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Patient-specific Unibody Bifurcated Branched Device Delivered Through Upper Extremity Access To Treat Complex Abdominal Aortic Aneurysm In A Patient With Severe Bilateral Iliac Artery Disease.
Paula Huertas, M.D, Jesus Porras, M.D, Andres V. Figueroa, M.D, Marilisa Soto - Gonzalez, M.D, Natalia Coronel, M.D, Shadman Baig, M.D, Carlos H. Timaran, M.D.
UT Southwestern, Dallas, TX, USA.
Background: Endovascular management of complex aortic aneurysms typically relies on transfemoral access. In patients with extensive peripheral arterial disease, alternative access strategies become essential.
Case: A 77 y/o male with a history of hypertension, hyperlipidemia, type II diabetes mellitus, paraplegia due to trauma, and bilateral above-knee amputations, presented with enlarging 6.2 cm complex suprarenal AAA, small right common iliac artery aneurysm measuring 15 mm and small bilateral external iliac arteries (3.4mm) with partial occlusion and poor distal runoff. Because of severe peripheral artery disease, an endovascular aortic repair using a patient specific company manufactured device was planned to be delivered through the left axillary artery. The device customized with four downward-facing branches, low profile unibody bifurcated graft, loaded in reverse to facilitate a distal-to-proximal release approach. The contralateral limb corresponded to an internal - external side branch and was bridged to the right common iliac artery and the ipsilateral iliac branch to the left common iliac artery. To deliver the main device, an 8 mm conduit graft was anastomosed to the left axillary artery through a infraclavicular approach. A through-and-through access was established between the left axillary artery and left common femoral artery to facilitate device tracking. The main device was advanced through the left axillary and deployed under FORS and IVUS guidance. The target vessels were sequentially catheterized and stented. Iliac outflow was restored by stenting both common iliac arteries using balloon expandable VBX stents, bridging them into the graft limbs. After successful deployment, the left axillary conduit was then ligated and oversewn.
The procedure was completed successfully without intraoperative complications. Completion angiography confirmed accurate graft placement, target vessel perfusion and exclusion of the aneurysm sac. The patient recovered uneventfully and remained hemodynamically stable. Post-operative CTA revealed patent bridging stents, absence of endoleaks, and effective exclusion of the aneurysm sac.
Conclusion: Upper extremity access is an alternative access for branched endografts in patients with complex aortic aneurysm and severe iliofemoral occlusive disease.
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