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Background
The axillary artery approach has been used for access in complex endovascular aortic procedures, such as Thoracic Endovascular Aortic Repair (TEVAR) with poor anatomy for traditional deployment, as well as for fenestrated and branched aortic endografts. We report the first case of an iliac graft limb deployment through the axillary artery during an EVAR for maintenance of anterograde internal iliac flow in a patient with chronic ipsilateral occlusion of the external iliac and femoral artery.
Case Report
A 65 year old male patient with a previous history of coronary artery disease, heart failure, hypertension and COPD was referred to our institution for a symptomatic Abdominal Aortic Aneurysm (AAA) with a maximum diameter of 5.7cm. Anatomically, this AAA was not suitable for EVAR as the proximal neck had an angulation superiorly of 90 degrees. In addition, a bifurcated graft was not indicated as the aortic bifurcation was small at 11x14mm and there was occlusion of the left external iliac and femoral arteries. Due to patient’s symptomatology and multiple comorbidities, we decided to proceed with endovascular treatment. However, the patient’s left hypogastric artery was deemed to be crucial for the viability of his left lower extremity and pelvic perfusion. A bifurcated graft was utilized, with deployment of the left iliac limb through the left axillary artery. The operation was without complications after the addition of a proximal aortic cuff for an endoleak. At 6 months’ follow up, the clinical examination revealed no abdominal pulsatility, no buttock claudication and a CT scan of the AAA demonstrated a reduced sac diameter.
Conclusion
The axillary artery can be used in selected cases of complex endovascular treatment of aortic pathology. This is the first reported case of successful deployment of the iliac limb from the axillary artery during EVAR. It provided an excellent solution for a patient that otherwise would have required a more complex open bypass procedure.