J Korean Med Sci.  2014 Dec;29(12):1678-1683. 10.3346/jkms.2014.29.12.1678.

Surgeon Custom-Made Iliac Branch Device to Salvage Hypogastric Artery during Endovascular Aneurysm Repair

• Park YE
• Lee JH
• Yun WS
• Park KH

• KMID: 2069958
• DOI: http://doi.org/10.3346/jkms.2014.29.12.1678

Abstract

Endovascular salvage of the hypogastric artery using iliac branch device (IBD) during endovascular aortic aneurysm repair (EVAR), offers less invasive alternative solution to surgery to prevent pelvic ischemia. We have performed the first Korean surgeon custom-made IBD for this purpose to overcome the limitation of unavailability of the devices in Korea. Four patients with abdominal aortic aneurysm with bilateral common iliac artery aneurysm (CIAA) were treated using custom-made IBDs from October 2013 to December 2013. IBD was created in back table before EVAR operation using TFLE Zenith iliac limb stent graft (Cook Inc.). Three V12 (Atrium, Inc.) one Viabahn (Gore, Inc.) were used for bridging between IBD and target hypogastric artery. With this modification of IBD procedure, exteriorize the guide wire without snare device is possible which offers another benefit in terms of reducing medical costs comparing to commercial IBD. All operations were successful without any device related complications or postoperative endoleaks. During the mean follow up of 3 months, all IBD were patent without clinical complications. Surgeon custom made IBD is feasible and useful to preserve pelvic perfusion especially in the situation of limited commercial IBD availability in many countries. Long-term follow-up is needed to evaluate stent graft patency and IBD-related complications.

Keyword

Iliac Branch Device; Custom-Made; Endovascular Aneurysm Repair

MeSH Terms

Aged
Aortic Aneurysm, Abdominal/*surgery
*Blood Vessel Prosthesis
Endovascular Procedures/*instrumentation
Equipment Design
Equipment Failure Analysis
Female
Humans
Iliac Aneurysm/*surgery
Iliac Artery/*surgery
Male
Salvage Therapy/*instrumentation/methods
*Stents

Figure

• 

  Fig. 1 Back table customization of IBD (liac branch device) with Cook Zenith TFLE 12-73 iliac stent graft limb. (A) Partial proximal deploy of limb. (B) Elliptical graftotomy is made round 2nd row of stent column using electric cautery. (C) 15 mm long cuff, using PTFE (polytetrafluoroethylene) graft is sutured with Prolene sutures. (D) For distal cuff orientation, gold marker is attached to cuff (black arrow). (E) Completed modification of IBD. (F) Proper shape of angio-catheter with guidewire preloaded through cuff to enhance iliac artery cross-over. (G) Custom made IBD with PTFE cuff.

• 

  Fig. 2 Procedure of IBD (iliac branch device) during EVAR (endovascular aortic aneurysm repair). (A) Two operators work cooperatively to reload IBD into big sheath (20 Fr Saint Jude, Inc.) with preload angio catheter. (B) First step, big sheath is introduced to aortic bifurcation level at ipsilateral side. (C) After introducing IBD, guidewire is passed and exteriorized with proper type of angio-catheter. (D) Using guidewire as through-through guidewire, proper sized of sheath to introduce covered stent is advanced up to cuff of IBD. (E) After cannulation of target hypogastric artery, the length between cuff and hypogastric artery needs to be measured with sizing catheter. (F) Balloon expandable stent-graft is used for aneurismal changed hypogastric artery to adjust distal sealing zone. (G) After deploying main body via contralateral side for EVAR, bridging between contralateral limb and IBD is proceeded. (H) In final aortogram, there is no endoleak. (I) In early post operative CT angiogram, the patency of IBD is confirmed.

• 

  Fig. 3 Procedure in case number 4. (A) Preoperative CT angiogram showed 8 cm abdominal aortic aneurysm with severe angle between common iliac artery. (B) The procedure was challenging by difficulties in advancing limb stent graft to avoid displacement of pre-deployed IBD, flexible limb stent graft with paving sheath is used. (C) In postoperative follow up CT angiogram, successful aneurysm exclusion is accomplished without endoleak.

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