Alternative access techniques with thoracic endovascular aortic repair, open iliac conduit versus endoconduit technique Guido H.W. van Bogerijen, MD,

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Presentation transcript:

Alternative access techniques with thoracic endovascular aortic repair, open iliac conduit versus endoconduit technique Guido H.W. van Bogerijen, MD, David M. Williams, MD, Jonathan L. Eliason, MD, Narasimham L. Dasika, MD, G. Michael Deeb, MD, Himanshu J. Patel, MD Journal of Vascular Surgery Volume 60, Issue 5, Pages 1168-1176 (November 2014) DOI: 10.1016/j.jvs.2014.05.006 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 Key steps of the endoconduit (EC) approach. A, Left iliac angiogram demonstrates a stenotic segment in the left common iliac artery and a high grade stenosis of the origin of the left hypogastric artery. Because of the small caliber left external iliac artery and delivery sheath occlusion, no filling with contrast was identified in this vessel. We believe that this patient required an alternative access approach and in this case the EC approach was chosen. B, A balloon was advanced from the left femoral artery access and placed in the left common iliac artery to perform angioplasty of the critical stenotic segment. After angioplasty the entire left common iliac artery segment is theoretically large enough to be able to advance the required delivery sheath (24 French). C, The internal EC was partially deployed in the left external iliac artery. D, From the contralateral/right side a balloon was placed in the ipsilateral/left proximal common iliac artery. In cases with a widely patent internal iliac artery, a compliant balloon is sometimes extended into the ipsilateral hypogastric artery. After this proximal control is established, angioplasty and subsequent controlled rupture of the midportion of the left external iliac artery is performed. E, A control angiogram was performed to detect if the patient had ongoing hemorrhage. The iliac arteriogram revealed extravasation of contrast into the pelvis at the proximal landing zone of the iliac stent graft. F, Treatment was proximally extended into the common iliac artery. After extension proximally with two stent grafts in the left common iliac artery to the aortic bifurcation and eventually relining the entire iliac segment with another stent graft, a final control angiogram showed an excluded endoleak without extravasation of contrast into the pelvis. Note crosspelvic collaterals filled distal left hypogastric artery branches after coverage of the origin of the left hypogastric origin. Right to left collaterals were well developed because of pre-existing high grade stenosis of the origin of the left hypogastric artery. Journal of Vascular Surgery 2014 60, 1168-1176DOI: (10.1016/j.jvs.2014.05.006) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 The endoconduit (EC) approach of the external iliac artery only. A, A marker pigtail catheter was used to measure the length of the iliac artery and a right iliac angiogram was performed, which showed a widely patent origin of the right hypogastric artery. In this patient the right common iliac artery was of adequate diameter and only right external iliac artery disease appeared to preclude passage of the 24 French stent graft delivery sheath. Therefore, an EC approach bridging the right external iliac artery was chosen. B, The stent graft was deployed in the right external iliac artery and was narrowed by a stenotic segment in the middle portion of this vessel. C, By advancing a sheath from the contralateral/left side and placing a compliant balloon into the ipsilateral/right common and internal iliac arteries, proximal control of the iliofemoral system was established. After proximal control, the right external iliac artery is intentionally ruptured in a controlled fashion. The catheter from the contralateral/left side is placed into the right hypogastric artery, for two additional reasons. It marks the origin of the hypogastric artery to aid precise placement of the EC. It also maintains access to the right hypogastric artery in case coiling of the vessel origin is required. D, Retrograde injection of contrast showed no extravasation. Passage of the stent graft delivery sheath (24 French) was smooth and uneventful. Journal of Vascular Surgery 2014 60, 1168-1176DOI: (10.1016/j.jvs.2014.05.006) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 The endoconduit (EC) approach for the common and external iliac arteries with preservation of the hypogastric artery. A, The preoperative three-dimensional reconstruction of the aorta and iliofemoral system is shown. This patient was selected for thoracic endovascular aortic repair (TEVAR) with an EC approach for the right common iliac artery, and the right external iliac artery was considered of adequate size to pass the required stent graft delivery sheath. Preoperatively, this patient was considered to be at high risk for paraplegia and therefore preservation of the hypogastric artery was desirable. B, The EC was dilated after deployment in the right common iliac artery. C, The femoral artery sheath could not be advanced into the aorta because of resistance in the proximal right external iliac artery, with the arteriogram showing narrowing of the iliac bifurcation and the proximal right external iliac artery. D, Another stent graft was deployed in the right external iliac artery with preservation of the origin of the right hypogastric artery. As the stent graft was post dilated with the balloon, the narrowed middle portion of the right external iliac artery was intentionally ruptured. The iliac artery segment at the level of the origin of the hypogastric artery was of normal caliber allowing passage of a stent graft delivery sheath (24 French) without risking uncontrolled iliac artery rupture in that section. E, A control angiogram shows no extravasation of contrast into the pelvis and preservation of the right hypogastric artery between the proximal and distal ECs. F, Postoperative three-dimensional reconstruction of the iliofemoral tract demonstrated ECs in the right iliac artery with preservation of the right hypogastric artery. Journal of Vascular Surgery 2014 60, 1168-1176DOI: (10.1016/j.jvs.2014.05.006) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 Two-year Kaplan-Meier survival curve for the endoconduit (EC) vs the retroperitoneal open iliac conduit (ROIC) approach, with the numbers at risk demonstrated for the two different approaches at 0, 12, and 24 months. Cumulative surviving time is 66.1 ± 12.5% at 2 years. The standard error exceeds 10% after 4 months for the EC approach and after 13 months for the ROIC approach. Journal of Vascular Surgery 2014 60, 1168-1176DOI: (10.1016/j.jvs.2014.05.006) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 Freedom from late limb loss, claudication, or revascularization. Two-year Kaplan-Meier analysis between the retroperitoneal open iliac conduit (ROIC) and endoconduit (EC) approaches is shown with the numbers at risk at 0, 12, and 24 months. Cumulative surviving time is 75.0 ± 21.7% at 2 years. The standard error exceeds 10% after 14 months for the EC approach and does not exceed 10% for the ROIC approach during the 2-year follow-up. Journal of Vascular Surgery 2014 60, 1168-1176DOI: (10.1016/j.jvs.2014.05.006) Copyright © 2014 Society for Vascular Surgery Terms and Conditions