Early Experiences of Sandwich Technique to Preserve Pelvic Circulation during Endovascular Aneurysm Repair

Novel Strategies for the Hostile Iliac Artery during Endovascular Aortic Aneurysm Repair

Successful endovascular aneurysm repair can be achieved with favorable aortic and iliac arterial anatomies. However, patients with challenging iliac anatomy, such as stenotic, calcified, tortuous arteries, or concomitant iliac artery aneurysms, are commonly encountered. Such a hostile iliac anatomy increases the risk of intraprocedural complications and worsens long-term outcomes. This review addresses various technical options for treating patients with a hostile iliac anatomy, including innovative endovascular solutions, physician-modified endografts, and hybrid procedures. These considerations demonstrate the wide scope of therapies that may be offered to patients with an unfavorable iliac anatomy.

Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

Sandwich stent located in the iliac artery dislodged into the thoracic aorta and its remedy

The sandwich stent technique is a commonly used method to preserve unilateral internal iliac artery flow when treating iliac artery aneurysm. In this case, covered stent grafts (Viabahn, Gore) were used to build the iliac limb of a sandwich stent. However, if Viabahn is released without long sheath protection, the trigger wire is easily wound on another stent, resulting in the Viabahn delivery system being inseparable from the stent. If we drag it forcefully, it would easily cause the entire sandwich stent graft to shift or even fall into the thoracic aorta. This complication is catastrophic. Here we report the case of a patient whose sandwich stent system disengaged and entered the thoracic aorta. We took corresponding measures to remedy it.

Selection of Stents by Calculation of Arterial Cross-sectional Area in Modified Sandwich Technique for Complex Aortoiliac Arterial Lesions

BACKGROUND

We prospectively evaluated the modified sandwich technique for treatment of complex aortoiliac arterial lesions using commercial stent grafts selected according to the arterial cross-sectional area. The primary outcomes were technical feasibility and mid-term follow-up results.

METHODS

We prospectively enrolled 13 patients (mean age 63.85 ± 6.12 years) with aortoiliac arterial lesions (5 infrarenal abdominal aortic dissections, 1 lower abdominal aortic occlusion, 5 iliac artery aneurysms, 1 external iliac arterial pseudoaneurysm, and 1 type IB endoleak following endovascular aneurysm repair) for endovascular repair with the modified sandwich technique. All lesions were complex and unsuitable for routine endovascular treatment. The bifurcated stent-graft diameters were determined by calculating the arterial cross-sectional area. Success and complication rates were recorded. Patients were followed for 20.69 ± 6.51 (range 6-31) months and stent patency determined by contrast-enhanced ultrasound and computed tomography 1, 3, and 6 months post-operatively and every 12 months thereafter.

RESULTS

The initial technical success rate was 100%, and no surgical complications occurred. The primary patency of the stent grafts was 100% during follow-up. Post-procedural type I "gutter" endoleaks occurred in 4 patients (30.8%) after 1 month. At 3 months, the endoleaks in 3 of the 4 patients had disappeared without treatment, and the remaining endoleak resolved after coil embolization.

CONCLUSIONS

The sandwich technique is a safe and effective therapy for complex aortoiliac arterial lesions. Stent-graft sizes based on the arterial cross-sectional area can ensure technical success and reduce the rate of "gutter" endoleaks.

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.