Implantation of an Iliac Branch Device After EVAR via a Femoral Approach Using a Steerable Sheath

Introduction

Endovascular aneurysm repair (EVAR) is currently the first treatment option for abdominal aortic aneurysms. In cases where the aneurysm extends to the common iliac artery, sealing is often compromised. This problem can be overcome relatively easily by embolization/occlusion of the hypogastric artery and extension of the stent-graft to the external iliac artery. Unfortunately, this maneuver can be associated with pelvic ischemia (varying from 28% to 55%), including buttock claudication, colon ischemia, and/or erectile dysfunction. ¹ To circumvent this problem, iliac branch devices were developed to maintain blood flow in the hypogastric artery. A 2010 meta-analysis revealed a patency rate of ~90% ² ; single-center results approach 95%. ³

In patients developing an iliac aneurysm after EVAR, a transbrachial/axillary approach is usually needed to cannulate the hypogastric artery.^4,5 However, this antegrade approach can be associated such problems as embolization, stroke, dissection, and nerve injury and requires even longer sheaths, including shuttle sheaths, ⁵ catheters, and wires. At the same time, the contralateral femoral approach can be dangerous because advancing the sheath over the neobifurcation of the existing stent-graft can move the graft downward. Additionally, the force of pushing the bridging stent-graft through the tight neobifurcation to the hypogastric artery has to be considered. Herein is suggested a technique to improve the safety of the contralateral femoral approach.

Technique

The technique is demonstrated in an 80-year-old man. The patient underwent EVAR in 2011 to implant an Endurant stent-graft (Medtronic CardioVascular, Santa Rosa, CA, USA) with a 28-mm flared limb on the left side. The postoperative computed tomography (CT) scans showed no evidence of endoleak. In follow-up, expansion of the left common iliac artery to >4 cm was noted (Figure 1A). Endovascular repair was planned using a self-expanding Jotec E-Iliac Stent-Graft (Jotec GmbH, Hechingen, Germany) delivered via a ipsilateral femoral approach and a balloon-expandable Jotec E-Ventus bridging stentgraft via a contralateral femoral approach using a 8.5-F steerable guiding sheath with a 22-mm curve (Destino Twist; Oscor Inc, Palm Harbor, FL, USA).

OPEN IN VIEWER

Figure 1.

(A) Multiplanar reconstruction in maximum intensity projection showing the enlargement of the common iliac artery on the left side, with near detachment of the left limb of the stent-graft. (B) The steerable sheath is inserted via the right femoral artery and positioned above the neobifurcation of the bifurcated stent-graft. After steering the tip of the sheath, a 0.014-inch guidewire was snared from the left femoral artery. (C) The iliac limb is cannulated with a Terumo wire via the steerable sheath. A centimeter sizing catheter is advanced. Note the stable position of the sheath above the neobifurcation (circle marks the flow divider). (D) The Jotec E-Ventus bridging stent-graft is advanced into the hypogastric artery and balloon dilated. Note the rebound of the steerable sheath due to the implanting forces, but still holding the position above the neobifurcation (circle marks flow divider). (E) Completion angiography after removal of the sheaths and wires. The hypogastric artery is normally perfused, and there is no evidence of endoleak.

After cutdown in both groins, standard 0.035-inch wires were inserted. The steerable guiding sheath was inserted via the right groin and positioned over the neobifurcation; a 0.014-inch wire (Roadrunner; Cook Inc, Bloomington, IN, USA) was advanced to the left external iliac artery and then snared via the left femoral artery to establish a through-and-through wire for stabilization (Figure 1B). The E-iliac branch device was than inserted via the left groin and placed over the left iliac bifurcation and opened. Afterward, the iliac limb was cannulated via the steerable sheath (Figure 1C) with a 0.035-inch Terumo wire (Terumo Corp., Somerset, NJ, USA) and then exchanged over a sizing catheter (Cook Inc) to a 0.035-inch Rosen guidewire (Cook Inc). Holding and stabilizing this position with the 0.014-inch through-and-through wire facilitated delivery of the bridging stent-graft (Jotec E-Ventus) to the iliac branch device to achieve complete seal (Figure 1D). Angiography showed normal perfusion of the hypogastric artery and no evidence of endoleak (Figure 1E). The postoperative course was uneventful, and the patient was discharged on postoperative day 7.

Discussion

A limitation of iliac branch device implantation after EVAR is that the normal contralateral femoral approach is not possible. To overcome this problem, a brachial/axillary approach can be used. ⁴ These supra-aortic approaches can be associated with dissection of the vulnerable artery wall, occlusion, embolism, stroke, and local nerve injuries.^{6 –9} We were able to deliver the bridging stent-graft to the hypogastric artery through the iliac limb via a steerable sheath in order to avoid the antegrade approach. This was possible without impairment of the neobifurcation of the bifurcated stent-graft. To achieve enough pushability, a 0.014-inch through-and-through wire was kept taut during the complete delivery procedure.

It is important to pay special attention to maintain the position of the sheath to prevent dislocation of the neobifurcation. As shown in Figures 1C and D, the curve of the steerable sheath should always be over the flow divider. A special mark at the flow divider of the Endurant stent-graft was particularly helpful in maintaining visual control of the sheath position.

In our opinion, it is necessary to prepare the patient before the operation for a supra-aortic approach because in case the procedure should fail from the contralateral femoral side, it still has to be completed after implanting the iliac branched device. It is also necessary to have a stock of iliac limbs on hand should the aortobi-iliac grafts become detached.

Conclusion

The contralateral femoral approach for iliac branch graft implantation can be safely executed in cases with existing bifurcated stent-grafts using a steerable sheath and a through-and-through wire.