The Up-and-Over Endoconduit Technique for Complex Endovascular Aortic Aneurysm Repair
Carlos H. Timaran, David E. Timaran, MD, Cindy Ha, MD, Marilisa Soto Gonzalez, MD, Angie Garcia, MD.
University of Texas Southwestern Medical Center, Dallas, TX, USA.
Objectives: Fenestrated EVAR (FEVAR) is a treatment option for patients with complex aortic aneurysms. Challenging Iliofemoral anatomy may prevent FEVAR. The use of controlled dilatation of the iliac arteries with a covered stent (endoconduit) may improve access, but rupture and vascular injuries may occur. The aim of this study is to describe the use of staged endoconduit creation using contralateral femoral access prior to FEVAR.
Methods: Over a 2-year period, 17 patients (7 male and 10 female) underwent staged endoconduit creation prior to FEVAR using Viabahn self-expanding covered stents (median diameter, 10 mm; IQR, 8-10mm). In all cases, the Viabahn was delivered percutaneously "up and over" across the aortic bifurcation and extended into the mid-segment of the common femoral artery(Fig A-H). All FEVAR procedures were performed percutaneously accessing directly the Viabahn in the common femoral artery under ultrasound guidance. Technical success was defined as successful access, closure and delivery of the endografts for FEVAR.
Results: Median age was 79 years (IQR, 72-81years). The median aneurysm diameter was 59mm (IQR, 54-77mm). Median diameter of the common iliac, external iliac and common femoral arteries was 7 mm (IQR, 5-9), 5 mm (IQR, 4-6 mm) and 6 mm (IQR, 5-8), respectively. Both common iliac and external iliac arteries were stented in 10 patients (58%), but only in 3 (17%) was the origin of the hypogastric artery excluded. Technical success was 94%. In one patient, the Viabahn was disrupted with occlusion after closure. All FEVAR procedures were completed uneventfully at a median follow-up interval of 4 weeks (IQR, 3-6) after the endoconduit creation. No intraoperative vascular injuries occurred. Low-profile devices were introduced the last 6 months of the study with smaller endoconduits required (8 mm). In all these latter cases, distal perfusion was maintained based on intraoperative neuro-monitoring.
Conclusion: Staged "up-and-over" endoconduit creation is a useful technique prior to FEVAR with adverse iliofemoral anatomy. Avoiding accessing the main femoral access site during the first stage prevents local vascular or access site injuries. Even though low-profile devices may be used, endoconduit creation may still be useful to prevent limb ischemia during FEVAR. 
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