1. Percutaneous Reconstruction of the Aortoiliac Bifurcation
Presented by:
Amit Nanavati, MD
Cardiology Fellow
Authors:
Amit Nanavati, MD,
Sarang Mangalmurti, MD, Bryan Kluck, DO No disclosures

2. Case Presentation
49 year-old female with dyslipidemia (LDL 207) presents with gangrene of the left second toe (Rutherford 5).
MRA demonstrated infrarenal aortic occlusion with reconstitution prior to the aortoiliac bifurcation with significant right common iliac disease and fair distal flow (TASC D lesion).

3. Left - Initial aortogram demonstrating infrarenal aortic occlusion with distal reconstitution prior to the aortoiliac junction. Significant proximal right common iliac disease also seen.
Center – An angled glidewire was advanced into the left common iliac artery through the 90 cm left brachial sheath and percutaneous transluminal angioplasty (PTA) of the distal aorta was performed.
Right - Little change in flow was noted after PTA. A flap was noted at the origin of the right common iliac

4. Left – Right femoral artery access was obtained and a wire exteriorized through the left brachial sheath
Center – Simultaneous self expanding bare metal stents were deployed in the distal aorta into each the left and right common iliac, effectively recreating the aortoiliac bifurcation. Distinct stenosis is noted in the left common iliac artery.
Right – Balloon expansion of the stents to improve flow

5. Left – Intravascular Ultrasound confirms tissue prolapse in the left common iliac artery. PTA was performed to this region.
Right – Final result demonstrating brisk flow with patent stents and no focal obstructions

6. Discussion
Indications for reconstruction stenting can include infrarenal aortic disease (crossing configuration) or significant iliac disease (abutting configuration)
Persp in Vasc Surg and
Endovasc Ther 2008, 20(1): 50-60

7. Comparison with Surgery
Ann Vasc Surg : 4-13

8. Previous Studies
173 consecutive patients (41% with TASC D lesions) were studied with 1% 30 day mortality
Stent type did not influence patency
Patency rate similar regardless of complexity of lesion
From European Journal of Vascular and Endovascular Surgery Volume 36, Issue

9. Discussion
Access site as well as distal embolization are the primary complications (3.5% vs. 8-13% OR rate)
Geometric mismatch may affect patency rates:
Aggressive disease, graft problems
From Annals of Vascular Surgery Volume 22, Issue

10. Conclusion
Traditional aortobifemoral bypass may be undesirable in younger patients and consideration should be given to percutaneous intervention, which has good outcomes
Contact Information:
Amit Nanavati
Cardiology Fellow
Lehigh Valley Health Network
Allentown, PA