Results of iliac branch devices for hypogastric salvage after previous aortic repair

OBJECTIVE

The aim of this multicentric study was to assess the "REsults of iliac branch deviceS for hypogastriC salvage after previoUs aortic rEpair (RESCUE)."

METHODS

All consecutive patients who underwent implantation of iliac branch devices (IBDs) after previous open aortic repair (OAR) or endovascular aortic repair (EVAR) at seven centers were captured. The study cohort was divided into two groups according to the type of repair originally performed. Early outcomes included immediate technical success and perioperative adverse events. Late outcomes included survival, side branch (SB) primary patency, SB instability, and new onset buttock claudication.

RESULTS

A total of 94 patients (82 male) were included in the study, 10 of them received bilateral implantation of IBDs. This resulted in a total of 104 devices included in the final analysis. Indication for treatment were endoleak 1b or progressive iliac aneurysmal degeneration or distal para-anastomotic aortic aneurysms; 73 were implanted after previous EVAR and 31 after previous OAR. Technical success was 100% in both groups. The 3-year rate of freedom from SB instability was 90.1% after previous EVAR and 85.4% after previous OAR, respectively (P = .05). The 3-year estimates of SB primary patency were significantly lower in patients who had received OAR as compared with those that had received EVAR (89.8% vs 94.9%; P = .05).

CONCLUSIONS

Endovascular treatment with IBDs following previous OAR or EVAR is safe and effective up to 3 years. Freedom from SB instability during follow-up was lower in patients who had previously undergone OAR than EVAR.

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.

Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report

INTRODUCTION

Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients.

PATIENT CONCERNS

A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup.

DIAGNOSES

Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length.

INTERVENTIONS

After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD.

OUTCOMES

The stent grafts were patent without endoleak at the 6-month follow-up.

LESSONS

In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Secondary Relining With Focal Flaring of Novel-Generation Balloon-Expandable Covered Stents for Endovascular Treatment of Significant Diameter Mismatch in the Aorto-Iliac Territory

OBJECTIVES

The aim of this study was to report on the safety and feasibility of secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory. Significant diameter mismatch was defined as >20% difference in the nominal diameter between the intended proximal and distal landing zones.

METHODS

Patient A was an 84-year-old man with prior abdominal aortic aneurysm open repair with a straight 20 mm Dacron tube. He presented with a right common iliac artery aneurysm (Ø88 mm) with contained rupture. The Gore Viabahn endoprosthesis (9 mm × 5 cm) was inserted proximally about 15 mm above the occluded ostium of the internal iliac artery. Subsequently, the BeGraft Aortic® (16 mm × 48 mm) was inserted proximally up to the common iliac artery origin; its proximal portion was flared to 22 mm. Patient B was a 77-year-old man with prior endovascular abdominal aortic aneurysm repair with a Medtronic Endurant stent-graft. He presented with occlusion of the right limb of the aortic endoprosthesis and thrombosis that extended down to the level of the superficial femoral artery. After mechanical thrombectomy, two Gore Viabahn endoprosthesis (first one, 8 mm × 10 cm; second one, 10 mm × 15 cm) were inserted into the right iliac limb. Subsequently, the BeGraft Aortic® (12mm × 39mm) was inserted proximally up to the gate of the aortic stent-graft; its proximal portion was flared to 16 mm.

RESULTS

Technical success and clinical success were achieved in both patients. Imaging follow-up (6 months for Patient A, 12 months for Patient B) showed correct placement of all stent-grafts without any graft-related adverse event. The patients remained free from new reinterventions or recurrent symptoms. Patient A died 8 months after the index procedure from acute respiratory failure after community acquired pneumonia.

CONCLUSION

Secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory is safe and feasible. Although mid-term results seem to be effective, longer follow-up is warranted to establish durability of the technique.

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.