Endovascular Repair of Acute Symptomatic Pararenal Aortic Aneurysm With Three Chimney and One Periscope Graft for Complete Visceral Artery Revascularization

Purpose To describe a modified endovascular technique for complete revascularization of visceral and renal arteries in symptomatic pararenal aortic aneurysm (PRAA). Technique Arterial access was surgically established in both common femoral arteries (CFAs) and the left subclavian artery (LSA). Revascularization of the left renal artery, the celiac trunk, and the superior mesenteric artery was performed through one single sheath via the LSA. Suitable covered stents were put in the aortic branches but not deployed. The right renal artery was accessed over the left CFA. Due to the longitudinal extension of the presented aneurysm two stent-grafts were introduced via the right CFA. After deploying the aortic stent-grafts, all covered stents in the side branches were deployed consecutively with a minimum overlap of 5 mm over the cranial and caudal stent-graft edges. Simultaneous ballooning was performed to fully expand all stent-grafts and warranty patency. Conclusion This is the first report in the literature of chimney grafting in PRAA for complete revascularization of visceral and renal branches by using more than two covered stents introduced from one side through one single sheath. However this technique is modified, it should be used only in bailout situations when branched stent-grafts are not available and/or surgery is not suitable.