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Purpose: Emergent repair of paravisceral aortic aneurysms (pAAs) with in situ laser fenestration (ISLF) technique is associated with renovisceral ischemia. We describe two strategies of temporary gutter endoleak creation to ensure renovisceral perfusion during ISLF.

Technique: Two patients (79- and 83-year-old) presented with symptomatic pAA. A Cook Zenith Alpha endograft (Cook Medical LLC, Bloomington, IN, USA) was used in both cases. All visceral vessels were prestented to serve as guide markers. Prior to the deployment of the endograft, a Cook Flexor 8F-sheath (Cook Medical LLC, Bloomington, IN, USA) was placed in the superior mesenteric artery (SMA) (patient #1), and a 5 mm × 200 mm angioplasty Armada balloon (Abbott, Green Oaks, Illinois, USA) was placed between the endograft and the aortic wall (patient #2). Angiograms after visceral coverage confirmed perfusion of the renovisceral arteries through the intentional gutter endoleaks. Thereafter, ISLF and bridging stenting for SMA and the renal arteries were performed before the removal of the sheath or balloon to stop the gutter endoleak. Both patients did not experience any kind of perioperative complications.

Conclusions: The above-described techniques for gutter endoleak creation during emergent pAA repair with ISLF can potentially reduce reno visceral ischemia and increase the ISLF technique’s safety.

Clinical Impact: The ISLF technique for pAA repair typically requires coverage of the visceral arteries with unpredictable ischemia time until laser fenestrations are established. The gutter endoleak technique reduces the renovisceral ischemia and potentially increases the safety of the ISLF repair.