Emergency triple chimney in a patient with giant symptomatic pararenal pseudoaneurysm and subsequent gutter embolization

We report a case of pararenal pseudoaneurysm endovascular correction with triple chimney technique and the following gutter embolization procedure

Key points:

-Previous fEVAR attempt (failed because of extremely tortuous accesses)
-Emergency procedure during the night
-Bilateral percutaneous femoral access
-Double axillary puncture on both sides
-Challenging endograft advancement on through and through guidewire
-Triple ChEVAR (SMA, RRA, LRA)
-Subsequent gutter embolization


    Prof. Konstantinos Donas
    November 20, 2018

    Great case dear Gioele, very impressive with a successful exclusion of the aneurysm. I would like to ask you if you would retrospectively have done more oversizing with the aortic stent-graft to wrap up better the 3 chimney grafts? Can you provide us an information about the degree of oversizing?
    I noted also that you preferred to puncture the axillary artery? How is your experience with this approach? Do you have nerve injuries and related complications? As you know we prefer to perform in general cut down.
    Congratulations again for the beautiful demonstration of the utility of ch-EVAR in such demanding cases.

    Dr Gioele Simonte
    November 22, 2018

    Thank you very much Prof Donas, I’m very pleased to receive a comment on the case from a master of chimney technique like you.
    We used a 36 mm wide endurant graft which actually is the larger available, moreover we considered the fact that we are going to perform a triple chimney implant, thus we forecasted more than 30% oversizing (36 mm graft in 25-26 mm new neck). frankly I would pick the same sizes when facing a similar case. agree with me?
    Unfortunately going with more than two chimneys can lead to important gutters itself, like you already demonstrated….
    About the axillary accesses probably I didn’t explain clearly: we actually exposed the arteries surgically and performed a parallel double direct arterial puncture on each side (one access per vessel and one more for through and through wire).
    We tried in elective case axillary percutaneous access with satisfactory results but I would never perform it in an emergent case like this one

    Prof. Konstantinos Donas
    December 3, 2018

    Yes, I agree; in case of a single chimney in a 25mm neck I would consider 32mm, but for multiple chimneys then 36mm.
    Congratulations and warm regards

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