Complete endovascular renal and visceral artery revascularization and exclusion of a ruptured type IV thoracoabdominal aortic aneurysm.

PURPOSE To present a technique for renal and visceral revascularization allowing complete endovascular treatment of a ruptured type IV thoracoabdominal aneurysm using devices already stocked in most centers performing endovascular aneurysm repair. TECHNIQUE Open arterial access is obtained to both common femoral arteries and the left subclavian artery (LSA). Access to the visceral and renal arteries is obtained through separate 8-F sheaths for each visceral and renal branch. Both visceral arteries (celiac trunk and superior mesenteric artery) are accessed through 2 separate sheaths placed into the LSA, and both renal arteries are accessed through 2 separate sheaths placed into the left common femoral artery. Corresponding covered stents are introduced and positioned in the celiac trunk, superior mesenteric artery, and both renal arteries but not deployed. The aortic stent-graft is then introduced and deployed through the right common femoral artery. Once the aneurysm exclusion is completed, the stent-grafts to the branches are deployed so that they are positioned between the aortic wall and the aortic stent-graft. Finally, the branch stent-grafts as well as the aortic stent-graft are fully expanded with balloon catheters inflated simultaneously as in the kissing balloon technique. CONCLUSION To our knowledge, no one has reported using this technique to successfully treat a ruptured thoracoabdominal aneurysm and revascularize all 4 major renovisceral arteries. A main advantage of this technique over use of branched stent-grafts is that it can be performed even in the emergency setting with devices that are in stock in most institutions performing endovascular aneurysm exclusion.