Aorto-iliac Endovascular Reconstruction by Kissing Stenting Through Bilateral Brachial Access

Abstract

Nowadays, iliac artery stenting is accepted therapy for aorto-iliac artery disease with or without superficial femoral artery involvement [1–3]. Standard routes for iliac artery angioplasty and stenting are retrotegrade ipsilateral femoral artery access and antegrade controlateral crossing-over femoral access. Bilateral retrograde access is preferable in the case of bilateral aorto-iliac stenosis, whereas antegrade crossing-over access is preferable in cases of controlateral iliac artery occlusion which are poorly approachable retrogradely [4]. In rare cases the procedure cannot be accomplished through standard access and a radial access has been suggested [5]. We report a case of bilateral aorto-iliac occlusive disease, where retrograde routes could not be used, which was managed through a bilateral brachial access and a modified kissing stent technique. A 70-year-old woman affected by hypertension and hypercholesterolemia was referred to our center for syncope, excertional dyspnea, and bilateral claudication with a 15-m threshold. Echocardiography revealed severe aortic valve stenosis, and because she developed rest angina during her first day in hospital, she was listed for coronary angiography. The procedure failed through both retrograde femoral accesses even using a hydrophilic guide wire, so brachial access was used to perform the coronary and left ventricle angiographies. Triple-vessel coronary artery disease (80% stenosis of proximal left anterior descending coronary artery, 90% stenosis of middle circumflex artery, and 70% stenosis of distal right coronary artery) with severe left ventricle dysfunction (ejection fraction, 30%) was detected. Hemodynamic examination confirmed the presence of severe mitral insufficiency. Aorto-iliac angiography showed a calcified and diseased abdominal aorta with subocclusive disease of the aortic bifurcation involving the ostia and body of both common iliac arteries (Fig. 1). A Doppler ultrasound confirmed the presence of both iliac stenosis and patency of both superficial and tibioperoneal arteries. After a collegial discussion with the cardiothoracic staff, due to the need to find a viable access for the balloon counterpulsation catheter which was likely to be required following the surgical procedure, it was decided to submit the patient to endovascular repair of aorto-iliac disease