Successful Endovascular Repair of a Narrow-Ruptured Aorta With an Iliac Branch Device: Case Report and Literature Review

Introduction

Iliac branch devices (IBDs) have become, in the last decades, a safe and effective option with excellent mid-term outcomes for the treatment of iliac artery and aorto-iliac aneurysms while maintaining hypogastric artery patency. With the development of endovascular expertise, some off-label uses of these devices have already been reported. We describe the case of a very narrow ruptured infrarenal aorta treated with a Gore iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) used as a bifurcated aortic stent graft. A complete literature review of IBD off-label applications is included. Written informed consent was obtained prior to writing this report.

Case Report

A 47-year-old man was admitted to the emergency department of our hospital with acute abdominal pain and hypotension. Anamnesis revealed a history of intravenous drug addiction (cocaine), hypertension, long-term ischemic heart disease, obesity, and hepatitis C virus (HCV)-related long-term hepatitis. Blood test results included: white blood cell count, 40 000/μl (90% neutrophils); hemoglobin level, 9 mg/dL; creatinine, 1.4 mg/dL; C-reactive protein level, 26 mg/dL; electrocardiogram (ECG) findings: tachycardia (105 bpm), previous anterior wall myocardial infarction, and left ventricular hypertrophy. Urgent thoracic-abdominal computed tomography (CT) demonstrated a ruptured infrarenal aorta with large retroperitoneal hematoma (Figure 1). Owing to the unstable hemodynamics, the multiple comorbidities, the obesity, and the suspicion of an infected aorta complicated with sepsis, an endovascular emergent treatment was chosen.

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Figure 1.

Axial (A) and coronal (B) sections showing a ruptured infrarenal aorta with large retroperitoneal hematoma.

The preoperative planning showed lengths, angulations, iliac axes, and access vessels suitable for endovascular repair. However, the proximal aortic neck and the distal aortic diameters were too narrow (13.5 vs 14 mm of caliber) for many available bifurcated devices, and this would have precluded the contralateral limb from opening (Figure 2). Therefore, our strategy based on using a Gore IBE (Figure 3) as a bifurcated aortic stent graft, immediately available in our warehouse and considered helpful with his precannulated gate in case of not proper opening of the contralateral limb. The intervention was performed under general anesthesia in a hybrid room. Through a bilateral percutaneous ultrasound-guided groin access via common femoral arteries Gore Excluder IBE (23-12-100 mm) was placed as main body, inserted through the right femoral artery, and deployed just below the right renal artery while the initial angiogram was carried out through left femoral access (Figure 4A). The procedure was completed with a Gore iliac extension bilaterally (left: 16-12-120, right 16-12-70 mm) above the iliac bifurcations. There were no intraoperative complications. Postoperative angiogram showed a correct positioning of the endoprosthesis with a complete exclusion of the aortic rupture and patency of renal and iliac arteries (Figure 4B). Total operative time was 75 min, and fluoroscopic time was 20 min. Blood cultures resulted positive for Candida albicans, Staphylococcus aureus, and Streptococcus pyogenes. The patient has been discharged from hospital after 20 days without signs of sepsis (white blood cell [WBC] 9000 u/L, C-reactive protein [CRP] 1, procalcitonin [PCT] 0.2). However, a long-term antibiotic therapy (daptomycin 8 mg/kg/die, clindamycin 900 mg 3 times/die, fluconazole 800 mg/die) was started.

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Figure 2.

Aortic diameters at rupture level (A) and aortic bifurcation (B).

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Figure 3.

Gore iliac branch endoprosthesis.

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Figure 4.

Preoperative (A) and postoperative (B) angiogram.

The 6-month CT scan revealed a well-positioned stent graft, no signs of infections, with preserved renal and iliac flow (Figure 5).

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Figure 5.

Six-month CT scan showing the aortic rupture coverage with renal and iliac arteries patency.

Discussion

During the last years, IBDs became a valid option to preserve hypogastric artery in patients with common iliac artery and aorto-iliac aneurysms.^1–3 There are currently 5 IBD designs by 3 different manufacturers. If used within instructions for use (IFU), IBDs show excellent technical success and patency rates at early and mid-term follow-up, without increase in mortality or stent-graft-related complications.^4–6 However, with the improvement of the expertise in endovascular treatments, different successful off-label use of these devices has been recently reported.^7–15 In this case, the CT scan revealed a very small native aorta (13.6 mm at the narrowest section), and the possibility of facing an aortits was very high. A suspected infected aorta is one of the most challenging problems for vascular surgeons due to the associated high morbidity and mortality, and open surgical repair (OSR) is still considered the gold standard for a definitive treatment. Open surgical repair involves surgical resection, debridement of the infected aorta, and peri-aortic tissue, in situ or extra-anatomical arterial reconstruction, followed by a long-term antibiotic therapy.^1,3 Nevertheless, most recent studies with a long-term follow-up suggest that endovascular repair may have a short-term benefit over OSR, with no late disadvantages. Endovascular treatment is a less-invasive alternative than OSR, and according to the latest guidelines of the mycotic aortic aneurysms, may be a durable treatment if associated with long-term antibiotic therapy, and it can be considered in emergency situations as a bridge to later definitive surgery.^1,3 In our patient, an OSR with transperitoneal approach was excluded because of multiple comorbidities and hostile abdomen (obesity), while a retroperitoneal approach was supposed to be time-consuming, thus a less-invasive treatment was preferred. However, the small diameters of the aorta made the use of a bifurcated stent graft very challenging due to the high risk of a failure of the contralateral gate opening and/or subsequent cannulation. Aorto-uniliac devices with a femoral crossover bypass, or unibody stent grafts were also excluded because of the urgent setting (not available “off-the-shelf” at our Institution). In addition, the aneurysm morphology may have theoretically allowed treatment with a straight tube graft, a bifurcated device was selected due to its potentially greater efficacy in ensuring stable fixation and sealing. To manage these issues, we opted for an off-label use of Gore IBE, immediately available in our warehouse. It has 2 primary components: the iliac branch component (a bifurcated device with an external iliac leg and an internal iliac artery gate) and the internal iliac component. The internal iliac gate presents a removable guidewire tube, with a preloaded flexible through-wire that allows a through-and-through technique for a fast internal iliac artery cannulation. Although the IFU requires a minimum diameter of 17 mm at the proximal implantation zone, the precannulated gate could be very useful to perform bailout maneuvers in case of not proper opening. Some off-label uses of different IBDs have been already reported. Piazza et al ⁷ reported 13 cases of IBD used as an infrarenal abdominal bifurcated endograft in cases unsuitable for standard endovascular (6 aortic repair abdominal and/or iliac aneurysms, 3 occlusive disease, and 4 complex aneurysms in association with a proximal fenestrated/branched endograft). Also, 3 cases of a Gore Excluder IBE used in an off-label fashion as main body were described in literature: to rescue an acutely occluded aorto-femoral bypass, ⁸ to treat a bilateral common iliac artery aneurysm in aortic bifurcation narrowness in previous open aortic repair, ⁹ and to exclude a posttraumatic aortic pseudoaneurysm. ¹⁰ In addition, a case of revascularization of an occluded aorto-bifemoral bypass using Rotational Excisional Atherectomy System (Rotarex [Straub Medical AG, Wangs, Switzerland]) combined with IBE has been described. ¹¹ The Cook IBD was the first iliac bifurcated device used to treat an aortic aneurysm in a very narrowed aorta, in association with an Advanta V12 balloon expandable stent graft released proximally. ¹² Hwang et al ¹³ reported a case of an isolated common iliac artery aneurysm and a tapered narrow aorta treated with concomitant off-label use of a Cook IBD and a reversed Medtronic Endurant Iliac limb. Rossi et al ¹⁴ and Gemayel, ¹⁵ respectively, presented 2 other cases of a Jotec IBD successfully placed at the aortic bifurcation in a narrowed aorta. To date, this is the first case which reported the use of a Gore IBE to treat a suspected infected narrow ruptured aorta.

Conclusions

The endovascular approach is a less-invasive alternative compared to open surgery and in emergency settings may be a life-saving bridge treatment particularly in unstable patients. With the improvement of vascular surgeons’ expertise, more devices are used in off-label fashions with acceptable results mostly in challenging situations. The use of a Gore Excluder IBE as a bifurcated aortic stent graft can be a good tool in case of aortic rupture when presented with small calibers even in urgent settings.