Management of complex juxtarenal total aortoiliac occlusion following failed open and endovascular interventions

Abstract

PurposeTo present two cases of complex juxtarenal aortoiliac occlusions with failed previous aortic open and endovascular interventions, treated via aortoiliac endovascular recanalization due to presentation of chronic limb threatening ischemia. Case descriptionCase 1: A 67-year-old Caucasian male former smoker with multiple severe cardiac and pulmonary comorbidities presented with bilateral lower extremity ischemic rest pain. He had a history of prior open abdominal aortic aneurysm (AAA) repair with a tube graft that was acutely complicated and required two common iliac interventions with stents at an outside hospital but which re-thrombosed within a few months. He presented to us with a history of two years of physical limitations and an aortoiliac occlusion that was flush to the renal arteries. Endovascular recanalization of the infrarenal aorta, bilateral iliac arteries, and previous stents was achieved successfully with a complex crossing technique and a combination of covered and bare-metal stents. On a 36-month follow-up, he remained free of claudication, with palpable pedal pulses bilaterally. Case 2: A 64-year-old Caucasian male former smoker, with multiple cardiovascular and metabolic comorbidities presented with a painful non-healing ulcer on the left fourth toe and signs of sepsis. He had a history of aortoiliac occlusive disease and multiple prior endovascular revascularizations. Computed tomography angiogram (CTA) showed chronically occluded iliac artery stents as well as bilateral occlusions of the common and external iliac arteries. In addition, his left superficial femoral artery was occluded at the level of the adductor hiatus with significant collaterals reconstituting the popliteal artery. A diagnosis of acute, focal osteomyelitis secondary to complex vascular occlusion was made. A decision to pursue incision and drainage of the foot abscess followed by hybrid left lower extremity revascularization was made. An open left femoral endarterectomy with bovine patch angioplasty and endovascular recanalization of the left aortoiliac system by relining with stent-grafts was performed along with an amputation of his left fourth toe. On 6-month follow-up, he remained symptom-free with improved ankle-brachial index (ABI) and almost fully healed left foot. ConclusionAlthough challenging, total percutaneous or hybrid approach for management of complex juxtarenal total aortoiliac occlusions with previously failed covered-stents or open aortic repair can be done successfully with extensive preoperative planning and carefully selected patients.