English Polski
Vol 24, No 1 (2018)
Case report
Published online: 2018-04-12

open access

Page views 1072
Article views/downloads 1034
Get Citation

Connect on Social Media

Connect on Social Media

Aorto-renal bifurcation stenting in a juvenile non-specific aorto-arteritis: case report

Amro Alsharabi1, Tomasz Jakimowicz1, Piotr Hammer2, Sławomir Nazarewski1
Acta Angiologica 2018;24(1):18-24.


Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major
branches with usual affliction among patients younger than 50 years and rarely among children. We present
a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between
right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of
left subclavian artery, left renal artery and juxtarenal aorta which was subsequently confirmed on aortogram.
He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood
pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial
lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

Article available in PDF format

View PDF Download PDF file


  1. Shennan T. Dissecting aneurysms. Stationery off. Oxford, London 1934.
  2. Stanson AW, Kazmier FJ, Hollier LH, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg. 1986; 1(1): 15–23.
  3. Murgo S, Dussaussois L, Golzarian J, et al. Penetrating atherosclerotic ulcer of the descending thoracic aorta: Treatment by endovascular stent-Graft. CardioVascular and Interventional Radiology. 1998; 21(6): 454–458.
  4. Park J, Chung J, Choo I, et al. Fenestrated Stent-Grafts for Preserving Visceral Arterial Branches in the Treatment of Abdominal Aortic Aneurysms: Preliminary Experience. Journal of Vascular and Interventional Radiology. 1996; 7(6): 819–823.
  5. Guillou M, Bianchini A, Sobocinski J, et al. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg. 2012; 56(1): 65–73.
  6. Verhoeven ELG, Vourliotakis G, Bos WT, et al. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010; 39(5): 529–536.
  7. Cook Medical. Zenith® t-Branch® Thoracoabdominal Endovascular Graft. 2017. https://www.cookmedical.eu/products/b50ed018-b896-4645-b24f-853a12dfff2c/.
  8. Coady M, Rizzo J, Hammond G, et al. Penetrating ulcer of the thoracic aorta: What is it? How do we recognize it? How do we manage it? Journal of Vascular Surgery. 1998; 27(6): 1006–1016.
  9. Eggebrecht H, Herold U, Schmermund A, et al. Endovascular stent-graft treatment of penetrating aortic ulcer: results over a median follow-up of 27 months. Am Heart J. 2006; 151(2): 530–536.
  10. Eggebrecht H, Plicht B, Kahlert P, et al. Intramural hematoma and penetrating ulcers: indications to endovascular treatment. Eur J Vasc Endovasc Surg. 2009; 38(6): 659–665.
  11. Vilacosta I. Acute aortic syndrome. Heart. 2001; 85(4): 365–368.
  12. Vilacosta I, San Román JA, Aragoncillo P, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol. 1998; 32(1): 83–89.
  13. Baikoussis NG, Apostolakis AA. Penetrating atherosclerotic ulcer of the thoracic aorta: diagnosis and treatment. Hellenic J Cardiol. 2010; 51(2): 153–157.
  14. Sundt TM. Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. Ann Thorac Surg. 2007; 83(2): S835–41; discussion S846.
  15. Cho K, Stanson A, Potter D, et al. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. The Journal of Thoracic and Cardiovascular Surgery. 2004; 127(5): 1393–1401.
  16. Macura KJ, Corl FM, Fishman EK, et al. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 2003; 181(2): 309–316.
  17. Romanowski Ł, Grochowiecki T, Szmidt J. Evaluation of the results of penetrating atherosclerotic ulcers surgical treatment. Journal of Vascular Surgery. 1993; 17(6): 1118–1119.
  18. Avlonitis VS, Bury RW, Duncan AJ, et al. Penetrating ulcer of the aortic arch presenting with hemoptysis. J Thorac Cardiovasc Surg. 2009; 137(1): e10–e12.
  19. Chandrashekar G, Kumar VMN, Kumar AK. Repair of aortoesophageal fistula due to a penetrating atherosclerotic ulcer of the descending thoracic aorta and literature review. J Cardiothorac Surg. 2007; 2: 12.
  20. De Bakey ME. Segmental thrombo-obliterative disease of branches of aortic arch. Journal of the American Medical Association. 1958; 166(9): 998.
  21. Diethrich E, Garrett H, Ameriso J, et al. Occlusive disease of the common carotid and subclavian arteries treated by carotid-subclavian bypass. Am J Surg. 1967; 114(5): 800–808.
  22. AbuRahma AF, Robinson PA, Jennings TG. Carotid-subclavian bypass grafting with polytetrafluoroethylene grafts for symptomatic subclavian artery stenosis or occlusion: a 20-year experience. J Vasc Surg. 2000; 32(3): 411–418.
  23. Owens LV. Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks. J Vasc Surg. 1995; 22(3): 217–221.
  24. Wittwer T, Wahlers T, Dresler C, et al. Carotid-subclavian bypass for subclavian artery revascularization: long-term follow-up and effect of antiplatelet therapy. Angiology. 1998; 49(4): 279–287.
  25. Ziomek S, Quiñones-Baldrich WJ, Busuttil RW, et al. The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass. J Vasc Surg. 1986; 3(1): 140–145.
  26. Matsumura JS, Lee WA, Mitchell RS, et al. Society for Vascular Surgery. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 2009; 50(5): 1155–1158.
  27. Conrad M, Crawford R, Davison J, et al. Thoracoabdominal Aneurysm Repair: A 20-Year Perspective. Ann Thorac Surg. 2007; 83(2): S856–S861.
  28. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007; 83(2): S862–4; discussion S890.
  29. Schepens MA, Heijmen RH, Ranschaert W, et al. Thoracoabdominal aortic aneurysm repair: results of conventional open surgery. Eur J Vasc Endovasc Surg. 2009; 37(6): 640–645.
  30. Chuter TAM, Rapp JH, Hiramoto JS, et al. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg. 2008; 47(1): 6–16.
  31. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008; 118(8): 808–817.
  32. Reilly L, Rapp J, Grenon M, et al. Branched Thoracoabdominal Aortic Aneurysm Repair: Efficacy and Durability of the Caudally Directed Cuff Technique. Journal of Vascular Surgery. 2011; 54(2): 588.
  33. Verhoeven EL, Tielliu IF, Bos WT, et al. Present and future of branched stent grafts in thoraco-abdominal aortic aneurysm repair: a single-centre experience. Eur J Vasc Endovasc Surg. 2009; 38(2): 155–161.
  34. Oderich GS, Reilly L. Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts. J Thorac Cardiovasc Surg. 2017; 153(2): S32–S41.
  35. Chuter TA, Gordon RL, Reilly LM, et al. An endovascular system for thoracoabdominal aortic aneurysm repair. J Endovasc Ther. 2001; 8(1): 25–33.
  36. Austermann M, Donas KP, Panuccio G, et al. Pararenal and thoracoabdominal aortic aneurysm repair with fenestrated and branched endografts: lessons learned and future directions. J Endovasc Ther. 2011; 18(2): 157–160.
  37. Bisdas T, Donas KP, Bosiers M, et al. Anatomical suitability of the T-branch stent-graft in patients with thoracoabdominal aortic aneurysms treated using custom-made multibranched endografts. J Endovasc Ther. 2013; 20(5): 672–677.
  38. Hammer P, Jakimowicz T, Romanowski L, et al. Application of Zenith t-Branch system in symptomatic thoracoabdominal aortic aneurysm with unfavourable anatomy — case report. Acta Angiologica. 2015; 21(2): 47–52.
  39. Mastracci TM, Eagleton MJ. Endovascular repair of type II and type III thoracoabdominal aneurysms. Perspect Vasc Surg Endovasc Ther. 2011; 23(3): 178–185.
  40. Sweet M, Hiramoto J, Park KH, et al. A standardized multi-branched thoracoabdominal stent-graft for endovascular aneurysm repair. J Endovasc Ther. 2009; 16(3): 359–364.
  41. Bisdas T, Donas KP, Bosiers M, et al. One-year follow-up after total endovascular repair of a contained-ruptured thoracoabdominal aortic aneurysm with the sandwich technique. J Vasc Surg. 2013; 58(2): 482–485.
  42. Gasper WJ, Reilly LM, Rapp JH, et al. Assessing the anatomic applicability of the multibranched endovascular repair of thoracoabdominal aortic aneurysm technique. J Vasc Surg. 2013; 57(6): 1553–1558.
  43. Bosiers MJ, Bisdas T, Donas KP, et al. Early experience with the first commercially available off-the-shelf multibranched endograft (t-branch) in the treatment of thoracoabdominal aortic aneurysms. J Endovasc Ther. 2013; 20(6): 719–725.
  44. Bisdas T. Custom-made versus off-the-shelf multibranched endografts for endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2014; 60(5): 1392.
  45. Banga PV, Oderich GS, Reis de Souza L, et al. Neuromonitoring, cerebrospinal fluid drainage, and selective use of iliofemoral conduits to minimize risk of spinal cord injury during complex endovascular aortic repair. J Endovasc Ther. 2016; 23(1): 139–149.
  46. Dias NV, Sonesson B, Kristmundsson T, et al. Short-term Outcome of Spinal Cord Ischemia after Endovascular Repair of Thoracoabdominal Aortic Aneurysms. Journal of Vascular Surgery. 2015; 61(4): 1101.
  47. Katsargyris A, Oikonomou K, Kouvelos G, et al. Spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms with fenestrated and branched stent grafts. J Vasc Surg. 2015; 62(6): 1450–1456.
  48. Maurel B, Haulon S. Re: ‘The Impact of Early Pelvic and Lower Limb Reperfusion and Attentive Peri-operative Management on the Incidence of Spinal Cord Ischemia During Thoraco-abdominal Aortic Aneurysm Endovascular Repair’. Eur J Vasc Endovasc Surg. 2015; 49(3): 248–254.
  49. O'Callaghan A, Mastracci TM, Eagleton MJ. Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia. J Vasc Surg. 2015; 61(2): 347–354.e1.
  50. Drinkwater SL, Goebells A, Haydar A, et al. Regional Vascular Unit, St Mary's Hospital, Imperial College NHS Trust. The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention. Eur J Vasc Endovasc Surg. 2010; 40(6): 729–735.
  51. Bisdas T, Panuccio G, Sugimoto M, et al. Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2015; 61(6): 1408–1416.
  52. Chang CK, Chuter TAM, Reilly LM, et al. Spinal arterial anatomy and risk factors for lower extremity weakness following endovascular thoracoabdominal aortic aneurysm repair with branched stent-grafts. J Endovasc Ther. 2008; 15(3): 356–362.
  53. Mehmedagic I, Resch T, Acosta S. Complications to cerebrospinal fluid drainage and predictors of spinal cord ischemia in patients with aortic disease undergoing advanced endovascular therapy. Vasc Endovascular Surg. 2013; 47(6): 415–422.
  54. Roselli EE, Greenberg RK, Pfaff K, et al. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007; 133(6): 1474–1482.