Complextreatmentofatype1bendoleaka3erEVARandaninternaliliacaneurysm
MichelBosiers,MDVascularandEndovascularSurgeonDepartmentofVascularSurgerySt.Franziskus-HospitalMünster,Germany
Case presenta*on
• 76ymalepaKent
• EVAR+singlechimney2009
• OverstenKngandocclusionrightinternaliliacarteryduetotype1bendoleak2010
• Cuff-ImplantaKon+triplechimney+embolisaKonusingonyxduetotype1aendoleak2013
• Now:Type1bendoleakonthele3side+internaliliacarteryaneurysm
ComorbidiKes:• CAD• NYHA2• Hypertension• COPD
Problems:
• Only1patentinternaliliac(IIA)
• IIAisaneurysmaKc(5cm)
• Stenosedglutealartery
• IMAisoccluded
Solu4ons:
• Donothing?
• Iliacsidebranch?
• OverstenKngIIAandembolisaKon?
• Openconversion
• Other?
Our solu*on for type 1b endoleak in this case:
1. Wedidn´twanttoriskbowelischemia(occlusionrightIIA,IMA),thereforeIIAshouldbepreserved
2. IIAaneurysmshouldbetreatedinthiscase(5cm)
3. Inouropinionnotfitforopenkonversion(keepinmind,hehas3chimneystentgra3s)
4. OpensurgeryforIIAaneurysmisverydifficultinthiscase:largeanddeepinthepelvis
Iliacsidebranchdevice
• Transfemoralpercutaneousapproach• Cutdownaxillarartery
1. IliacsidebranchfromCOOK:ZBIS-12-61-412. proximalextensionusingEndurantlimb(Medtronic)3. Closingofthegrointorestorebloodflowtothele3limb
Transaxillaryapproachfortheiliacsidebranch
Advancing8FsheaththroughthebranchintotheIIA
AlreadyimplanKngabridgingballoonexpandablecoveredstentgra3(VBX8x59,Gore)togetamorestabilPosiKoninsidetheIIA
• VeryinstableposiKonofthewire
intheglutealartery
• Wecouldn´tadvanceanycatheters
WewerethenabletoadvanceaLP6x100Viabahn(Gore)overa14inchSpartacorewire(Abbok)HowevernotlongenoughtoreachthealreadyimplantedVBX
SointryingtoakachthemwithanotherStentgra3....DislocaKonoftheviabahn
Wemanagedtostraigthentheviabahn Andconnectthemwithashort
VBX8x39mm
However:typeIIIendoleak
AdvancinganAdvanta8x59
dislocatedtheviabahn...again
Butnowa„stable“connecKonwasmade
withsKllsometypeIIIendoleak
Welinedallofitwitha8x100mm
Viabahn
FinalResult
• Intheend:goodresult
• Dischargeatpostopday5
• NocomplicaKons
• Nobowelischemia
Ques4onstoVascupedians:1. Worththemoney?
2. Whatwouldyouhavedonedifferently?
3. Whatisyourtrickinveryinstable
wireposiKonstoadvanceacatheterorstent
4. Doyouhaveexperiencewithiliacside
branchdevices?Whichoneandwhatisyour
opinionaboutthem?
5. Whodoesn´tcareabouttheIIAandwould
haveembolisedit?