Back to 2026 Abstracts
Transcaval Approach For Complex Endovascular Aortic Repair In The Setting Of Iliofemoral Occlusive Disease
Lauren Ellyse Cralle, MD, Andrew Barleben.
UC Davis Health, Sacramento, CA, USA.
DEMOGRAPHICS: Patient 1 was an 83-year-old woman with a history of hypertension, coronary artery bypass grafting, chronic obstructive pulmonary disease, tobacco use, and 5.8cm thoracoabdominal aortic aneurysm (TAAA).Patient 2 was a 76-year-old woman with a history of hypertension, stroke, tobacco use, obesity, and 5.6cm TAAA.
HISTORY: Preoperative imaging revealed extent 4 TAAA and extensive atherosclerotic disease with small caliber iliofemoral vessels -- minimal luminal diameters 4-5mm bilaterally. This posed a challenge for delivery of large diameter grafts.
PLAN: Due to the small caliber of vessels, we planned to use transcaval access to deliver Gore Excluder thoracoabdominal multibranch endoprosthesis (TAMBE), as they were unable to undergo iliac artery revascularization prior to delivery of TAMBE due to extent and pattern of atherosclerosis. We obtained bilateral femoral arterial followed by right femoral venous access, then positioned a steerable sheath in the inferior vena cava (IVC) and a laser atherectomy catheter toward the medial wall of the IVC. After creating a venotomy then arteriotomy with the laser, we selected the descending thoracic aorta from the right femoral venous sheath and upsize the venous sheath to a 22Fr Gore DrySeal sheath positioned in the infrarenal aorta. This transcaval communication was used to deliver the proximal aortic repair with TAMBE. The visceral vessels were cannulated using left femoral arterial access and right femoral venous access. Prior to completing the infrarenal portion, the sheath was retracted back to the IVC with the completion of the repair providing coverage of the aorto-venous fistula. Both patients spent 1-2 days in the intensive care unit and were discharged home within a week.
DISCUSSION: With increasing complexity of endovascular repairs, larger delivery sheaths are needed to accommodate branches, fenestrations, and the stent graft itself. This poses a challenge for patients with small caliber access vessels or aortoiliac occlusive disease, often precluding them from both off-label and on-label repairs, which require 20-26 French delivery systems. We propose a method of transfemoral with transcaval access to the infrarenal abdominal aorta as a safe and effective approach to delivering large devices in patients with iliofemoral disease that would otherwise prohibit traditional transfemoral arterial delivery.
Back to 2026 Abstracts
