PresentedVascular Surge

Division oUniversity Sch

CorrespondSurgery and EClifton Road, A

Ann Vasc SurgDOI: 10.1016/� Annals of V

Preservation of Hypogastric Artery BloodFlow During Endovascular Aneurysm Repairof an Abdominal Aortic Aneurysm WithBilateral Common and Internal Iliac ArteryInvolvement: Utilization of Off-the-ShelfStent-Graft Components

Paul J. Riesenman, Joseph J. Ricotta II, and Ravi K. Veeraswamy, Atlanta, Georgia

A72-year-oldmale presentedwith a 7.4-cmabdominal aortic aneurysmwith bilateral commonandinternal iliac involvement. To maintain pelvic perfusion, preservation of the patient’s left hypogas-tric artery (HA) was pursued. Two weeks after right HA embolization, endovascular repair of thepatient’s aneurysms was performed using a branched endograft approach. A 22-mm main bodybifurcated endograft was unsheathed and the proximal covered stent was removed. The contra-lateral gate was preloaded with a wire and catheter. The device was resheathed and placed in theleft common iliac artery. The preloaded wire in the contralateral gate was snared from the rightside, establishing through-and-through femoral access. A contralateral femoral sheath wasadvanced up and over the aortic bifurcation from the right side into the contralateral gate of thebifurcated endograft. The repair was bridged to the left HA using a balloon-expandable stent-graft,followed by standard endovascular abdominal aortic aneurysm repair. Completion angiographydemonstrated exclusion of patient’s aneurysms, without evidence of endoleak, and maintenanceof pelvic blood flow through the left HA. The patient recovered without complication and wasdischarged home on postoperative day 4. This technique illustrates the technical feasibility ofusing a preloaded commercially available endograft to preserve HA blood flow andmaintain pelvicperfusion during endovascular aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) of infrarenal

abdominal aortic aneurysms (AAAs) is associated

with significantly lower aneurysm-related mortality

compared with conventional open surgical recon-

struction,1 and is the preferential form of treatment

for the majority of patients with known AAAs.2

The application of EVAR to patients with concomi-

tant common iliac artery (CIA) aneurysms may

at the 21st Annual Winter Meeting of the Peripheralry Society, Steamboat Springs, CO, January 28-30, 2011.

f Vascular Surgery and Endovascular Therapy, Emoryool of Medicine, Atlanta, GA.

ence to: Ravi K. Veeraswamy, MD, Division of Vascularndovascular Therapy, Emory Clinic Building A, 1365tlanta, GA 30322, USA, E-mail: rveeras@emory.edu

2012; 26: 109.e1-109.e5j.avsg.2011.10.004ascular Surgery Inc.

necessitate extension of the endograft limbs into

the external iliac arteries (EIAs), with subsequent

coverage of the hypogastric arteries (HAs), to obtain

an adequate distal seal. Interruption of blood flow

to both HAs may lead to complications from the

resulting pelvic ischemia, which most commonly

manifests as buttock claudication or erectile

dysfunction.3-5

Several techniques to preserve pelvic perfusion

and facilitate EVAR in patients with aortoiliac aneu-

rysms have been described.6-8 More recently,

commercially manufactured branched endografts

have been developed, but remain unavailable for

use in the United States, outside of physician-

sponsored investigational device exemption studies.9

To overcome limited device availability, several

authors have described the modification and/or

application of currently available endograft

109.e1

109.e2 Case reports Annals of Vascular Surgery

components to construct branched endografts and

maintainHApatency.10-13We describe themodifica-

tion of a readily available abdominal aortic endograft

bifurcated main body component to facilitate

modular endovascular bypass of the HAand preserve

pelvic perfusion in a patient with extensive aortoiliac

aneurysms.

CASE REPORT

A 72-year-old white male was found to have an asymp-

tomatic extensive aorto-bi-iliac artery aneurysm after

evaluation for a prominent abdominal pulsation detected

on physical examination. Medical history was significant

for coronary artery disease with previous coronary artery

bypass surgery, reoperative coronary artery bypass

surgery, percutaneous coronary artery angioplasty,

hyperlipidemia, and gout. Computed tomographic angi-

ography (CTA) evaluation of the abdomen and pelvis

revealed a 7.4-cm AAA with bilateral CIA and HA aneu-

rysms. The patient’s CIA aneurysms extended to the iliac

bifurcation, and both EIAs were nonaneurysmal. The

measured maximal cross-sectional aneurysm diameters

were as follows: right CIA, 4.5 cm; left CIA, 3.7 cm; right

HA, 5.5 cm; and left HA, 2.8 cm. Open surgerywas consid-

ered to be high risk and technically challenging, given the

patient’s cardiac comorbidities and extensiveness of the

right HA aneurysm. After discussions with the patient,

an endovascular intervention was pursued.

Two weeks before EVAR, selective coil embolization of

the distal right HA branches was performed using eight

6 � 40-mm platinum coils (Boston Scientific Corporation,

Natick, MA). Angiography of the right iliac artery at the

time of EVAR confirmed complete thrombosis of the right

HA. To maintain pelvic perfusion through the left HA, an

iliac branched endograft was configured. A 22 � 74-mm

bifurcated main body Zenith AAA endovascular graft

(Cook Medical Inc., Bloomington, IN) was partially

unsheathed, thereby exposing the contralateral limb.

Ophthalmologic cautery was used to transect the uncov-

ered and proximal covered stents from the main body

component, yielding a 54-mm-long modified bifurcated

device (Fig. 1A). A 4-F KMP catheter (Cook Medical Inc.)

was preloaded through the contralateral gate with

a Bentson wire (Fig. 1B). The preloaded endograft was

resheathed within a 22-F sheath (Cook Medical Inc.)

(Fig. 1C). Through open femoral access, the reconstrained

device was advanced through a 24-F peel-away Cook

sheath into the left CIA. Angiography confirmed that the

contralateral gate was above the iliac bifurcation and

oriented toward the left HA (Fig. 2A). A 0.025-inch Metro

wire (Cook Medical Inc.) was advanced through the cath-

eter into the abdominal aorta, where it was snared from

the right side and brought out through the right femoral

sheath, therebyestablishing through-and-through femoral

access (Fig. 2B). Over the femoral-femoral wire, a 12-F

Ansel I sheath (Cook Medial Inc.) was advanced from the

right side over the aortic bifurcation. The contralateral

limbwasdeployed, and the sheathwasadvancedantegrade

over the preloaded wire into the contralateral gate. From

the right side, aKMPcatheter andglidewirewere advanced

alongside the femoral-femoral wire into the distal HA

branches. The glidewire was exchanged for an Amplatz

ST-1 guidewire (Boston Scientific), and a 7-F Flexor

Check-Flo introducer sheath (Cook Medical Inc.) was

advanced through the 12-F Ansel sheath into the left HA

(Fig. 3A). The repairwas bridgedwith a 10� 59-mm iCAST

stent-graft (Atrium,Hudson,NH)andpostdilated to12mm

to facilitate a seal with the contralateral limbmeasuring 12

mm in diameter. The iCast stent-graft was reinforced with

a 10 � 60-mm S.M.A.R.T. stent (Cordis Endovascular,

Miami Lakes, FL) to prevent kinking due to HA tortuosity

and/or subsequent aortic remodeling.

The modified endovascular device was then fully

unsheathed, deploying the ipsilateral limb into the left

EIA. A 26 � 111-mm bifurcated main body Zenith Flex

AAA endovascular graft (CookMedial Inc.) was advanced

up the right side and deployed just below the renal

arteries. The contralateral limb of the 26-mm device and

the modified 22-mm component in the left CIA were

bridged using a 24� 56-mm flared iliac limb. On the right

side, the ipsilateral limb of the 26-mm device was

extended into the EIA using a 10 � 88-mm iliac limb.

Completion angiography demonstrated exclusion of all

aneurysms, no evidence of endoleak, and patency of the

left HA branch with preservation of pelvic blood flow

(Fig. 3B). CTA performed on postoperative day 3 demon-

strated no evidence of endoleak. The patient was dis-

charged home on postoperative day 4. At follow-up

6 weeks after EVAR, the patient denied any buttock clau-

dication or sexual dysfunction, and CTA imaging at that

time confirmed integrity of the repair (Fig. 4).

DISCUSSION

Concomitant aneurysmal involvement of the CIAs

occurs in up to 35% of patients who undergo

EVAR for AAAs.6,14 Successful endovascular exclu-

sion may necessitate coverage of one or both HAs

through extension of the endograft limb(s) into

the external iliac territory. Traditionally, planned

extension of iliac limbs into the EIA is preceded by

embolization of the HA to be covered to prevent

a type II endoleak.3 Despite the extensive arterial

collateral network of the pelvic circulation, inter-

ruption of perfusion through the HA may result in

gluteal necrosis, colonic ischemia, paraplegia,

buttock claudication, and sexual dysfunction.3,15

Adjunctive procedures to preserve patency of at

least one HA would be favorable to expectant

management and the morbidity of these anticipated

complications. Described techniques have included

construction of a surgical bypass to the HA through

a retroperitoneal approach.6,16 Additionally, endo-

vascular techniques involving an endolumenal

Fig. 1. Device modification and placement of a preloaded

wire and catheter. (A) Removal of the uncovered and

proximal covered stents from the main body component.

(B) Placement of a wire and catheter into the contralat-

eral endograft limb. (C) Resheathed device with pre-

loaded catheter and wire into a 22-F sheath.

Fig. 2. (A) Modified bifurcated device with preloaded wire and catheter advanced into the patient’s left common iliac

artery. (B) Establishment of through-and-through femoral-femoral access.

Vol. 26, No. 1, January 2012 Case reports 109.e3

bypass to the HA from the ipsilateral CIA or EIAwith

the construction of a femoral-femoral bypass to

account for the interruption of in-line iliac artery

perfusion have also been reported.7,17 These proce-

dures necessitate the construction of an open

surgical bypass, contributing additional morbidity

to the intended endovascular repair. Alternatively,

a totally endovascular approach in which the EIA

and HA are endolumenally bypassed through

a ‘‘snorkel’’ or parallel endograft approach has

recently been described.18

Alternatively, modular branched endovascular

devices afford the ability to exclude iliac aneurysmal

lesions through a totally endovascular approach.

Two commercially manufactured iliac branch

devices produced by Cook Medical Inc. are available

for use outside the United States. These two designs

consist of either a straight single sidearm branch or

a helical sidearm through which stent-grafts are

placed to bridge the branched component to the

HA.9,19 Both of these branched devices make use of

a preloaded wire placed through the HA branch,

which exits through the proximal aspect of the

device. The use of this preloaded wire facilitates the

establishment of through-and-through femoral-

femoral access over which a contralateral sheath is

advanced into the HA branch limb for the placement

of mating stent-grafts. Early reported outcomes

using these devices has been favorable, with a tech-

nical success rate of 85% to 100% for current

devices.19

The use of readily available off-the-shelf endog-

rafts to construct branched HA configurations

facilitating preservation of pelvic perfusion has

been previously described.11-13 Oderich and Ricotta

recently described the construction and use of

a surgeon-modified branched Zenith iliac limb

stent-graft with a polyester sidearm graft.12 As

with the commercially manufactured iliac branch

devices, a preloaded wire and catheter were placed

as part of the device modification to facilitate

advancement of the contralateral sheath into the

Fig. 3. (A) A 12-F sheath is present in the contralat-

eral endograft limb with a 7-F sheath advanced into

the hypogastric artery. (B) Completion angiography

demonstrates patency of the branched hypogastric

artery stent-graft and preservation of pelvic blood

flow.

Fig. 4. Computed tomographic angiography with three-dimensional reconstruction (A) preoperatively, and (B) 6

weeks after endovascular aneurysm repair.

109.e4 Case reports Annals of Vascular Surgery

HA branch. Several authors have described the use

of either Gore Excluder (W. L. Gore and Associates,

Flagstaff, AZ) or Zenith (Cook Medical Inc.) AAA

main body bifurcated components as branch grafts

to preserve HA blood flow.10,11,13 The advantage of

using a bifurcated main body device is that these

components avoid the need to construct a branched

limb, and may only require minimal or no device

modification. In the case of the Zenith device,

removal of the proximal uncovered stents, as well

as the first row of covered stents, is necessary to

obtain an adequate working length to allow for

device positioning and contralateral limb alignment.

In many of the described cases, a brachial or axillary

approach is used to place bridging stent-grafts into

the HA. In our case, we modified the bifurcated

device by placing a preloaded wire in the contralat-

eral limb to establish femoral-femoral access and

facilitate sheath advancement into the branched

limb. This technique may be especially helpful in

situations involving challenging aortic anatomy.

There are a few limitations to the application of

this technique. Placement of a preloaded wire into

the bifurcated device necessitates resheathing in

a 22-F sheath and introduction into the femoral

artery through a 24-F sheath; therefore, the patient’s

access vessels must be of adequate diameter to

accommodate these large sheaths. Furthermore,

areas of narrowing or tortuosity within the iliac

system may prevent device advancement and

Vol. 26, No. 1, January 2012 Case reports 109.e5

positioning. Although the use of a bifurcated main

body device obviates the need to construct a sidearm

branch, these components have more limitations in

terms of diameter and modifiable lengths compared

with surgeon-modified branched iliac limbs.

Additionally, the use of two bifurcated main body

components to enable this method of EVAR adds

substantially tomaterial cost of the overall aneurysm

repair. Finally, the approval of commercially manu-

factured iliac branch devices will make these

techniques largely unnecessary, assuming the wide-

spread availability of a broad range of device

configurations.

CONCLUSION

Preservation of HA blood flow during EVAR of

extensive aortoiliac aneurysms is technically feasible

using an off-the-shelf bifurcated main body AAA

endograft. Surgeon modification of the endograft

by preloading the branched limb with a wire and

catheter facilitates sheath advancement for place-

ment of bridging stent-grafts.

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