“Paving and Cracking”:An Endovascular Technique to Facilitate the Introduction of Aortic Stent-Grafts Through Stenosed Iliac Arteries

Technical tips and procedural steps in endovascular aortic aneurysm repair with concomitant recanalization of iliac artery occlusions

PURPOSE

The goal of this paper is to describe our technical strategy and procedural steps for endovascular aneurysm repair (EVAR) when performed with concomitant recanalization of the iliac artery occlusion.

MATERIALS AND METHODS

Three octogenarians having abdominal aortic aneurysm (AAA)/common iliac artery aneurysms (CIAA) with unilateral external iliac artery (EIA) occlusion underwent EVAR with recanalization of the occluded iliac arteries. Crossing the iliac artery occlusions was attempted in a retrograde approach using a 0.035 inch-hydrophilic guidewire. After passage of a guidewire, predilation was performed using 6mm balloon. Then a 12-Fr sheath was advanced via the occluded EIA for contralateral iliac limb delivery. Internal iliac artery embolization was subsequently performed as needed. A self-expanding stent was then placed in the occluded EIA after EVAR.

RESULTS

Recanalization of the EIA occlusion, followed by stentgraft delivery through the occlusion and EVAR, was successfully performed in all three patients. Penetration of the occluded EIA was successfully achieved only by retrograde approach in two patients, and by bidirectional approach in the other patient. No perioperative complication or death occurred. Postoperative CT showed no type I or III endoleaks in the aneurysms and patent iliac arteries in all patients.

CONCLUSIONS

Total endovascular repairs were successfully performed for three patients with AAA and concomitant unilateral EIA occlusions. The proposed steps described in this report might reduce the complication rate and enhance the technical success rate associated with this procedure.

Endovascular aortic repair with the chimney technique using the ultra low-profile Ovation stent-graft for juxtarenal aneurysms having small iliac access vessels

PURPOSE

To report the first experience using the chimney technique in combination with the latest-generation low-profile stent-graft to seal abdominal aortic aneurysms having a very short neck (proximal sealing zone) and difficult access due to very small iliac vessels.

MATERIALS AND METHODS

Use of an ultra low-profile 14F delivery aortic stent-graft system (Ovation; Trivascular, Santa Rosa, CA) with chimneys to the lowermost renal arteries in two patients who were not anatomically suitable for endovascular aortic aneurysm repair (EVAR) and too frail for open surgery.

RESULTS

Implantation of stent-grafts and chimneys was technically successful without endoleak or other postinterventional complications. Follow-up after >1 year confirmed complete aneurysm exclusion, shrinkage of the aneurysm sac, and patent renal perfusion by way of the chimney.

CONCLUSION

Ultra low-profile aortic stent-graft systems are particularly helpful in case of inadequate small iliac access vessels and allow EVAR for short-necked aortic aneurysms if technical contraindications obviate FEVAR and physical impairment discourages open surgical repair.

Transapical endovascular deployment of a stent-graft in the thoracic descending aorta

We report the case of a 74-year-old man with a large aneurysm (60 mm) of the descending thoracic aorta. Because of severe calcification and kinking of the iliac vessels, the expected access-related complication during the endovascular repair urged us to search for an alternative strategy. Having good experience with transcatheter aortic valve implantation, we thought that the transapical approach may be the best option in this case. The stent-graft was successfully deployed through the heart apex without any complications. The postoperative imaging showed an excellent result.

Imaging of the thoracic aorta

Three-dimensional vascular imaging techniques offer a significant advantage over traditional imaging techniques. Spatial resolution of current state-of-the-art allows sufficient depiction of anatomical detail. Pre-operative planning of complex endovascular procedures is facilitated by state-of-the-art imaging. Cone-beam CT holds great promise in guiding complex endovascular procedures.

Use of internal endoconduits as an adjunct to endovascular aneurysm repair in the setting of challenging aortoiliac anatomy

The combination of Trans-Atlantic Intersociety Consensus (TASC) D aortoiliac occlusive disease as well as a symptomatic abdominal aortic aneurysm (AAA) is not a common occurrence. Extensive calcified atherosclerotic disease, occlusions, and small iliofemoral segmental arteries make transfemoral access difficult, if not impossible, for endovascular aneurysm repair (EVAR) in these patients. We present a case in which "controlled rupture" of the external iliac artery with a covered stent allowed transfemoral delivery of an aortouni-iliac stent graft with a completion femoral-to-femoral bypass. The patient is a 60-year-old male with a 5.3 cm symptomatic infrarenal AAA and a history of one block right leg claudication. Preoperative computed tomography angiography revealed the patient to have occlusion of the right common iliac artery, extensive calcified stenoses of his aortoiliac segments, and a prohibitively small left external iliac artery, which measured 4.5 mm at its narrowest diameter. The patient, despite discussions concerning the suitability of his iliac arteries as conduits for the delivery of the stent graft, insisted on an endovascular approach to lessen his chances of postoperative sexual dysfunction as well as minimize his length of stay. Access was obtained through bilateral femoral artery cutdowns, and attempts at dilating the left external iliac artery using 16-French dilators were performed without success. An 8 mm x 5 cm covered self-expanding stent was deployed in the diseased 4.5 mm left external iliac artery, followed by angioplasty performed with an 8 mm noncompliant balloon to disrupt the vessel. This endoconduit now allowed accommodation of our 18-French introducer for the aortouni-iliac stent graft. The operation was completed with a femoral-femoral bypass. Flow to both hypogastric arteries was preserved. We believe use of such techniques will ultimately expand the number of patients eligible for EVAR and avoid devastating access-related complications.