatory abdominal aortic aneurysms (AAAs), the currently recommended diameter threshold for operative management is the same. Open repair has been associated with increased morbidity compared with noninflammatory AAAs, and a retroperitoneal approach or minimal dissection transperitoneal approach has been recommended to avoid duodenal and retroperitoneal structural injuries. Endovascular aneurysm repair has been increasingly used, especially for patients unfit for open surgery. It is important to exclude an infectious etiology before the initiation of immunosuppressive therapy or operative repair. Multimodality imaging follow-up is critical to monitor disease activity and secondary involvement of retroperitoneal structures by the associated fibrotic process. Maintenance of immunosuppressive therapy will be needed postoperatively for most patients with active systemic disease, especially those with IgG4-RD and those with persistent symptoms. Additional interventions aimed at ureteral decompression could also be required, and lifelong follow-up is mandatory.
Preoperative multimodality imaging is a diagnostic cornerstone for assessment of the disease extent and activity. IgG4-RD is an increasingly recognized category of IAAAs, with implications for tailoring adjunctive medical therapy. Open surgical repair remains the procedure of choice, although endovascular aneurysm repair is increasingly being offered. Maintenance immunosuppressive therapy can be offered according to the disease activity as assessed by follow-up imaging studies.
Infective native arterial aneurysms and inflammatory abdominal aortic aneurysms: An overview with a focus on emergency settings
2023, Seminars in Vascular Surgery
Infective native arterial aneurysms and inflammatory aortic aneurysms are rare but morbid pathologies seen by vascular surgeons in the emergency setting. Presentation is not always clear, and a full workup must be obtained before adopting a management strategy. Treatment is multidisciplinary and is tailored to every case based on workup findings. Imaging with computed tomography, magnetic resonance, or with fluorodeoxyglucose-positron emission tomography aids in diagnosis and in monitoring response to treatment. Open surgery is traditionally performed for definitive management. Endovascular surgery may offer an alternative treatment in select cases with acceptable outcomes. Neither technique has been proven to be superior to the other. Physicians should consider patient's anatomy, comorbidities, life expectancy, and goals of care before selecting an approach. Long-term pharmacological treatment, with antibiotics in case of infective aneurysms and immunosuppressants in case of inflammatory aneurysms, is usually required and should be managed in collaboration with infectious disease specialists and rheumatologists.

: Disclosures: All the authors have no conflicts to disclose.

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Case ReportJuxtarenal Inflammatory Aneurysm Treated with Bilateral Iliac–Renal Bypass Using the Gore Hybrid Device and Total Sealing of the Aneurysmal Sac with a Nellix Device

Section snippets

Case Report

Discussion

Conclusions

Ann Vasc Surg

J Vasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

J Vasc Surg

Case Report
Juxtarenal Inflammatory Aneurysm Treated with Bilateral Iliac–Renal Bypass Using the Gore Hybrid Device and Total Sealing of the Aneurysmal Sac with a Nellix Device