Delayed endovascular revascularization of renal artery bridging stent occlusion after complex Endovascular aortic repair

Delayed endovascular revascularization of renal artery bridging stent occlusion after complex Endovascular aortic repair | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delayed endovascular revascularization of renal artery bridging stent occlusion after complex Endovascular aortic repair Stevo Duvnjak, Kim Kargaard Bredahl, Antonia Rinaldi, Timothy Andrew Resch This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8512489/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Complex aortic endovascular procedures are the preferred treatment for thoracoabdominal aortic disease. One potential complication is target vessel instability (including stenosis and thrombosis), particularly in renal arteries targeted by branches. Materials and Methods This is a retrospective analysis of patients treated between October 2019 and November 2024 at a tertiary referral center and who experienced occlusion of one or both renal bridging stents. Technical success was defined as successful recanalization of the occluded renal bridging stent graft with restoration of flow into the renal and segmental renal artery branches. Clinical success was defined as the patient being free from dialysis and improvement in renal function in patients without dialysis. Results Eleven patients underwent renal artery endovascular recanalization for bridging stent graft thrombosis. None of the study patients were on dialysis preoperatively and they had either normal renal function or mild renal impairment. Six patients (54%) presented with either a contained aortic rupture or an aneurysm size >8 cm and were treated acute/subacute using an off-the-shelf stent graft, four patients (36%) received custom-made devices, one patient was treated with fenestrated cuff. The mean age was 68.7 ± 5 years, and nine patients (81%) were male. The main symptoms included anuria in nine patients (81%), nausea, diarrhea, and abdominal flank pain in ten patients (90%). All patients experienced delayed renal ischemia of more than 24 hours from diagnosis to treatment initiation, ranging from 24 to 96 hours, with a mean of 27.2 hours. The mean time from index operation to renal stent graft thrombosis was 10.4 months (range 2–48 months). Technical success was achieved in 85% of cases. Perioperative complications occurred in 18% of patients. Nine patients (81%) required dialysis after intervention; in 73% of these cases, dialysis was temporary, while three patients (27%) required permanent dialysis. The cause of renal stent graft occlusion could not be determined in 55% of patients. The median follow-up after recanalisation was 18.5 months (IQR, 0-33). Conclusion Renal bridging stent graft thrombosis is not infrequent, and treatment is challenging. It seems to be more frequent in the emergent setting when IFU violations may play a role. The use of inner branch configurations was also overrepresented in our series. Delayed renal stent graft recanalization is a relatively safe and prolonged occlusion time alone should not be the deciding factor in pursuing recanalization. Instead, we advocate for a more aggressive approach in cases of renal stent graft thrombosis particularly when signs of kidney perfusion remain. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Complex aortic endovascular procedures including fenestrated (FEVAR) and branched repair (BEVAR), is the preferred treatment for thoracoabdominal aortic disease due to lower morbidity and mortality rates compared to open surgery [ 1 ]. One potential complication is target vessel stenosis and thrombosis, particularly in renal arteries targeted by branches [ 2 ]. According to the literature, the incidence of renal bridging stent thrombosis is approximately 9% during medium-term follow-up and increases to 13% in BEVAR cases [ 2 , 3 ]. Renal stent graft thrombosis is especially concerning in patients with bilateral disease or those with a single functioning kidney. In previous studies, renal ischemia lasting more than six hours was considered beyond salvage and attempts at renal reperfusion might be harmful [ 4 ]. Consequently, patients with prolonged renal ischemia are often considered as ineligible for interventions aimed at restoring renal function. However, some studies report successful outcomes following delayed (> 6 hours) treatment of renal stent graft thrombosis after BEVAR [ 5 , 6 ]. However, there is still no consensus on the optimal timing or method of treatment, largely due to limited data and small patient cohorts. The primary aim of this study is to evaluate and analyze the technical success and short-term clinical outcome of delayed recanalization of renal artery occlusion after endovascular repair of complex aneurysms. Materials and Methods This is a retrospective analysis of patients treated with F/BEVAR between October 2019 and November 2024 at a tertiary referral center and who experienced occlusion of one or both renal bridging stents. All patients presented with imaging confirmed thrombosis or occlusion of the renal artery bridging stent graft. Technical success was defined as successful recanalization of the occluded renal bridging stent graft with restoration of flow into the renal and segmental renal artery branches, even if residual thrombus remained visible. Clinical success was defined as the patient being free from dialysis (for patients who had required dialysis) and return of renal function to baseline niveau. The need for temporary and permanent dialysis was recorded. Renal function was assessed at baseline before index intervention, during admission when renal artery occlusion occurred, and throughout recovery and follow-up using the changes in estimated glomerular filtration rate (eGFR) and the difference in creatinine levels. Renal function impairment was classified according to the chronic kidney disease (CKD) classifications [ 7 ]. Data on type of aortic stent graft and type of bridging stent used for primary treatment, onset of symptoms and time to intervention, access route, type of intervention, technical success, complications, mortality, secondary interventions, and maximum follow-up duration were recorded. Ethical approval was waived by the regional ethics committee. The study was considered a quality control study and approved by the center for patient journal data (Center for journal data). Statistical analysis Normally distributed variables are presented as mean and range and non-normally distributed variables as median and interquartile range (IQR). Categorical variables are presented as numbers and percentages. Paired Students t-test was used for statistical analysis, and a p-value < 0.05 was considered statistically significant. Results Between 2019 and 2024, 363 patients were treated with FEVAR/BEVAR. Eleven patients underwent renal artery endovascular recanalization for bridging stent graft thrombosis and were included in the current analysis. None of the study patients were on dialysis preoperatively and they had either normal renal function or mild renal impairment according to the CKD classification. Four patients (36%) had normal > 90 mL/min/1.73 m 2 eGFR, and seven patients (64%) had mildly impaired renal function eGFR 40 mL/min/1.73 m 2 (CKD: 1–3). Demographic baseline data and indications for treatment are listed in Table 1. All patients were on either acetylsalicylic or clopidogrel medication upon discharge after F/BEVAR. Six patients (54%) presented with either a contained aortic rupture or an aneurysm size > 8 cm and were treated acute/subacute using an off-the-shelf COOK T-branch device (COOK Medical, Bjaevreskov, Denmark); four patients (36%) received custom-made devices with inner branches (Artivion, Hechingen, Germany); one patient (9%) was treated with a custom-made devices fenestrated cuff (COOK Medical Inc, Bjaevreskov, Denmark) due to type 1 endoleak after previous EVAR. Indications for treatment and type of stent graft are listed in Table 2. The mean age was 68.7 ± 5 years, and nine patients (81%) were male. Contrast-enhanced CT scans confirmed renal stent graft thrombosis in all cases (Fig. 1). The main symptoms included anuria in nine patients (81%), nausea, diarrhoea, and abdominal flank pain in ten patients (90%). All patients experienced delayed renal ischemia of more than 24 hours from diagnosis to treatment initiation, ranging from 24 to 96 hours, with a mean of 27.2 hours. Four patients (36%) had a single functioning kidney due to previous asymptomatic renal stent graft thrombosis in the contralateral artery. Four patients (36%) had bilateral renal stent graft thrombosis or occlusion. Three patients (27%) had a solitary kidney after prior nephrectomy at the time of the primary repair. The mean time from index FEVAR/BEVAR to renal stent graft thrombosis was 10.4 months (range 2–48 months). Technical success, defined as restoration of renal artery patency after recanalization, was achieved in 85% of cases (Fig. 2). Two patients (15%) with bilateral bridging stent graft occlusion had only one renal bridging stent successfully reopened. Perioperative complications occurred in 18% of patients, including bleeding from a renal segmental branch during recanalization caused by guide wire perforation which required perioperative embolisation (Fig. 3). Another patient experienced local brachial access bleeding and hematoma requiring open surgery. Seven patients (63%) underwent relining with a new stent graft and/or bare metal stent combined with simple manual aspiration thrombectomy. Two patients were treated with thrombolysis using alteplase at 0.5 mg/hour followed by relining. One patient underwent endovascular thrombectomy with Penumbra Indigo (Alameda, California) device followed by relining. A single patient had a satisfactory outcome after thrombolysis alone, with no relining required. In Table 2, the type of intervention and materials used during renal recanalization are listed. Femoral access was used in nine patients (82%) and brachial access in two (18%). There was no perioperative mortality. An overview of perioperative complications and the used material is presented in Table 3. Overall mortality during the follow-up period was 18%. One patient died within 30 days due to multiple organ failure, and another died two months post-recanalisation from intracerebral bleeding of unknown cause, the patient received dual antiplatelet drugs scheduled for three months after recanalization. Nine patients (81%) required dialysis after intervention; in 73% of these cases, dialysis was temporary, while three patients (27%) required permanent dialysis. Mean value of eGFR before primary operation was 76 mL/min/1.73 m 2 (range:51–90). Mean eGFR was 8.9 mL/min/1.73 m 2 (range:8–40) at the acute event with renal thrombosis, and mean eGFR after recanalization in follow-up was 27.8 mL/min/1.73 m 2 (range:5–49). Mean creatinine before primary operation was 87.5 µmol/L (range:53–161), creatinine value at renal graft event thrombosis was 627 µmol/L (range: 159–1530), and in follow-up, the mean value was 250 µmol/L(range:94–612). Significant deterioration of renal function in all cases occurred and remained significantly reduced compared with baseline renal function in the follow-up period, calculated by eGFR (p < 0.001) and creatinine course (p < 0.001). Changes in eGFR and creatinine values before, at renal graft thrombosis and after recanalization are presented in Fig. 4 and Fig. 5. The cause of renal stent graft occlusion could not be determined in 55% of patients. In 45% (n = 5), occlusion was attributed to mechanical stent compression (n = 4) or discontinuation of dual antiplatelet therapy due to scheduled biopsy (patient = 1). The median follow-up after recanalisation was 18.5 months (IQR, 0–33). No secondary interventions on renal stent grafts were required during follow-up, and no mortality. Discussion We present our experience with recanalization of delayed renal artery bridging stent graft thrombosis after B/FEVAR, achieving an improved clinical outcome in 73% of patients and avoiding chronic dialysis in 70% of patients treated despite renal ischemia time exceeding 24 hours in all cases. 10/11 patients presenting had BEVAR and 6/11 were originally treated in an urgent setting. Overall, 81% of patients required dialysis during the treatment phase of rencanalization, but in 73% of those, it was temporary. Improvement in quality of life is a key outcome for these patients, and with a relatively simple and fast endovascular procedure, renal function can be restored to a sufficient level to permit dialysis-free living. However, significant impairment in renal function was observed in nearly all patients, and a future episode of renal thrombosis may likely result in permanent dialysis dependency. The published literature reports ischemia times ranging from a few hours to more than 24 hours, with most cases achieving high technical success rates and low complication rates. Collateral flow from lumbar and other vessels is thought to provide some kidney perfusion in cases of main renal artery thrombosis [ 5 , 6 ]. From a clinical perspective, the appearance of contrast in either the renal parenchyma or in the renal artery distal to the occlusion can be used as a sign of renal viability and thus serve as a basis for potential renal salvage. There is currently no consensus on the optimal technique for recanalization to rescue renal function. In the literature, various treatments have been reported, ranging from relining and aspiration thrombectomy to thrombolysis [ 2 , 3 , 5 – 7 ]. A combination of mechanical thrombectomy and relining likely represents the fastest and most reliable approach. With the availability of steerable sheaths, transfemoral access is now almost always feasible, reducing the risk of stroke associated with upper limb access. In our series, 2/11 patients experienced perioperative complications all of which were perioperatively managed without additional morbidity. Careful guidewire manipulation may help prevent such bleeding complications and the use of steerable sheaths reduce the need for upper limb access. In nearly half of the cases, the exact cause of bridging stent graft thrombosis could not be clearly identified, consistent with other reports. The most cited cause remains mechanical compression [ 5 , 6 ]. A recent publication reported a patency loss of 17% at 24 months and up to 41% at 48 months in cases involving inner-branched stent grafts [ 8 ]. In the current report, most cases were either after emergent cases using an off the shelf BEVAR or after CMD devices with inner branches. Only one case was seen after FEVAR despite this being the vastly predominant procedure at our center during the time. Longer bridging stents and motion during respiration are known risk factors for thrombosis. There is no universal follow-up protocol for these patients; instead, individual centers typically develop their own strategies. In our department, follow-up imaging is performed at 3 months post-op, and then annually. It is difficult to argue that more frequent follow-up would reliably detect early thrombosis before complete occlusion, so a universal prevention strategy remains elusive. Cone-beam CT (CBCT) is an important part of these procedures and is strongly recommended. In our series, we did not perform any additional interventions based on CBCT findings, although the literature reports that up to 17% clinically significant structural issues can be detected on CBCT after FEVAR [ 9 ]. The inner diameter of the aorta at the visceral segment is a critical factor; when the diameter is < 24 mm, the risk of bridging stent graft compression increases. However, in acute situations, real-world clinical judgment often necessitates proceeding with less-than-ideal anatomy to save lives. Technical success rates are high both in the literature and in our experience, but in 15% of cases, we were unable to recanalize the thrombosed renal stent graft. Stent graft thrombosis can occur both early and late after FEVAR/BEVAR, necessitating lifelong surveillance and a low threshold for secondary intervention if any sign of compression is noted on follow-up CT imaging. In our cohort, bilateral renal bridging stent graft thrombosis occurred in 36% of patients. However, in half of those cases, emergency treatment was indicated. This rise question about violating instruction for use in such cases and eventually escalating in antithrombotic medications at least in the first months after procedure. However, small number of patients allow us not to draw some conclusion rather to initiate further discussion and data accumulation and present limitation of the study. Conclusion Renal bridging stent graft thrombosis is not infrequent, and treatment is challenging. It seems to be more frequent after BEVAR use particularly in the emergent setting when IFU violations may play a role. The use of inner branch configurations was also overrepresented in our series. Delayed renal stent graft recanalization is a relatively safe and efficient intervention that can preserve residual renal function and improve quality of life. Prolonged occlusion time alone should not be the deciding factor in pursuing recanalization. Instead, we advocate for a more aggressive approach in cases of renal stent graft thrombosis particularly when signs of kidney perfusion remain. Declarations Ethics approval and consent to participate- Not applicable Consent for publication: -Not applicable Funding: No Authors' contributions: All Authors provide significant contribution trough all phase of manuscript and all part of manuscript. Acknowledgements: Not Applicable Availability of data and material: Yes Competing interests: TR- Medtronic, Bentley, COOK, Artivion. No other authors have conflict of interest. References O’Donnell TFX, Boitano LT, Deery SE, Schermerhorn ML, Schanzer A, Beck AW et al (2020) Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms. Ann Surg 271:969e77 Eagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y (2016) Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg 63:930–942 Pini R, Faggioli G, Gallitto E, Mascoli C, Fenelli C, Ancetti S et al (2020) The different effect of branches and fenestrations on early and long-term visceral vessel patency in complex aortic endovascular repair. J Vasc Surg 71:1128–1134 Blum U, Billmann P, Krause T, Gabelmann A, Keller E, Moser E et al (1993) Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion. Radiology 189:549–554 Heidemann F, Kölbel T, Debus ES, Diener H, Carpenter SW, Rohlffs F et al (2018) Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching. J Endovasc Ther 25:466–473 Konstantinou N, Kölbel T, Dias NV, Verhoeven E, Wanhainen A, Gargiulo M et al (2021) Revascularization of occluded renal artery stent grafts after complex endovascular aortic repair and its impact on renal function. J Vasc Surg 73:1566–1572 KCW Group (2013) KDIGO 2012 clinical practice guideline for the evaluationand management of chronic kidney disease. Kidney Int Suppl 3:1–150 Torrealba JI, Panuccio G, Nana P, Giordano A, Al Sarhan DY, Kölbel T (2025) Midterm single-center results with the use of custom-made endografts with inner branches, a call for attention. J Vasc Surg 81:310–317 Berczeli M, Jirström W, Mohammed Y, Karelis A, Sonesson B, Dias NV (2025) Plain cone beam computed tomography during fenestrated endovascular aortic repair minimizes secondary interventions due to structural defects. J Vasc Surg ; 12:S0741-5214(25)01598-8. Tables Table 1 Demographic characteristics, baseline eGFR function and treatment type. Value Number (%) Age Male 68 9 (81%) Hearth comorbidities (coronary ischemia/ congestive heart diseases 7 (70%) COPD-chronic obstructive lung disease 4 (40%) Hypertension arterials 11 (100%) Diabetes mellitus 3 (30%) eGFR > 90 ml/min 4 (36%) eGFR 40 ml/min 7 (64%) eGFR < 40 ml/min 0 Emergency FEVAR/BEVAR 6 (54%) Elective FEVAR /BEVAR 5 (46%) Table 2 Overview about Aortic diseases type and used stent graft during index operation. Type of aortic disease / Number (%) Type of used FEVAR/BEVAR stent graft Number/% Type of used bridging renal stent-index operation Iuxtarenal AAA 1 (10%) T Branch COOK Medical of the shelf 6 (50%) VBX (GORE)- 6 mm BE GRAFT (Bentley Innomed) -6 mm Endoleak type 1 a after previously EVAR 1 (10%) Fenestrated COOK Medical aortic cuff- 4 fenestration 1 (10%) ADVANTA (GETINGE) -6 mm THAA typ1 and 2 2 (20%) E-nside, Artivion Inner branch stent graft 2 (20%) VIABAHN (GORE) -6 mm BE GRAFT (Bentley Innomed) − 6 and 7 mm THAA type 3 and 4 6 (50%) E-nside, Artivion Inner branch stent graft 1 (10%) VBX-GORE − 6 and 7mm COVERA (BARD) -8 mm ADVANTA (GETINGE) -6 mm BE GRAFT (Bentley Innomed) − 6 and 7 mm Aortic dissection 1 (10%) E-nside, Artivion Inner branch stent graft 1 (10%) VBX (GORE)- 6 mm BE GRAFT (Bentley Innomed )- 6 mm Table 3 List of periprocedural complications and type of secondary interventions. Type of complications/number/% Type of interventions/number/% Type of used stent graft for religning Access site complication 1 (9%) Aspiration thrombectomy and stent graft religning 7 (64%) VIABAHN stent graft (GORE) Be graft (Bentley Innomed) Advanta stent graft (Getinge) Bleeding complications 1 (9%) Thrombolysis and religning 2 (18%) Dedicated thrombectomy devices and religning 1 (9%) Be graft (Bentley Innomed) Bare metal stent (Pulsar, Biotronic; EverFlex, Medtronic) Without complications 9 (82%) Solely thrombolysis 1 (9%) VBX stent graft (GORE) Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 08 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 06 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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06:13:50","extension":"png","order_by":32,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4832,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/4392e445df053247a5ee8de3.png"},{"id":100012434,"identity":"79683a34-5620-4bfd-a368-adee07f4193d","added_by":"auto","created_at":"2026-01-12 06:13:51","extension":"xml","order_by":33,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60615,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED25005570structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/fa37f3dd456982df5424e0d6.xml"},{"id":100362001,"identity":"b8dea419-398c-41bf-a6ba-3a43c6526bcc","added_by":"auto","created_at":"2026-01-16 07:46:02","extension":"html","order_by":34,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70012,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/da2ea7fd6af736dd6779d516.html"},{"id":100012398,"identity":"b214dfb3-f2a8-4890-a5b3-ce6aa0492655","added_by":"auto","created_at":"2026-01-12 06:13:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":185573,"visible":true,"origin":"","legend":"\u003cp\u003eContrast enhanced computed tomography axial reconstruction shows occluded left bridging renal stent graft (right side of image-arrow) after BEVAR and still visible contrast in segmental renal branches and in renal parenchyma (left side of image -arrow).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/e36f29f442fb6f27f3a5bda9.png"},{"id":100012401,"identity":"a289e323-6766-4cc9-9b51-2c91e4e3dbae","added_by":"auto","created_at":"2026-01-12 06:13:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269218,"visible":true,"origin":"","legend":"\u003cp\u003eBilateral renal bridging stent graft occlusion. Left renal stent graft could not be saved. Successful recanalization of occluded right renal bridging stent graft. Femoral access, mechanical thrombectomy and religning with VIABAHN stent graft and distally bare metal stent (arrow). Residual thrombus but achieved flow through the main renal artery and a few segmental arteries, considered as adequate.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/6a58b4c7acbc08c2254871f8.png"},{"id":100012405,"identity":"d98c528d-381b-4c43-828c-e3060e4a322d","added_by":"auto","created_at":"2026-01-12 06:13:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":241714,"visible":true,"origin":"","legend":"\u003cp\u003eThe same patient as in figure 2. A few hours patient became hemodynamic unstable and acute control CT scan showed hematoma in retroperitoneum and in right renal due to iatrogenic guidewire perforation. Angiographic images and embolization with coils of lower part of right kidney and arresting of bleeding. Still the patient recovery with temporary dialysis and actual is patient without dialysis.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/e8ca8e3847bd6debf6a4e331.png"},{"id":100361938,"identity":"60bf8e4d-8f77-412f-97b6-6ae7b22687a6","added_by":"auto","created_at":"2026-01-16 07:45:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":12514,"visible":true,"origin":"","legend":"\u003cp\u003eCurse of eGFR before FEVAR/BEVAR intervention, during acute renal occlusion and in the follow-up period. Significant deterioration of renal function, p\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/229ee29c546540dd011b18bb.png"},{"id":100361327,"identity":"2857c1f8-50b3-49ad-8d75-81e7ec02c4c1","added_by":"auto","created_at":"2026-01-16 07:44:57","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":83950,"visible":true,"origin":"","legend":"\u003cp\u003eCurse of eGFR before FEVAR/BEVAR intervention, during acute renal occlusion and in the follow-up period. \u0026nbsp;Significant increasing of creatinine level p\u0026lt;0-01.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/b658b9678a816d4be7e69b0d.png"},{"id":100381266,"identity":"e87162a4-ff0e-4ba3-be76-3fe9b6682748","added_by":"auto","created_at":"2026-01-16 10:37:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1303975,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8512489/v1/330db646-da50-4201-aeea-349a6ec7c051.pdf"}],"financialInterests":"","formattedTitle":"Delayed endovascular revascularization of renal artery bridging stent occlusion after complex Endovascular aortic repair","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplex aortic endovascular procedures including fenestrated (FEVAR) and branched repair (BEVAR), is the preferred treatment for thoracoabdominal aortic disease due to lower morbidity and mortality rates compared to open surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne potential complication is target vessel stenosis and thrombosis, particularly in renal arteries targeted by branches [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the literature, the incidence of renal bridging stent thrombosis is approximately 9% during medium-term follow-up and increases to 13% in BEVAR cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Renal stent graft thrombosis is especially concerning in patients with bilateral disease or those with a single functioning kidney.\u003c/p\u003e \u003cp\u003eIn previous studies, renal ischemia lasting more than six hours was considered beyond salvage and attempts at renal reperfusion might be harmful [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, patients with prolonged renal ischemia are often considered as ineligible for interventions aimed at restoring renal function. However, some studies report successful outcomes following delayed (\u0026gt;\u0026thinsp;6 hours) treatment of renal stent graft thrombosis after BEVAR [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, there is still no consensus on the optimal timing or method of treatment, largely due to limited data and small patient cohorts.\u003c/p\u003e \u003cp\u003eThe primary aim of this study is to evaluate and analyze the technical success and short-term clinical outcome of delayed recanalization of renal artery occlusion after endovascular repair of complex aneurysms.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis is a retrospective analysis of patients treated with F/BEVAR between October 2019 and November 2024 at a tertiary referral center and who experienced occlusion of one or both renal bridging stents. All patients presented with imaging confirmed thrombosis or occlusion of the renal artery bridging stent graft.\u003c/p\u003e\n\u003cp\u003eTechnical success was defined as successful recanalization of the occluded renal bridging stent graft with restoration of flow into the renal and segmental renal artery branches, even if residual thrombus remained visible. Clinical success was defined as the patient being free from dialysis (for patients who had required dialysis) and return of renal function to baseline niveau.\u003c/p\u003e\n\u003cp\u003eThe need for temporary and permanent dialysis was recorded. Renal function was assessed at baseline before index intervention, during admission when renal artery occlusion occurred, and throughout recovery and follow-up using the changes in estimated glomerular filtration rate (eGFR) and the difference in creatinine levels. Renal function impairment was classified according to the chronic kidney disease (CKD) classifications [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eData on type of aortic stent graft and type of bridging stent used for primary treatment, onset of symptoms and time to intervention, access route, type of intervention, technical success, complications, mortality, secondary interventions, and maximum follow-up duration were recorded.\u003c/p\u003e\n\u003cp\u003eEthical approval\u0026nbsp;was waived by the regional ethics committee. The study was considered a quality control study and approved by the center for patient journal data (Center for journal data).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eNormally distributed variables are presented as mean and range and non-normally distributed variables as median and interquartile range (IQR). Categorical variables are presented as numbers and percentages. Paired Students t-test was used for statistical analysis, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2019 and 2024, 363 patients were treated with FEVAR/BEVAR. Eleven patients underwent renal artery endovascular recanalization for bridging stent graft thrombosis and were included in the current analysis. None of the study patients were on dialysis preoperatively and they had either normal renal function or mild renal impairment according to the CKD classification. Four patients (36%) had normal\u0026thinsp;\u0026gt;\u0026thinsp;90 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e eGFR, and seven patients (64%) had mildly impaired renal function eGFR\u0026thinsp;\u0026lt;\u0026thinsp;90; \u0026gt;40 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e (CKD: 1\u0026ndash;3). Demographic baseline data and indications for treatment are listed in Table\u0026nbsp;1. All patients were on either acetylsalicylic or clopidogrel medication upon discharge after F/BEVAR.\u003c/p\u003e\n\u003cp\u003eSix patients (54%) presented with either a contained aortic rupture or an aneurysm size\u0026thinsp;\u0026gt;\u0026thinsp;8 cm and were treated acute/subacute using an off-the-shelf COOK T-branch device (COOK Medical, Bjaevreskov, Denmark); four patients (36%) received custom-made devices with inner branches (Artivion, Hechingen, Germany); one patient (9%) was treated with a custom-made devices fenestrated cuff (COOK Medical Inc, Bjaevreskov, Denmark) due to type 1 endoleak after previous EVAR. Indications for treatment and type of stent graft are listed in Table\u0026nbsp;2.\u003c/p\u003e\n\u003cp\u003eThe mean age was 68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5 years, and nine patients (81%) were male. Contrast-enhanced CT scans confirmed renal stent graft thrombosis in all cases (Fig.\u0026nbsp;1). The main symptoms included anuria in nine patients (81%), nausea, diarrhoea, and abdominal flank pain in ten patients (90%). All patients experienced delayed renal ischemia of more than 24 hours from diagnosis to treatment initiation, ranging from 24 to 96 hours, with a mean of 27.2 hours.\u003c/p\u003e\n\u003cp\u003eFour patients (36%) had a single functioning kidney due to previous asymptomatic renal stent graft thrombosis in the contralateral artery. Four patients (36%) had bilateral renal stent graft thrombosis or occlusion. Three patients (27%) had a solitary kidney after prior nephrectomy at the time of the primary repair.\u003c/p\u003e\n\u003cp\u003eThe mean time from index FEVAR/BEVAR to renal stent graft thrombosis was 10.4 months (range 2\u0026ndash;48 months).\u003c/p\u003e\n\u003cp\u003eTechnical success, defined as restoration of renal artery patency after recanalization, was achieved in 85% of cases (Fig.\u0026nbsp;2). Two patients (15%) with bilateral bridging stent graft occlusion had only one renal bridging stent successfully reopened.\u003c/p\u003e\n\u003cp\u003ePerioperative complications occurred in 18% of patients, including bleeding from a renal segmental branch during recanalization caused by guide wire perforation which required perioperative embolisation (Fig.\u0026nbsp;3). Another patient experienced local brachial access bleeding and hematoma requiring open surgery.\u003c/p\u003e\n\u003cp\u003eSeven patients (63%) underwent relining with a new stent graft and/or bare metal stent combined with simple manual aspiration thrombectomy. Two patients were treated with thrombolysis using alteplase at 0.5 mg/hour followed by relining. One patient underwent endovascular thrombectomy with Penumbra Indigo (Alameda, California) device followed by relining. A single patient had a satisfactory outcome after thrombolysis alone, with no relining required. In Table\u0026nbsp;2, the type of intervention and materials used during renal recanalization are listed. Femoral access was used in nine patients (82%) and brachial access in two (18%). There was no perioperative mortality. An overview of perioperative complications and the used material is presented in Table\u0026nbsp;3.\u003c/p\u003e\n\u003cp\u003eOverall mortality during the follow-up period was 18%. One patient died within 30 days due to multiple organ failure, and another died two months post-recanalisation from intracerebral bleeding of unknown cause, the patient received dual antiplatelet drugs scheduled for three months after recanalization.\u003c/p\u003e\n\u003cp\u003eNine patients (81%) required dialysis after intervention; in 73% of these cases, dialysis was temporary, while three patients (27%) required permanent dialysis.\u003c/p\u003e\n\u003cp\u003eMean value of eGFR before primary operation was 76 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e (range:51\u0026ndash;90). Mean eGFR was 8.9 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e (range:8\u0026ndash;40) at the acute event with renal thrombosis, and mean eGFR after recanalization in follow-up was 27.8 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e (range:5\u0026ndash;49). Mean creatinine before primary operation was 87.5 \u0026micro;mol/L (range:53\u0026ndash;161), creatinine value at renal graft event thrombosis was 627 \u0026micro;mol/L (range: 159\u0026ndash;1530), and in follow-up, the mean value was 250 \u0026micro;mol/L(range:94\u0026ndash;612).\u003c/p\u003e\n\u003cp\u003eSignificant deterioration of renal function in all cases occurred and remained significantly reduced compared with baseline renal function in the follow-up period, calculated by eGFR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and creatinine course (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Changes in eGFR and creatinine values before, at renal graft thrombosis and after recanalization are presented in Fig.\u0026nbsp;4 and Fig.\u0026nbsp;5.\u003c/p\u003e\n\u003cp\u003eThe cause of renal stent graft occlusion could not be determined in 55% of patients. In 45% (n\u0026thinsp;=\u0026thinsp;5), occlusion was attributed to mechanical stent compression (n\u0026thinsp;=\u0026thinsp;4) or discontinuation of dual antiplatelet therapy due to scheduled biopsy (patient\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\n\u003cp\u003eThe median follow-up after recanalisation was 18.5 months (IQR, 0\u0026ndash;33). No secondary interventions on renal stent grafts were required during follow-up, and no mortality.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe present our experience with recanalization of delayed renal artery bridging stent graft thrombosis after B/FEVAR, achieving an improved clinical outcome in 73% of patients and avoiding chronic dialysis in 70% of patients treated despite renal ischemia time exceeding 24 hours in all cases. 10/11 patients presenting had BEVAR and 6/11 were originally treated in an urgent setting.\u003c/p\u003e \u003cp\u003eOverall, 81% of patients required dialysis during the treatment phase of rencanalization, but in 73% of those, it was temporary. Improvement in quality of life is a key outcome for these patients, and with a relatively simple and fast endovascular procedure, renal function can be restored to a sufficient level to permit dialysis-free living. However, significant impairment in renal function was observed in nearly all patients, and a future episode of renal thrombosis may likely result in permanent dialysis dependency.\u003c/p\u003e \u003cp\u003eThe published literature reports ischemia times ranging from a few hours to more than 24 hours, with most cases achieving high technical success rates and low complication rates. Collateral flow from lumbar and other vessels is thought to provide some kidney perfusion in cases of main renal artery thrombosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. From a clinical perspective, the appearance of contrast in either the renal parenchyma or in the renal artery distal to the occlusion can be used as a sign of renal viability and thus serve as a basis for potential renal salvage.\u003c/p\u003e \u003cp\u003eThere is currently no consensus on the optimal technique for recanalization to rescue renal function. In the literature, various treatments have been reported, ranging from relining and aspiration thrombectomy to thrombolysis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A combination of mechanical thrombectomy and relining likely represents the fastest and most reliable approach. With the availability of steerable sheaths, transfemoral access is now almost always feasible, reducing the risk of stroke associated with upper limb access.\u003c/p\u003e \u003cp\u003eIn our series, 2/11 patients experienced perioperative complications all of which were perioperatively managed without additional morbidity. Careful guidewire manipulation may help prevent such bleeding complications and the use of steerable sheaths reduce the need for upper limb access.\u003c/p\u003e \u003cp\u003eIn nearly half of the cases, the exact cause of bridging stent graft thrombosis could not be clearly identified, consistent with other reports. The most cited cause remains mechanical compression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A recent publication reported a patency loss of 17% at 24 months and up to 41% at 48 months in cases involving inner-branched stent grafts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the current report, most cases were either after emergent cases using an off the shelf BEVAR or after CMD devices with inner branches. Only one case was seen after FEVAR despite this being the vastly predominant procedure at our center during the time. Longer bridging stents and motion during respiration are known risk factors for thrombosis. There is no universal follow-up protocol for these patients; instead, individual centers typically develop their own strategies. In our department, follow-up imaging is performed at 3 months post-op, and then annually. It is difficult to argue that more frequent follow-up would reliably detect early thrombosis before complete occlusion, so a universal prevention strategy remains elusive.\u003c/p\u003e \u003cp\u003eCone-beam CT (CBCT) is an important part of these procedures and is strongly recommended. In our series, we did not perform any additional interventions based on CBCT findings, although the literature reports that up to 17% clinically significant structural issues can be detected on CBCT after FEVAR [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The inner diameter of the aorta at the visceral segment is a critical factor; when the diameter is \u0026lt;\u0026thinsp;24 mm, the risk of bridging stent graft compression increases. However, in acute situations, real-world clinical judgment often necessitates proceeding with less-than-ideal anatomy to save lives.\u003c/p\u003e \u003cp\u003eTechnical success rates are high both in the literature and in our experience, but in 15% of cases, we were unable to recanalize the thrombosed renal stent graft. Stent graft thrombosis can occur both early and late after FEVAR/BEVAR, necessitating lifelong surveillance and a low threshold for secondary intervention if any sign of compression is noted on follow-up CT imaging.\u003c/p\u003e \u003cp\u003eIn our cohort, bilateral renal bridging stent graft thrombosis occurred in 36% of patients. However, in half of those cases, emergency treatment was indicated. This rise question about violating instruction for use in such cases and eventually escalating in antithrombotic medications at least in the first months after procedure. However, small number of patients allow us not to draw some conclusion rather to initiate further discussion and data accumulation and present limitation of the study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRenal bridging stent graft thrombosis is not infrequent, and treatment is challenging. It seems to be more frequent after BEVAR use particularly in the emergent setting when IFU violations may play a role. The use of inner branch configurations was also overrepresented in our series. Delayed renal stent graft recanalization is a relatively safe and efficient intervention that can preserve residual renal function and improve quality of life. Prolonged occlusion time alone should not be the deciding factor in pursuing recanalization. Instead, we advocate for a more aggressive approach in cases of renal stent graft thrombosis particularly when signs of kidney perfusion remain.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate-\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003e-Not applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo\u003c/p\u003e\u003ch2\u003eAuthors' contributions:\u003c/h2\u003e \u003cp\u003eAll Authors provide significant contribution trough all phase of manuscript and all part of manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e\u003ch2\u003eAvailability of data and material:\u003c/h2\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eCompeting interests: TR- Medtronic, Bentley, COOK, Artivion. No other authors have conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell TFX, Boitano LT, Deery SE, Schermerhorn ML, Schanzer A, Beck AW et al (2020) Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms. Ann Surg 271:969e77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y (2016) Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg 63:930\u0026ndash;942\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePini R, Faggioli G, Gallitto E, Mascoli C, Fenelli C, Ancetti S et al (2020) The different effect of branches and fenestrations on early and long-term visceral vessel patency in complex aortic endovascular repair. J Vasc Surg 71:1128\u0026ndash;1134\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum U, Billmann P, Krause T, Gabelmann A, Keller E, Moser E et al (1993) Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion. Radiology 189:549\u0026ndash;554\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeidemann F, K\u0026ouml;lbel T, Debus ES, Diener H, Carpenter SW, Rohlffs F et al (2018) Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching. J Endovasc Ther 25:466\u0026ndash;473\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKonstantinou N, K\u0026ouml;lbel T, Dias NV, Verhoeven E, Wanhainen A, Gargiulo M et al (2021) Revascularization of occluded renal artery stent grafts after complex endovascular aortic repair and its impact on renal function. J Vasc Surg 73:1566\u0026ndash;1572\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKCW Group (2013) KDIGO 2012 clinical practice guideline for the evaluationand management of chronic kidney disease. Kidney Int Suppl 3:1\u0026ndash;150\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorrealba JI, Panuccio G, Nana P, Giordano A, Al Sarhan DY, K\u0026ouml;lbel T (2025) Midterm single-center results with the use of custom-made endografts with inner branches, a call for attention. J Vasc Surg 81:310\u0026ndash;317\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerczeli M, Jirstr\u0026ouml;m W, Mohammed Y, Karelis A, Sonesson B, Dias NV (2025) Plain cone beam computed tomography during fenestrated endovascular aortic repair minimizes secondary interventions due to structural defects. J Vasc Surg ; 12:S0741-5214(25)01598-8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics, baseline eGFR function and treatment type.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003cp\u003e9 (81%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHearth comorbidities (coronary ischemia/ congestive heart diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD-chronic obstructive lung disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension arterials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026gt;\u0026thinsp;90 ml/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026lt;\u0026thinsp;90, \u0026gt;40 ml/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026lt;\u0026thinsp;40 ml/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency FEVAR/BEVAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective FEVAR /BEVAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview about Aortic diseases type and used stent graft during index operation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of aortic disease / Number (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of used FEVAR/BEVAR stent graft\u003c/p\u003e \u003cp\u003eNumber/%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType of used bridging renal stent-index operation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIuxtarenal AAA\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT Branch COOK Medical of the shelf\u003c/p\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVBX (GORE)- 6 mm\u003c/p\u003e \u003cp\u003eBE GRAFT (Bentley Innomed) -6 mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoleak type 1 a after previously EVAR\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFenestrated COOK Medical aortic cuff- 4 fenestration\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eADVANTA (GETINGE) -6 mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHAA typ1 and 2 2 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE-nside, Artivion Inner branch stent graft\u003c/p\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVIABAHN (GORE) -6 mm\u003c/p\u003e \u003cp\u003eBE GRAFT (Bentley Innomed) \u0026minus;\u0026thinsp;6 and 7 mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHAA type 3 and 4 6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE-nside, Artivion Inner branch stent graft\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVBX-GORE \u0026minus;\u0026thinsp;6 and 7mm\u003c/p\u003e \u003cp\u003eCOVERA (BARD) -8 mm\u003c/p\u003e \u003cp\u003eADVANTA (GETINGE) -6 mm\u003c/p\u003e \u003cp\u003eBE GRAFT (Bentley Innomed) \u0026minus;\u0026thinsp;6 and 7 mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic dissection 1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE-nside, Artivion Inner branch stent graft\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVBX (GORE)- 6 mm\u003c/p\u003e \u003cp\u003eBE GRAFT (Bentley Innomed )- 6 mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of periprocedural complications and type of secondary interventions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of complications/number/%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of interventions/number/%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType of used stent graft for religning\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess site complication\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAspiration thrombectomy and stent graft religning\u003c/p\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVIABAHN stent graft (GORE)\u003c/p\u003e \u003cp\u003eBe graft (Bentley Innomed)\u003c/p\u003e \u003cp\u003eAdvanta stent graft (Getinge)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding complications\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThrombolysis and religning\u003c/p\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003cp\u003eDedicated thrombectomy devices and religning\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBe graft (Bentley Innomed)\u003c/p\u003e \u003cp\u003eBare metal stent (Pulsar, Biotronic; EverFlex, Medtronic)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout complications\u003c/p\u003e \u003cp\u003e9 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolely thrombolysis\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVBX stent graft (GORE)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8512489/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8512489/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplex aortic endovascular procedures are the preferred treatment for thoracoabdominal aortic disease. One potential complication is target vessel instability (including stenosis and thrombosis), particularly in renal arteries targeted by branches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003cbr\u003e\n \u003c/strong\u003eThis is a retrospective analysis of patients treated between October 2019 and November 2024 at a tertiary referral center and who experienced occlusion of one or both renal bridging stents. Technical success was defined as successful recanalization of the occluded renal bridging stent graft with restoration of flow into the renal and segmental renal artery branches. Clinical success was defined as the patient being free from dialysis and improvement in renal function in patients without dialysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nEleven patients underwent renal artery endovascular recanalization for bridging stent graft thrombosis. None of the study patients were on dialysis preoperatively and they had either normal renal function or mild renal impairment. Six patients (54%) presented with either a contained aortic rupture or an aneurysm size \u0026gt;8 cm and were treated acute/subacute using an off-the-shelf stent graft, four patients (36%) received custom-made devices, one patient was treated with fenestrated cuff. The mean age was 68.7 ± 5 years, and nine patients (81%) were male. The main symptoms included anuria in nine patients (81%), nausea, diarrhea, and abdominal flank pain in ten patients (90%). All patients experienced delayed renal ischemia of more than 24 hours from diagnosis to treatment initiation, ranging from 24 to 96 hours, with a mean of 27.2 hours. \u0026nbsp;The mean time from index operation to renal stent graft thrombosis was 10.4 months (range 2–48 months). \u0026nbsp;Technical success was achieved in 85% of cases. \u0026nbsp;Perioperative complications occurred in 18% of patients. Nine patients (81%) required dialysis after intervention; in 73% of these cases, dialysis was temporary, while three patients (27%) required permanent dialysis. The cause of renal stent graft occlusion could not be determined in 55% of patients. The median follow-up after recanalisation was 18.5 months (IQR, 0-33).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRenal bridging stent graft thrombosis is not infrequent, and treatment is challenging. \u0026nbsp;It seems to be more frequent in the emergent setting when IFU violations may play a role. The use of inner branch configurations was also overrepresented in our series. Delayed renal stent graft recanalization is a relatively safe and prolonged occlusion time alone should not be the deciding factor in pursuing recanalization. Instead, we advocate for a more aggressive approach in cases of renal stent graft thrombosis particularly when signs of kidney perfusion remain.\u003c/p\u003e","manuscriptTitle":"Delayed endovascular revascularization of renal artery bridging stent occlusion after complex Endovascular aortic repair","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:13:45","doi":"10.21203/rs.3.rs-8512489/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-08T21:17:33+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T11:21:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T04:49:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2026-01-05T12:27:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"649a6aa2-6b84-49b7-8e95-a6685f42c937","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T13:59:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 06:13:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8512489","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8512489","identity":"rs-8512489","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}