Fenestrated Endovascular AAA Repair In Three Patients With Iliac Occlusions Using Utilizing Iliac Conduit, US Guided Reentry Device And Viabahn Endolining For Iliofemoral Bypass
Danielle M. Thesier, MD, Mariel Rivero, MD, Hasan H. Dosluoglu, MD
University at Buffalo, Buffalo, NY
Demographics/History: 1.66-year-old male with severe COPD, home O2, afib with 6.3cm juxtarenal AAA, with right CIA/EIA occlusion, s/p right BKA, with left CFA aneurysm, SFA occlusion.2.75-year-old male with severe COPD, home O2, hypertension, afib with 5.7cm juxtarenal AAA and left CIA occlusion, severe calcified stenosis of the right CIA and heavy aortic clot load.3.72-year-old male with cardiomyopathy, 20% EF, CAD, COPD, cocaine abuse with 5.7cm juxtarenal AAA, bilateral EIA occlusions, severely calcified CIA/EIAs and bilateral CFA aneurysms (2.5-3cm), bilateral SFA occlusions.
Plan: 1.Due to calcified, marginal lumen diameter of left CIA, a left CIA dacron conduit was placed via retroperitoneal incision for the main body of fenestrated graft and to avoid complex reconstruction of the left femoral aneurysm, the sheaths were delivered from the groin to the EIA in two separate punctures, as the SMA was planned to be snorkeled from brachial access. After the renal arteries were cannulated with 6F,7F sheaths, and the SMA stent graft (Atrium 10mmx38mm) was positioned, and the graft was deployed. A 2-stent Renu AI graft was placed after suprarenal stents were removed, and iliac limb was placed. Femoral-femoral bypass was not needed.2.Due to clot load in the distal aorta and flush left CIA occlusion, retrograde crossing and SMA snorkel was planned. Pioneer reentry device was needed to reenter the lumen form the left. The sheaths were placed and the FEVAR was completed as usual with SMA snorkel.3.After femoral cutdowns, retrograde crossing of left EIA failed due to severe calcification. Transbrachial crossing of left EIA stopped at mid-EIA, with inability to advance wire. The proximal EIA was exposed through the groin and the wire was retrieved (body floss). The right EIA was crossed retrograde. The sheaths were delivered and FEVAR was completed. A 9mmx10cm Viabahn was placed to proximal left EIA, brought to the groin, and the end was used as inflow for the dacron interposition graft to left DFA. Same was done on the right.
DISCUSSION: Repair of juxtarenal aneurysms with iliac occlusions with FEVAR is feasible utilizing a variety of techniques used for endovascular reconstructions for complex aortoiliac occlusive disease, including delivering all from one iliac system using a CIA conduit
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