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Endovascular treatment of abdominal aortic aneurysm in a patient with chronic renal failure
(Portuguese PDF version)

Cleoni Pedron,¹ Ana Carla M. Palis,² Arno von Ristow,³ Alberto Vescovi,⁴ Bernardo Massière,⁴ José Mussa Cury Filho,¹ Marcus Gress,⁴ Antonio Luiz de Medina,⁵

1. Vascular surgeon. Associate physician, Centervasc-Rio, Rio de Janeiro, RJ, Brazil. Professor, Graduate Program in Vascular Surgery, Pontifícia Universidade Católica do Rio de Janeiro (PUC/Rio), Rio de Janeiro, RJ, Brazil.
2. Ultrasonographer. Head, Ultrasonography Service, Hospital Quinta D'Or, São Cristóvão, RJ, Brazil.
3. Vascular surgeon. Director, Centervasc-Rio, Rio de Janeiro, RJ, Brazil. Associate Professor, Graduate Program in Vascular Surgery, PUC-Rio, Rio de Janeiro, RJ, Brazil.
4. Vascular surgeon. Associate physician, Centervasc-Rio, Rio de Janeiro, RJ, Brazil.
5. Vascular surgeon. Professor, Graduate Program in Vascular Surgery, PUC-Rio, Rio de Janeiro, RJ, Brazil.

This study was carried out at Centervasc-Rio - Center for Research, Prevention, Diagnosis and Vascular Treatment, Rio de Janeiro, RJ, Brazil. It was presented to SBACV - Regional RJ at the 464^th Scientific Meeting on 11/24/05.

Conflicts of interest: Cleoni Pedron, Arno von Ristow and Marcus Gress are clinical consultants at Nano Endoluminal S/A.

Correspondence:
Cleoni Pedron
Departamento de Cirurgia Vascular e Endovascular - Centervasc-Rio
Rua Sorocaba 464, 1º andar
CEP 22271-110 - Rio de Janeiro, RJ, Brazil
E-mail: cpedron@uol.com.br

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ABSTRACT

Non-dialytic chronic renal failure is a contraindication related to the endovascular treatment of abdominal aortic aneurysms. The use of alternative contrast agents, such as gadolinium, provides good-quality images and is associated with nephrotoxicity. We report a case of endovascular treatment of an abdominal aortic aneurysm guided by color-flow Doppler ultrasonography. An 82-year-old male patient, with abdominal aortic aneurysm (55 mm in diameter) and creatinine clearance of 17 ml/min, underwent implantation of modular bifurcated aortic stent-graft, using that imaging method associated with radioscopy. Iodinated contrast was not used. The immediate result and 1- and 6-month controls showed complete aneurysm exclusion. Renal function is still unaltered. We conclude that the stent-graft implantation guided by color-flow Doppler ultrasonography in patients with nonterminal chronic renal failure and with favorable anatomy is a feasible and safe method.

Keywords: Endovascular treatment, abdominal aortic aneurysm, renal failure, color-flow Doppler ultrasonography, duplex scan.

J Vasc Bras. 2006;5(4):325-30

Article submitted August 7, 2006, accepted October 16, 2006.

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INTRODUCTION

The association of abdominal aortic aneurysms (AAA) with stenotic lesions of many arteries is common. Coronary, carotid, renal and lower limb arteries are the most frequently affected.¹ Many patients with AAA present chronic renal failure, due to atherothrombosis of renal arteries, besides other diseases.² The presence of several associated diseases in patients with AAA increases operative risk. The endovascular treatment of AAA was developed with the aim of reducing mortality in this group of patients.³ The presence of nondialytic chronic renal failure is a contraindication concerning the endovascular treatment of AAA, due to the need of using iodinated contrast, which is nephrotoxic. In these cases, direct surgical treatment has been indicated, but this option is often imprudent due to the high surgical risk of these procedures.⁴ With the aim of solving this problem, alternative contrast media, such as gadolinium, have been used.⁵ These contrast media, besides having low opacity, are also associated with nephrotoxicity.⁶ Aiming to eliminate this limitation, we developed a technique and report a case of endovascular treatment of AAA, guided by color-flow Doppler ultrasonography.

CASE REPORT

An 82-year-old male patient, with infrarenal AAA, had been periodically assessed in our Program of Small Aortic Aneurysms Follow-up (PAAAP) for 4 years. The initial diameter of 32 mm increased to 55 mm, representing indication for treatment. The AAA was asymptomatic, but the patient presented many comorbid conditions: systemic arterial hypertension (SAH), hypothyroidism, dyslipidemia, chronic obstructive pulmonary disease (COPD), thrombocythaemia (57,000 mil/µl - reference values: 150,000 to 450,000 mil/µl) and chronic renal failure, with corrected creatinine clearance of 17.1 ml/min/1.73 m² (reference values: 60-160 ml/min/1.73 m²). The aneurysm was evaluated before the surgery using color-flow Doppler ultrasonography. For the therapeutic planning and stent-graft calculation, the aneurysm morphology was evaluated using computed tomography (CT), without contrast, with axial sections 3 mm interval, from the medium portion of the thoracic aorta to the common femoral arteries. To better assess the anatomy, axial images of the aorta and iliac arteries were reconstructed (Figure 1).

Figure 1 - Spiral computed tomography - reconstruction of the abdominal aorta and iliac arteries

When assessing the AAA, the CT and color-flow Doppler ultrasonography showed an AAA in the infrarenal position with maximum diameter of 55 mm. Aortic morphology was assessed using CT. The diameter and length of the proximal neck were 21 and 14 mm, respectively. The distal neck had a 22 mm diameter and 12 mm length. Common and external iliac arteries were not tortuous nor aneurysmal, with 12 mm diameters.

The clinical cardiologic risk according to the American Association of Anesthesiology , which evaluated several diseases present in the patient, was high (level III). Due to the high risk, the patient was referred for evaluation of the possibility of endovascular treatment of AAA, and a treatment with the aid of color-flow Doppler ultrasonography was planned.

The surgical procedure was performed on 09/29/2005. General anesthesia was used. For fluoroscopy, we used a C-arm BV Pulsera® (Philips), and Vivid 3® (GE Medical Systems) for the color-flow Doppler ultrasonography, with a convex 3.5-5 MHz transducer.

After invasive and noninvasive monitoring, the patient was given total endovenous anesthesia, using remifentanil, propofol and rocuronium.

The patient was placed on a radiolucent operating table, with indwelling catheter, disinfection and antisepsis, performed using Povidine®, followed by the insertion of clamps with exposure from the xiphoid process until the feet.

Through two oblique approaches in groin regions, the common and superficial femoral arteries were exposed. In both common femoral arteries, valved 7-F, 11-cm introducer sheaths were inserted, followed by systemic heparinization with Liquemine® 7,500 IU. Through the left side, a C1 Cobra catheter was inserted and the right renal artery - most distal renal artery - was catheterized, guided by fluoroscopy using color-flow Doppler ultrasonography (Figure 2). Through the right side, a 35 x 260 cm Lunderquist guide wire was inserted and its proximal extremity was placed in the ascending aorta. This maneuver was performed with the aid of a JB1 diagnostic catheter. The sheath was removed after artery clamping. A transverse arteriotomy was performed and the Apolo stent-graft deployment system was inserted (Nano Endoluminal, Florianópolis, Brazil), guided by fluoroscopy until deployment position. The color-flow Doppler ultrasonography confirmed the starting position of the stent-graft immediately distal to the origin of renal arteries. Fluoroscopy corroborated the placement of the catheter introduced in the renal artery and the juxta-renal position of the stent-graft.

Figure 2 - Catheterization of the right renal artery confirmed by color-flow Doppler ultrasonography

The size of the main body was 31 x 14 x 150 mm. The stent-graft was uneventfully deployed, and the introducer sheath was removed, as well as the C1 Cobra catheter, which was placed on the right renal artery. The color-flow Doppler ultrasonography confirmed the patency of renal arteries and the proper stent-graft placement, as well as the patency of the right hypogastric artery. A 33 mm latex balloon was used to inflate the stent-graft. Next, using fluoroscopy and JB1 catheter, the short branch of the stent-graft was catheterized and the pig-tail rotation maneuver was performed inside the stent-graft. The pig-tail catheter was replaced by a 35 x 260 cm rigid Amplatz guide wire. After transverse arteriotomy in the left femoral artery, the contralateral branch was introduced and implanted, measuring 14 x 14 x 90 mm. The color-flow Doppler ultrasonography confirmed the placement of the bifurcated stent-graft, with patency of renal and hypogastric arteries and no endoleaks (Figure 3). Next, the stent-graft was inflated using the same latex balloon (Figure 4). The arteriotomies were sutured, and blood flow was selectively released. Heparin was reversed, hemostasis was revised, incisions were closed and the presence of distal pulses was assessed. The patient was referred to a postoperative intensive care unit extubated, presenting proper postoperative progress and being discharged 48 h after the procedure.

Figure 3 - Intraoperative color-flow Doppler ultrasonography with patency of renal and hypogastric arteries and no endoleaks

SACO ANEU = aneurysmal sac; ENDO PROT = endovascular prosthesis.

Figure 4 - Stent-graft inflation using complacent balloon

In outpatient controls, the patient maintained the same level of renal function. Postoperative controls of aneurysm exclusion were performed using color-flow Doppler ultrasonography and CT without contrast on the 30^th postoperative day and 6 months thereafter, confirming aneurysm exclusion and thrombosis without endoleaks. Systolic velocity in the stent-graft was 112 cm/s. The thrombosed aneurysmal sac was measured, presenting a 54 x 52 mm diameter. Both branches are anchored in the common iliac arteries, also with systolic velocities of 112 cm/s, with patent external and hypogastric iliac arteries (Figure 5). Both renal arteries are patent, with normal two-phase flow and velocity.

Figure 5 - Postoperative color-flow Doppler ultrasonography with no signs of endoleak

a) aorta

b) iliac arteries

AICD = right common iliac artery; AICE = left common iliac artery; aneurisma trombo = thrombosed aneurysma; endoprotese = endovascular prosthesis.

DISCUSSION

Most patients with AAA are elderly and present major atherothrombotic disease. In these patients, there is frequent association of coronary disease, peripheral obstructive arterial disease, cerebral vascular insufficiency due to carotid stenosis, SAH, nephropathy and diabetes.^7-10 This profile significantly increases surgical risk, elevating the morbidity and mortality rates in the postoperative period.¹¹ With the aim of improvement the management of this group of high risk patients for conventional surgery, the endovascular therapy for the treatment of AAA was developed, in a publication by Parodi et al. in 1991.¹ Since then, there has been a new horizon for high risk patients, who were previously relegated to the natural history of AAA due to inoperability, especially because of a high clinical cardiologic risk. However, there are still contraindications to the use of the endovascular method in the treatment of AAA, such as presence of unfavorable anatomy, absence of proximal neck, presence of thrombi in the proximal neck and nondialytic nephropathy, among others.¹² After the development of the endovascular method, solutions for several contraindications were found, such as the development of fenestrated stent-grafts for aneurysms without proximal neck,^13,14 cerclage of common iliac arteries¹⁵ or revascularization of hypogastric arteries in patients with absence of distal neck.¹⁶

The same fact has occurred to patients with nondialytic chronic renal failure. It is known that increase in preoperative creatinine levels is related to a longer hospitalization period and increased mortality.³ Studies report up to 10% incidence of contrast-induced nephropathy in patients with normal renal function, and up to 35% in those with impaired renal function.^4,17,18 Alternative contrast media, such as gadolinium, have been used to perform these procedures in patients with nondialytic chronic renal failure.¹⁹ However, even the use of non-iodinated contrasts, such as gadolinium, is not without risks, contrast-induced nephropathy being described, especially when the use of a great volume is needed, such as the case of endovascular treatment of AAA.^5,11,17,20

Other territories, such as lower limbs and carotid artery, were the sites initially chosen to use the color-flow Doppler ultrasonography in endovascular procedures.^21,22 Approach to these places is facilitated by the superficiality of the vessels, with good visualization of vessels, working systems, guide wires, balloon-catheters and stents, which are all properly visualized by color-flow Doppler ultrasonography. This method presents many advantages, such as, for example, visualization of the complete expansion of the stent, absence or reduction in the amount of radiation for the patient and medical staff. The main advantages are the prevention of contrast-induced renal failure and maintaining the stability of renal function in patients with renal failure who require an endovascular procedure.

Studies using color-flow Doppler ultrasonography to control AAA treated with endovascular technique present good sensitivity and specificity to detect aneurysm growth and internal leakage,²³ and may be used to plan the procedure, which promotes safety to confirm intraoperative data.

The publication of those studies encouraged us to initially perform procedures in carotid arteries, lower limbs and inferior vena cava. We developed a protocol to perform the endovascular treatment of AAA guided by color-flow Doppler ultrasonography, based on the experience accumulated with more than 300 patients treated with this method, with 98.4% technical success rate.

In addition to our experience in endovascular therapy and procedures guided by color-flow Doppler ultrasonography, favorable anatomical conditions are necessary to implant the stent-graft. Among them, we stress presence of long proximal neck (> 15 mm), iliac arteries without tortuosities and/or aneurysms. Our preprocedure study protocol consists of tomography angiography of the aorta and iliac arteries with 3-mm sections and three-dimensional reconstructions without contrast, besides the anatomical study using color-flow Doppler ultrasonography with the ultrasonographer who will participate in the procedure. This is an essential condition for the planning and success of the procedure.

In our opinion, it will be possible to use this method with any type of stent-graft existing in the market.

 

CONCLUSION

The endovascular treatment of AAA guided by color-flow Doppler ultrasonography is a technique applicable to selected cases, with anatomy compatible with this therapeutic method. It is indicated for high risk patients, with nondialytic chronic renal failure. The endovascular treatment of AAA guided by color-flow Doppler ultrasonography and without iodinated contrast is feasible and should be considered in the treatment of this subgroup of patients.

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