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OBJECTIVES:
We describe the treatment of a 54 year-old patient with a neuromuscular disorder and complete infrarenal aortoiliac flush occlusion using endovascular techniques.
METHODS:
The patient had less than one block claudication and couldn’t ambulate around his home without pain. He had no history of smoking or other vascular risk factors, but did have a neuromuscular disorder. Prior treatment with cilostazol did not provide sufficient relief. He had been told by multiple vascular surgeons that aortobifemoral bypass was contraindicated due to the risk of respiratory failure and ventilator dependence after general anesthesia.
Initial exam showed absent femoral pulses and an ankle brachial index (ABI) of 0.64 in the right leg and 0.57 in the left. Computed tomography angiography and Digital subtraction aortogram both showed total occlusion of the aorta flush to the renal artery ostia and iliac vessels to both common femoral arteries (CFA).
RESULTS:
The procedure was performed under local anesthesia. Percutaneous access was obtained in the left brachial artery using a 4F sheath and in bilateral femoral arteries using 7F sheaths. Retrograde subintimal angioplasty (SIA) of the bilateral iliacs and the aorta was performed, during which, balloon angioplasty of both iliacs was performed to facilitate travel of the glidewire. Imaging done of the aorta using a pigtail catheter from the left brachial sheath was performed to guide reentry at the level of the right renal artery, after which, stiff 0.035 inch wires were placed. iCast (Atrium Medical Corporation, Hudson, NH) stents were deployed exactly at the ostium of right renal artery to recreate the aortic bifurcation at the renal arteries. Long Viabhan (W. L. Gore and Associates Inc, Flagstaff, AZ) stent grafts were extended down to the circumflex iliac arteries. Completion angiogram showed patency of the aorta from the renal arteries through external iliac arteries.
The patient did well postoperatively and was discharged post-procedure day 1. Six month Duplex ultrasound confirmed that stents were patent with multiphasic CFA waveforms. ABI's showed improvement to 0.71 in the right leg and 0.67 in the left. The patient reported complete resolution of his claudication.
CONCLUSIONS:
We demonstrate an endovascular option to treat chronic total infrarenal aortic and iliac occlusions under minimal anesthesia safely and effectively for non-surgical patients.