Hybrid Operative Approach To Aortoiliac Occlusive Disease And Concomitant Saccular Infrarenal Abdominal Aortic Aneurysm
Jeffrey Christopher Lawrence, MBBS, Daniel Torrent, MD.
Virginia Tech - Carilion Clinic, Roanoke, VA, USA.
DEMOGRAPHICS: 69 y.o male with type II diabetes, tobacco abuse, and hypertension.
HISTORY: Presented to clinic with bilateral lower extremity rest pain and nonhealing wounds of right foot. Toe brachial indices were 0.12 on right and undetectable on right[jl1] . Computed Tomography Angiography (CTA) demonstrated significant aortobililac occlusive disease as well as a 3.4 x 3.2 x 3.3 cm saccular infrarenal abdominal aortic aneurysm.
PLAN: Longitudinal cutdown was performed in the right groin and right common femoral artery (CFA) was exposed in standard fashion. Micropuncture percutaneous access was attempted in the left groin but was unsuccessful due to degree of disease[jl1] . 8 Fr sheath was introduced into the right CFA and angiography demonstrated occlusion of the entire iliac system. We proceeded with an antegrade approach via the left radial artery and were able to traverse the right iliac and the wire was then externalized. The 8 Fr sheath was then advanced over the externalized glidewire this and a 6mm balloon was inserted through this and used to serially dilate the calcific vessel until access to the aorta was obtained. Viabahn stents were placed bilaterally and a 10mm balloon was used to dilate. The 8 Fr sheaths were then upsized and a endograft was advanced into the aorta from the left and the contralateral limb was advanced from the right. This was deployed under fluoroscopy, ensuring that there was overlap distally over the Viabahn stents. Post deployment aortography showed excellent results. A right iliofemoral endarterectomy with bovine patch angioplasty was performed in standard fashion. After this repair, distal pulses were palpable with triphasic signals.
DISCUSSION:
This demonstrates a hybrid approach to treatment of complex aortoiliac occlusive disease with a concurrent saccular aneurysm. The rendezvous technique with an antegrade and retrograde to the iliac occlusions allowed us to cross while ensuring we were within the true lumen at either side of the occlusive disease. The overall aortic diameter was somewhat and the saccular aneurysm was fairly distal. Because of these features the Gore IBE device was a good fit with appropriate seal while also allowing us to treat the occlusive iliac disease. Additionally, the ability to pre-cannulate the contralateral limb eliminated the need to gain access to the gate after deployment in a confined space.
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