Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 316-327

2. Vascular Images & Techniques - Part 4

Date of Web Publication12-Sep-2020

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DOI: 10.4103/0972-0820.294903

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How to cite this article:
. 2. Vascular Images & Techniques - Part 4. Indian J Vasc Endovasc Surg 2020;7:316-27

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. 2. Vascular Images & Techniques - Part 4. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2022 Dec 7];7:316-27. Available from:

  2. Vascular Images & Techniques – Part 4 Top

Complex Aortic Aneurysm Repairs (continued from previous issue)

Aneurysm is a focal dilatation of 50% of the arterial diameter. The normal aortic diameter decreases from28mm in thoracic aorta to 20 mm in abdominal aorta. These aortic diameters are about 2mm smaller in females and perhaps in Indian population where the perceived diameter of the aorta can be 4 to 5 mm less than above. Majority aortic aneurysms are in infra renal aorta though 5 to 15% can extend above the renal arteries (supra renal) and juxta-renal is the term applied when the aneurysm arises less than 1 cm below the renal arteries. The second commonest site is the thoracic aorta. Majority of aneurysms are asymptomatic and size criteria have been defined where the rupture, the most dreaded and lethal complication of aneurysms, increases exponentially – this is 5.5 cm for AAA (Abdominal Aortic Aneurysm) and 6 cm for TAA (Thoracic Aortic Aneurysm) and TAAA (Thoraco Abdominal Aortic Aneurysms). All aneurysms reaching the above sizes and all symptomatic aneurysms irrespective of the size, and possibly saccular aneurysms (as opposed to usual fusiform) should be repaired, open, endovascular hybrid procedures, depending on several patient risk factors. The term “complex aneurysm” is applied to the repair which involves re-implantation of any visceral vessel or extends beyond routine repair. These are challenging and frequently, daunting, time consuming procedures. But when performed by well-trained vascular surgeon with excellent infra structure, the results are excellent. Here, in this and the next issue, we present pictorial depiction of several such patients who had complex thoracic, thoraco-abdominal and abdominal aortic aneurysms repair with surgical, endovascular and combined hybrid techniques. These procedures continue to evolve and showcase the ingenuity and innovation of these specialists – EDITORS

1. Dr. P C Gupta, Dr. A Gnaneswar, Dr. Venugopal Kulkarni, Dr. Y Vamsi Krishna, Dr. Pritee Sharma, Dr. B Pradeep, Dr. A Viswanath, Hyderabad

Title: Rapidly enlarging Suprarenal inflammatory aortic aneurysm with renal dysfunction

Case summary: 54-year old female, hypertensive, presented with back pain and intermittent abdominal pain of two months duration. She was seen elsewhere two months back and diagnosed to have a small aortic aneurysm (3.5mm) with mesenteric ischemia and shrunken left kidney based on MR angiography and started on anticoagulation. Repeat non contrast MR angiography showed suprarenal AAA measuring 5.3mm with normal celiac artery and SMA and shrunken left kidney. [Figure 1] Right renal artery was not well seen. SMA was arising from the upper end of the aneurysm. A plain CT scan was done to better define the anatomy. [Figure 2] DSA with minimal contrast was done to assess the right renal artery.

All investigations were normal except for a baseline serum creatinine of 2.5mg/dl.

Surgery: Thoracoabdominal retroperitoneal approach [Figure 4] with circumferential division of diaphragm. Tissues were grossly inflamed. Descending thoracic aorta and abdominal aorta above bifurcation controlled. Left common femoral artery also exposed. Heparinized.

Temporary shunt was created by cannulating the descending thoracic aorta and left CFA. A branch was taken from the shunt and two carotid balloon shunts were attached for visceral perfusion: celiac axis, SMA and right renal artery. 20mm Dacron graft used: proximal anastomosis included the visceral arteries and distal anastomosis was at aortic bifurcation. Standard closure over ICD was done. She had an uneventful recovery and was discharged on 6th post-operative day. Serum creatinine at discharge and during follow up (2 months) has been less than 2.5mg/dl.


  1. Single kidney with renal dysfunction
  2. Did not do contrast CT angiography to avoid nephropathy
  3. Inflammatory aneurysm was a on table surprise

2. Dr.P. Shivanesan, Dr. Vineeth Kumar, Dr. Ashutosh Pandey, Dr. Sriram, Dr. Neelam Sree Chitra Tirunal Institute, Trivandrum, Kerala

Case 1: B/l Iliac Artery Aneurysm in Operated case of Abdominal aortic Aneurysm

A 65 years male patient, a known case of infra renal abdominal aortic aneurysm; status post open repair 8 years back, now presented with pain abdomen. On evaluation he was diagnosed with bilateral common iliac artery aneurysm and left common femora artery aneurysm (During previous surgery only mild ectasia of Common Iliac Artery was noted). He was planned for redo laparotomy and repair of the aneurysm. Since the Iliac artery aneurysm was large and it was a redo laparotomy, we opted for bilateral Ureteric stent before surgery to ease in identifying ureters, so that inadvertent ureteric injury could be avoided. He underwent repair using 18 x 9 mm coated polyester graft (Proximal anastomosis into previous graft, Rt distal anastomosis into Rt CFA end - side and left distal anastomosis into Rt CFA bifurcation (end-end) and Lt internal iliac artery was bypassed from the Left limb of the graft. Patient made an uneventful post-operative recovery.

Case 2: Takayasu Arteritis with Thoraco abdominal aortic aneurysm

A 32 yr. old female, a known case of Takayasu arteritis, presented with lower limb claudication and back ache. Clinically lower limb pulses were absent. On CT there was a Large Type 3 TAAA with occlusion of Celiac Artery and SMA. There was large patent IMA supplying CA/SMA via collaterals. Also there was tight stenosis of aorta at the infra IMA level. She underwent open repair of the aneurysm along with reimplantation of the bilateral renal arteries and inferior mesenteric artery. Post-operative period was uneventful.

3. Sidharth Viswanathan, Sudhindran S; Dept of Vascular and Endovascular Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India.

Explanation and open repair for AAA following EVAR with late endoleak causing duodenal obstruction – lessons learnt though VSI Clinics

A 75 yr old hypertensive with CAD (S/P PTCA) presented with an enlarging abdominal lump associated with inability to tolerate oral feeds and vomiting suggestive of gastric/duodenal outlet obstruction. He had undergone EVAR for infra-renal AAA 12 years back but was lost to follow-up. Clinically he was hemodynamically stable but had a large pulsatile aneurysmal mass in the abdomen [Figure 1].

On interrogation with CT angiography, an expanding AAA that now measured 12cm maximum diameter was noted (it was 6.5 cm at the time of initial EVAR). The distal duodenum was severely compressed between the aneurysm sac and parietals with gross dilatation of stomach and proximal duodenum suggestive of obstruction. [Figure 2]. There was evidence of Type I endoleak within the sac posterior to the stent graft [Figure 3].

To alleviate the pressure effect of the hugely dilated aneurysm sac it was deemed better to proceed with open repair instead of endovascular re-intervention. On the 3-D reconstructed image, the stent graft was found to be devoid of the supra-renal fixation bare stents (older generation stent graft) [Figure 4].

During laparotomy, duodenum was found severely adherent to the aneurysm wall and was freed with difficulty [Figure 5]. After successfully applying an inter-renal clamp (better lower right renal and higher left renal), sac was opened and thrombo-atheroma extracted. Considering the lack of supra-renal fixation and as we felt we had almost reached the top of the stent, we embarked to remove the stent graft completely. But as it was remarkably adherent, although we managed to extract the top end of the stent graft [Figure 6], the remnant proximal neck was traumatised and friable and was extremely challenging to complete a water-tight anastomosis. On the contrary, the iliac limbs were cut across at the iliac origins and the iliacs suture closed along with the inlayed stent graft. The distal anastomosis was performed onto EIA on the left and CFA on the right.

The patient made satisfactory recovery in the post-operative period with good relief of his GI obstructive symptoms. A follow-up CT angiography done 6 weeks later showed satisfactory post-repair status [Figure 7].

Certain insights and suggestions that was made in VSI clinics after discussing this case is presented below:

- In may not always be necessary to explant the stent graft on surgical conversion for correction of type1 endoleaks. If the proximal neck and the common iliac arteries can be successfully looped, a constriction on the neck from outside onto the stent graft can be attempted using an umbilical tape. If successful, the sac can be opened just for decompression and buttressing to reduce the obstructive effect. If unsuccessful, one can always proceed with the intended explantation.

- It is probably safer to avoid trying to explant the stent graft in entirety. The stent graft can be cut using wire cutters or heavy scissors, like it was done at the distal end. This has the added advantage of providing an 'internal pledget' effect for securely suturing the new graft and avoiding further tissue loss.

- Always consider sending the aneurysm sac contents and stent graft for culture. Low grade infections can be a surprising finding.

- In cases of obvious stent graft infection, then total removal of the stent graft material and clos ure of the aortic stump is warranted, followed by extra-anatomical bypass as there is no safe scope of 'in-situ repair'.

4. Prof. Unnikrishnan, Trivandrum, Kerala

76yr old retired Government officer presented with symptoms of chest discomfort since 2 months Cardiac evaluation was unremarkable and Contrast Enhanced CT Aortography showed Thoracic aortic aneurysm beginning at distal aortic arch involving entire descending thoracic aorta extending up to infra celiac abdominal aorta.[Fig 1 a &b]

In view of his age and extensive aneurysmal domain he received Hybrid Arch and DTA aortic relining from zone 1 till below coeliac axis. Partial debranching was performed prior by Carotid to Carotid and subclavian bypass for optimal proximal sealing zone and coeliac axis was preserved using chimney[periscope] covered stent

Check study at 2 years postop shows intact repair and normal hepatic perfusion

At 5 years post procedure pt is keeping good health and having good quality of life

5. Dr (Col) Vikram Patra ; Army Hospital (R&R); Delhi Cantt, New Delhi

AAA open repair with Internal iliac artery reimplantation:

54 year old male, chronic Smoker, hypertensive,

Presented with Progressively increasing pulsatile abdominal lump for 06 months, not associated with anorexia/weight loss/abdominal angina. No H/o claudication/chest pain

On Examination: Vitals stable. All peripheral pulses palpable. ABI – 1 (Bilateral)

P/A: Lump noted in epigastric & Rt lumbar region, 12x10 cm, non-tender, ill defined, pulsatile, bruit heard over the lump. No organomegaly or free fluid. Bowel sounds normal.

2 D Echo: No RWMA, No MR, Trivial TR, No PE/ clot; LVEF- 60%.

CAG - large LCA aneurysm, managed conservatively by Cardiologist

CT Angiogram - Fusiform aneurysm of Juxta renal abdominal aorta involving bilateral common iliac arteries extending up to bifurcation on both sides for a length of 24 mm. The dilated aortic segment measures 14 cm in length with maximum diameter of 9.1 cm.

Management: Bilateral DJ stent placement on 21/01/2020.

He underwent Open Abdominal Aortic Aneurysmorrhaphy + End to End Aorto Bi Iliac Dacron graft (20X10 mm) from Juxta renal Aorta to bilateral external Iliac+ Reimplantation of left Internal Iliac Artery over graft (End to side) done under GA.

Per-op findings – large juxta renal abdominal aortic aneurysm involving bilateral common iliac and extending up to bifurcation on both sides.

Postoperatively - DJ stent removal done after 01 week of surgery.


6. Drs. Vivekananda, Vishnu M. Sumanth Raj, Roshan Rodney, Hemanth Chaudhari, JIVAS, Bengaluru

EVAR with Chimney Stent Grafts to bilateral renal arteries

70 year old male patient presented to us with complaints of pain abdomen since 3 months for which he was evaluated with ultrasound of abdomen and pelvis, which revealed an abdominal aortic aneurysm. Patient has hypertension, diabetes mellitus since 10 years. He was a smoker -stopped 3 months

On examination patient had transmitted pulsations present in the epigastric and umbilical region with palpable bilateral lower limb pulses

CT angiogram done revealed the following findings - Infrarenal AAA maximum diameter of around 5.7cm

  • Proximal neck length is 7mm (infrarenal aortic neck length)
  • Length from SMA to right renal artery is measuring around 18mm
  • Left renal is lowest renal artery
  • Infra SMA aortic diameter - is around 21.5mm
  • Length from left renal to AI bifurcation is measuring around 120mm
  • Rt. Common iliac length is around 40mm (dia 8.3mm)
  • Left common iliac length is around 43mm (dia 7.3mm)

Since there was inadequate length of the neck of the aneurysm he underwent EVAR + bilateral renal artery chimney. The minimum required neck length is 10mm; Endograft in this case where the neck was 7mm would have covered both the renal arteries. Hence Two separate stent grafts were placed from bilateral arm approach to preserve bilateral renal flow.

Patient did well post operatively with normal renal functions and the AAA completely excluded without any endoleaks.


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