Mateus P. Correa, Gustavo S. Oderich
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
BACKGROUND: Exclusion of one or both internal iliac arteries (IIA) during endovascular aortic aneurysm repair (EVAR) has been associated with a predictable rate of pelvic ischemic complications. We present the pre-operative planning and technique of implantation of Iliac Branch Device (IBD, Cook Inc., Brisbane, Australia) in a patient with bilateral common iliac artery (CIA) aneurysms using total percutaneous approach.
TECHNICAL DESCRIPTION: Computed tomography angiography (CTA) was used to determine measurements including CIA length (>50mm) and diameter of the CIA bifurcation (>16mm) and IIA (4-9mm). A right IIA bypass was performed in a first stage via small flank incision. For the second stage, EVAR was performed using bilateral percutaneous femoral approach. After systemic heparinization, a 12Fr Ansel sheath (Cook Inc., Bloomington, Indiana) was introduced via the right and IBD via the left femoral approach. A guidewire was advanced via the IBD pre-loaded catheter and snared, establishing femoral-femoral access. The IBD was partially deployed up to the side branch, which was opened 1cm proximal to the CIA bifurcation. The 12Fr sheath was advanced into the side branch, followed by selective catheterization the IIA and deployment of a 9x60mm self-expandable stent-graft into the IIA. The IBD was deployed into the left external iliac artery (EIA) and kissing balloon angioplasty was performed. The repair was completed by deployment of a Cook Zenith (Bloomington, Indiana) bifurcated stent-graft and iliac limb extensions to connect the IBD to the left contra-lateral gate and extend the repair to the right EIA. Completion angiography and CTA revealed widely patency stent-grafts with no endoleak. In conclusion, IBDs have expanded the indications of EVAR in patients with bilateral CIA aneurysms. The technique can be performed using a total percutaneous approach and has the potential to reduce rates of pelvic ischemic complications.
AUTHOR DISCLOSURES: M. P. Correa: Nothing to disclose; G. S. Oderich: Cook Medical, Research grants; W.L. Gore, Research grants.
Posted April 2013