Sandwich Technique for Aortoiliac Aneurysms Extending to the Internal Iliac Artery or Isolated Common/Internal Iliac Artery Aneurysms: A New Endovascular Approach to Preserve Pelvic Circulation

Abstract

To describe a new endovascular approach to preserve internal iliac artery (IIA) flow in patients with abdominal aortic aneurysm (AAA) involving the common iliac artery(ies) (CIA) or in cases of isolated CIA/IIA aneurysm. The sandwich technique for isolated CIA/IIA aneurysms or aortoiliac aneurysms extending to the IIA includes 5 steps: (1) bifurcated stent-graft main body insertion through an ipsilateral femoral approach and positioned such that the distal end of the iliac limb is 1 cm above the IIA origin; (2) catheterization of the ipsilateral IIA through a left brachial access with a long 5-F multipurpose catheter and a 0.035-inch extra stiff floppy tip guidewire; (3) placement of a covered self-expanding stent 2 cm inside the IIA with a 6-cm overlap into the iliac limb, followed by positioning of an iliac limb extension 1 cm below the covered stent's proximal end (the iliac limb extension is deployed first and then the covered stent); (4) modeling of the iliac limb stent-grafts using a latex balloon and dilation of the covered stent with an angioplasty balloon; and (5) deployment of the contralateral iliac limb. For bilateral CIA aneurysms extending to both IIAs, repeat steps 2-4. This technique was developed to overcome current anatomical and device constraints, expanding the limits of endovascular aneurysm repair (EVAR) in a safe, easy to perform, and cost-effective manner. The sandwich technique appears a promising tool in the EVAR armamentarium, but more experience with the method is warranted.