Abstract
BackgroundEndovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm. However, hostile proximal aneurysmal neck and tortuosity of access vessels remain challenges in selecting optimal stent-grafts in abdominal aortic aneurysms with difficult anatomy.Case presentationA 65-year-old woman complained of intermittent abdominal pain for one week. Computed tomography angiogram demonstrated a tortuous infrarenal abdominal aortic aneurysm with a tapered neck and a 136° of infrarenal angulation. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also showed. Endovascular approach using Endurant stent-graft was attempted at an outside hospital, but failed because of the significant tortuosity of the abdominal aorta and iliac arteries. Since the patient refused to have open aneurysm repair, he was transferred to our hospital for further evaluation and possible EVAR with a different approach. EVAR was performed successfully using Gore Excluder stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA). During the procedure, cannulation of the contralateral limb was unable to be achieved because of the tortuous aortoiliac course. Therefore, a snare was inserted from right radial artery, through the contralateral gate, to grasp the wire from left femoral artery. Two iliac stent-grafts were sequentially deployed with the lower end distal to the opening of the left internal iliac artery. Angiography confirmed complete sealing of the aneurysm with patency of bilateral renal arteries and external iliac arteries. The postoperative courses were uneventful and follow-up computed tomography angiogram at 6 months demonstrated patent bilateral femoral and renal arteries without endoleaks or stent migration.ConclusionAlthough endovascular repair of aortic aneurysm with hostile neck and tortuous access is rather challenging, choosing flexible stent-grafts and suitable techniques is able to achieve an encouraging outcome.
Highlights
Endovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm
Endovascular aneurysm repair (EVAR) has revolutionized the therapeutic strategy for abdominal aortic aneurysm (AAA) with low operative mortality and morbidity, short hospital stay, and minimal blood loss compared with open repair [1,2]
We report an EVAR case with severely angulated neck and hostile artery access treated successfully with Gore Excluder stent-graft system
Summary
Endovascular aneurysm repair (EVAR) has revolutionized the therapeutic strategy for abdominal aortic aneurysm (AAA) with low operative mortality and morbidity, short hospital stay, and minimal blood loss compared with open repair [1,2]. Aneurysmal dilatation and severe calcification of bilateral iliac arteries with a 17 mm and 23 mm diameter on the left and right respectively, and tortuosity of aortoiliac access were showed. An endovascular approach using Endurant stent-graft (Medtronic Vascular, Santa Rosa, CA, USA) was first attempted through left femoral access at an outside institution, but failed to angiographically confirm proximal neck after introducing delivery system below the origin of renal arteries because of the significant tortuosity of the abdominal aorta and iliac arteries. Two iliac stent-grafts of PXL121400 and PXL161407 (W.L. Gore & Associate, Flagstaff, AZ, USA) were successfully placed with the lower end distal to the opening of right internal iliac artery. Bilateral femoral and renal arteries were patent (Figure 3A,B)
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