Off-label use of the Gore Excluder iliac branch endoprosthesis in association with the Rotarex S catheter to achieve total endovascular recanalization of an occluded aortobifemoral bypass

We describe a successful case of hybrid revascularization of a totally occluded aortobifemoral bypass with retrograde use of the Rotarex S catheter (BD) and complete relining with a Gore Excluder iliac branch endoprosthesis (W.L. Gore & Associates). The repair procedure was performed with femoral surgical access and percutaneous brachial access. Despite left renal artery endoclamping, after the final angiography, deployment of a covered stent in the left renal artery was needed because of residual thrombotic material at the vessel ostium. The procedure was completed with reconstruction using a common femoral artery Dacron graft and bilateral complete iliac surgical branch relining using self-expanding covered stents, with recovery of distal pulses.

Endovascular Treatment of an Abdominal Aortic FALSE Aneurysm with a Very Narrow Distal Aorta and Aortic Lumen Using an Iliac Branch Device

INTRODUCTION

A narrow distal aorta (NDA) makes endovascular aortic repair (EVAR) challenging and prone to immediate and late complications. We describe a case of an abdominal aortic false aneurysm (AAFA) with an NDA and iliac occlusive disease that was treated by an iliac branch device (IBD) placed at the aortic bifurcation.

CASE REPORT

A 76-year-old male patient suffering from severe bilateral calf claudication presented to our clinic. He had a history of ischemic heart disease, diabetes mellitus, and left colectomy for colon cancer. His workup revealed an AAFA with severe iliac occlusive disease. His aortic lumen and his aortic bifurcation were very narrow (10 mm) precluding a classic bifurcated EVAR. An open repair was not possible because of his multiple comorbidities. We successfully used an IBD by placing its Y configuration at the level of the aortic bifurcation, bridging the branch into one iliac artery with a balloon-expandable covered stent and extending the main component proximally up to the renal arteries with an aortic cuff.

CONCLUSIONS

Bifurcated EVAR may not be suitable in patients with an NDA. Using an IBD at the level of the aortic bifurcation is feasible. This technique offers a total endovascular solution in high-risk patients for open repair.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair

OBJECTIVE

The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0 mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR).

METHODS

A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0 mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two ≥5.0 mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration.

RESULTS

Twenty-four patients with 28 <4.0 mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288 ≥5.0 mm incorporated RAs. Study group patients were significantly younger than controls (72 ± 8 vs. 75 ± 8 years, p = .04) and more often females (46% vs. 21%, p = .018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0 mm and 99% for ≥5.0 mm RA incorporation (p = .05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p = .009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p = .05). At one year, primary patency was 79 ± 9% vs. 94 ± 1% (p < .001) and secondary patency was 84 ± 8% vs. 97 ± 1% (p < .001) for study vs. control group; freedom from branch instability was 79 ± 9% vs. 93 ± 2% (p = .005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21 ± 14 months.

CONCLUSION

Incorporation of <4.0 mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

Custom-Made Iliac Fenestrated Device

Iliac branch devices (IBDs) are undergoing rapid popularization. They allow for treatment of an iliac aneurysm while preserving blood flow to the hypogastric artery. Certain anatomic criteria are necessary for the use of an iliac side branch device to be technically feasible. Custom-made fenestrated iliac stent grafts may provide an alternative when anatomic criteria for an IBD are not met.

Successful Off-Label Use of an Iliac Branch Device to Rescue an Occluded Aortofemoral Bypass Graft

Purpose: To report an alternative approach for rescue of an occluded aortofemoral bypass using the Gore Excluder Iliac Branch Endoprosthesis (IBE). Case Report: A 52-year-old man presented with acute right limb ischemia because of displaced and occluded iliac stents and was treated with aortofemoral bypass. On the third postoperative day, there was early bypass failure due to distal embolization from aortic thrombus. After fluoroscopy-guided balloon thrombectomy of the bypass, an endovascular bailout strategy was used. The Gore Excluder IBE was deployed below the renal arteries (with the external iliac limb opening in the surgical prosthesis and the gate opening within the aortic lumen). After antegrade catheterization of the gate, a Gore Viabahn endoprosthesis was inserted as the bridging endograft and deployed so that it landed just above the preimplanted aortoiliac kissing stents without overlapping them. Completion angiography showed technical success without complications; results were sustained at 1-year follow-up. Conclusion: The Gore Excluder IBE may represent a versatile solution for the rescue of complex cases when open surgery would be associated with a considerable risk. This off-label application of a well-recognized endovascular device is safe and feasible and may prove useful as a valuable alternative in properly selected patients.