Contralateral Common Iliac Artery Research Articles

Validating a 3D-printed endovascular simulator for use in training surgical residents

ObjectiveThree-dimensional (3D)-printed endovascular models can be an accessible alternative to expensive, state-of-the-art endovascular simulators but currently lack the rigorous validation needed to be dependable educational tools. This study describes the manufacture of a 3D-printed endovascular model of an aorta and determines the construct validity and preliminary content and face validity of the model. MethodsA 3D-printed aorta was created using segmented data from a patient computerized tomography scan and a FormLabs 3B 3D printer with FormLabs Clear resin. Participants were asked to perform two tasks from a femoral access point: catheterize the contralateral common iliac artery and the superior mesenteric artery. Participants were assessed for task completion, technique, and time. Performance was compared between levels of education (medical student vs lower-year resident vs upper-year resident vs attending) and levels of endovascular experience (<5 procedures vs 6-20 procedures vs 21-100 procedures vs >100 procedures). Users completed questionnaires assessing the face and content validity of the simulator after their participation. Results48 participants were recruited (12 medical students, 19 lower-year residents, 13 upper-year residents, and 4 attendings). Of these, 26 participants had performed <5 procedures, 10 had performed 6 to 20 procedures, 7 had performed 21 to 100 procedures, and 5 had performed >100 real-world procedures. Neither education level nor experience level correlated with task completion. Increasing levels of training progressively increased rates of correct technique for both tasks combined (8% vs 21% vs 46% vs 75%, P = .032) and decreased cumulative time (307.3 vs 252.2 vs 185.8 vs 139 seconds, P = .005). Similarly, increased levels of experience progressively increased rates of correct technique for both tasks combined (7% vs 50% vs 71% vs 80%, for increasingly experienced groups, P < .001) and decreased cumulative completion times (276 vs 237 vs 187 vs 113 seconds, P = .003) for both tasks. Multivariate analysis showed that training level was not a predictor for time taken to complete any task, while experience level was a predictor for superior mesenteric artery cannulation time (P < .02). Participants rated the model as having somewhat realistic haptics, dissimilar “look and feel” to the operating room, and strongly believed that the model was valuable for practicing endovascular surgery. ConclusionsThese findings verify the construct validity of this endovascular simulator, as those with the most real-world experience used a correct technique more often and completed the tasks the fastest. Survey results supported the content validity of the model. Basic 3D-printed endovascular models should be considered as an affordable, readily accessible adjunct to surgical education.

Validating a 3D-Printed En7dovascular Simulator for Use in Training Surgical Residents

Endovascular simulators have become a standard in education for surgical residents. However, these products are expensive to purchase and maintain, limiting their accessibility. Endovascular models created using in-house 3D printing can be an affordable alternative but currently lack the rigorous validation needed to be a dependable educational tool. The purpose of this study is to determine the construct validity of a 3D-printed endovascular model of an aorta. A 3D rendering of an aorta was created using a patient computed tomography scan and subsequently printed on a Form B printer with transparent clear V4 resin (Fig 1). The pieces were combined to create a final product with a material cost of $50. Participants were asked to perform 2 tasks from a femoral access point: catheterizing the contralateral common iliac artery and cannulating the superior mesenteric artery (SMA). For each task, a 5-point rubric was created to assess whether all components of the tasks were done correctly. Participants were also assessed on the time taken to perform the tasks. Participants’ level of education (medical student vs surgical resident vs attending) and level of endovascular experience (<5 procedures = no experience, 6-100 = some experience, and >100 extensive experience) were noted. Of a total of 37 participants, 12 were medical students, 21 were residents, and 4 were attendings. A total of 26 participants had no experience, 6 had some experience, and 5 had extensive experience. Neither education level nor experience level had a significant bearing on whether either task was completed. Those with higher education completed the SMA task more accurately (P = .007), but this pattern was not observed for higher levels of experience. Univariate analysis shows that both higher education and greater experience resulted in faster times for both tasks, but multivariate analysis shows that only the level of experience was a predictor for faster completion (Fig 2, P = .02). This is reinforced by the finding that among participants with no experience, higher levels of education do not result in faster times (P = .16). These findings verify the construct validity of this endovascular simulator, as those with the most real-world experience completed the tasks the fastest. The observation that residents did more of the steps correctly than medical students may be because they have greater knowledge of endovascular procedures, but this did not translate to faster performance, which requires muscle memory. Basic 3D-printed endovascular models should therefore be strongly considered as an affordable, readily accessible adjunct to surgical resident education.Fig 2Combined time, in seconds, for participants with no experience, some experience, and extensive experience to complete the catheterization of the contralateral common iliac artery and superior mesenteric artery (SMA). Error bars show 95% confidence interval (CI). Increasing real-world endovascular experience trends with decreased completion times, with statistical significance (P < .05) achieved between the “no experience” and “extensive experience” groups, denoted by *.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Ectopic vascularization of the right kidney arising from contralateral common iliac artery

Variant renal arteries have been reported in 20~30% of the entire population. The anatomic variations among advanced patients should be investigated when performing surgery or interventional procedures on the kidney. Most variant renal arteries originated from various level of the abdominal aorta. Very rarely, this case shows renal artery originated from the contralateral common iliac artery with other accessory arteries. MDCT angiography revealed several anatomical variants of the right kidney. There were four right renal arteries. The main renal artery originated from the left proximal common iliac artery and other renal artery originated from the aortic bifurcation. The other two renal arteries arose from the abdominal aorta, lower thoracic T12 level and lower lumbar L4 level. The right kidney was located at the level of the third to fifth lumbar vertebra. And renal pelvis of the right kidney was laterally rotated. This case documented a rare anatomic variant, involving multiple accessory renal arteries, including the main artery originating from the contralateral iliac artery, caused by a specific renal embryological condition. These variants should be analysed to effectively perform surgical and interventional procedures.

Endovascular management of unilateral common iliac artery ostial occlusive disease; bilateral kissing stents, unilateral stent with contralateral supporting balloon or unilateral stent with contralateral safety wire; comparative study

Aim To evaluate the safety, early, and short-term efficacy of kissing stents, unilateral common iliac artery (CIA) stent with contralateral supporting balloon, and unilateral CIA stent with contralateral safety wire in patients with symptomatic unilateral CIA ostial occlusive disease. Patients and methods This prospective study was carried out from April 2016 to November 2019 at 6 October Insurance Hospital, Cairo, and Sohag University Hospitals on 79 patients complaining of de novo unilateral CIA ostial occlusive disease, Rutherford category 3, 4, and 5, who were divided randomly into three groups to be treated endovascularly by bilateral kissing stent technique (group A), unilateral CIA stent in affected side associated with supporting balloon in the contralateral CIA (group B), or unilateral CIA stent in affected side associated with a safety wire in the contralateral CIA (group C). Patients were scheduled to be evaluated and followed up for 1 year. Results Technical success rate was 100, 87, and 67.9 in groups A, B, and C, respectively (P=0.006). One-year primary patency rate was 91.7, 90.9, and 87.5% in groups A, B, and C, respectively (P=0.998). A total of seven (9.3%) patients developed significant stenosis. Of the seven patients, and three continued medically, as they were claudicant; three cases were treated by drug-coated balloon angioplasty, and one patient by aortofemoral bypass. Plaque shift incidence was 4.3 and 14.3% in groups B and C, respectively (P=0.095). Distal embolization occurred in the contralateral side in 8.7 and 17.9% in groups B and C, respectively (P=0.083). Conclusion Kissing stent technique for treatment of unilateral ostial CIA occlusive disease achieves excellent technical success with minimal early and short-term procedure-related complications compared with unilateral stent with contralateral supporting balloon or unilateral stent with contralateral safety wire.

Morphology and Computational Fluid Dynamics Support a Novel Classification of Common Iliac Aneurysms

Isolated common iliac artery aneurysms (CIAAs) are uncommon, and evidence concerning their development, progression, and management is weak. The objective was to describe the morphology and haemodynamics of isolated CIAAs in a retrospective study. Initially, a series of 25 isolated CIAAs (15 intact, 10 ruptured) in 23 patients were gathered from multiple centres, reconstructed from computed tomography, and then morphologically classified and analysed with computational fluid dynamics. The morphological classification was applied in a separate, consecutive cohort of 162 patients assessed for elective aorto-iliac intervention, in which 45 patients had intact CIAAs. In the isolated CIAA cohort, three distinct morphologies were identified: complex (involving a bifurcation); fusiform; and kinked (distal to a sharp bend in the CIA), with mean diameters of 90.3, 48.3, and 31.7 mm, and mean time averaged wall shear stresses of 0.16, 0.31, and 0.71 Pa, respectively (both analysis of variance p values < .001). Kinked cases vs. fusiform cases had less thrombus and favourable haemodynamics similar to the non-aneurysmal contralateral common iliac artery (CIA). Ruptured isolated CIAAs were large (mean diameter 87.5 mm, range 55.5–138.0 mm) and predominantly complex. The mean CIA length for aneurysmal arteries was greatest in kinked cases followed by complex and fusiform (100.8 mm, 91.1 mm, and 80.6 mm, respectively). The morphological classification was readily applicable to a separate elective patient cohort. A new morphological categorisation of CIAAs is proposed. Potentially this is associated with both haemodynamics and clinical course. Further research is required to determine whether the kinked CIAA is protected haemodynamically from aneurysm progression and to establish the wider applicability of the categorisation presented.

Native Microchannel Recanalization with Orbital Atherectomy as a Viable Alternative to Failed Standard Recanalization of TASC II D Aortoiliac Occlusive Disease

Endovascular treatment of Trans-Atlantic Inter-Society Consensus (TASC) II D aortoiliac lesions is now an accepted form of revascularization. We sought to demonstrate that native microchannel recanalization and orbital atherectomy is a successful recanalization method of TASC II D aortoiliac lesions refractory to standard recanalization techniques. Four consecutive patients from 2016 to 2018 with symptomatic TASC II D aortoiliac occlusive disease prohibitive for open bypass and failed traditional prodding guidewire or device recanalization technique were identified and underwent advanced native microchannel selection and subsequent orbital atherectomy (Cardiovascular Systems, Inc, St Paul, MN). Native microchannels of the calcified lesions were probed and traversed with a 0.014″ wire. The atherectomy crown was tracked over the wire, and orbital atherectomy was initiated with a 1.25mm crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2mm-balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. The kissing stent technique was then used to recreate the aortic bifurcation. A ViperSlide lubricant solution was used in all cases per indication for use. Patients were all heparinized to maintain an activated clotting time of 250. Lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were also analyzed. All 4 patients underwent successful native microchannel recanalization and orbital atherectomy of the common iliac artery (CIA). There were no intraoperative ruptures, embolizations, or dissections. All 4 patients presented with unilateral CIA occlusion with contralateral CIA stenosis. The average occlusion lesion length of the CIA was 6.0cm. The average contralateral stenosis length was 2.3cm. The kissing stent technique was used in all patients for reconstruction of the aortic bifurcation. At 30days, all patients had improvement in pain and primary patency of 100%. Long-term follow-up at 21.6months noted continued improvement in symptoms and primary patency of 75%. The fourth patient died at 4months from lung cancer with occluded iliac stents by imaging at that time. Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aortoiliac disease who have failed traditional recanalization techniques. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

Morphology and Computational Fluid Dynamics Support a Novel Classification of Common Iliac Aneurysms

Isolated common iliac artery aneurysms (CIAAs) are uncommon, and evidence concerning their development, progression, and management is weak. The objective was to describe the morphology and haemodynamics of isolated CIAAs in a retrospective study. Initially, a series of 25 isolated CIAAs (15 intact, 10 ruptured) in 23 patients were gathered from multiple centres, reconstructed from computed tomography, and then morphologically classified and analysed with computational fluid dynamics. The morphological classification was applied in a separate, consecutive cohort of 162 patients assessed for elective aorto-iliac intervention, in which 55 patients had intact CIAAs. In the isolated CIAA cohort, three distinct morphologies were identified: complex (involving a bifurcation); fusiform; and kinked (distal to a sharp bend in the CIA), with mean diameters of 90.3, 48.3, and 31.7mm, and mean time averaged wall shear stresses of 0.16, 0.31, and 0.71Pa, respectively (both analysis of variance p values<.001). Kinked cases vs. fusiform cases had less thrombus and favourable haemodynamics similar to the non-aneurysmal contralateral common iliac artery (CIA). Ruptured isolated CIAAs were large (mean diameter 87.5mm, range 55.5-138.0mm) and predominantly complex. The mean CIA length for aneurysmal arteries was greatest in kinked cases followed by complex and fusiform (100.8mm, 91.1mm, and 80.6mm, respectively). The morphological classification was readily applicable to a separate elective patient cohort. A new morphological categorisation of CIAAs is proposed. Potentially this is associated with both haemodynamics and clinical course. Further research is required to determine whether the kinked CIAA is protected haemodynamically from aneurysm progression and to establish the wider applicability of the categorisation presented.

Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery

We present a patient requiring aorto-uni-iliac (AUI) endovascular aneurysm repair with a review of indications and outcomes of this procedure. A 72-year-old male presented at Jain Institute of Vascular Sciences due to infrarenal saccular abdominal aortic aneurysm with a maximum diameter of 4.5 cm. A low-lying, the dominant left accessory renal artery with inadequate length from the origin of the left accessory renal artery to aortic bifurcation (50 mm) precluded the deployment of a bifurcated device (since the length of the aorta from the origin of the left accessory renal artery to aortic bifurcation was inadequate for the contralateral limb to open). Hence, AUI stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femorofemoral bypass was performed.

In Situ Fenestration to Convert an Aorto-Uni-Iliac Into a Bifurcated Endograft

Introduction - Narrow distal aorta and severely calcified aorto-iliac occlusive disease (AOID) represent conditions at risk of failure during endovascular aortic repairs. In such situations, an aorto-uni-iliac repair associated with a crossover femoro-femoral bypass (CFFB) may be preferable. We here present the results of an in situ fenestration (ISF) technique that allows conversion of an aorto-uni-iliac endograft (AUIE) into a bifurcated repair. Methods - Between January 2014 and January 2017, 163 patients underwent standard EVAR in our department. Among them, 20 patients (12%) underwent ISF of AUIE. All were considered at high surgical risk. After AUIE deployment, ISF was performed through the contralateral common iliac artery with a transjugular intrahepatic access set. The fabric hole was enlarged with a cutting balloon, and kissing iliac covered stents were positioned to convert the AUIE into a bifurcated repair. Data was collected prospectively. Results are presented as median with range. Results - The series included 13 males (65%) and 7 females (35%), aged 77 year-old (range, 37-88). Distal aortic diameter was 13 mm (range, 9-17). CFFB was felt at risk for complication in all cases for various reasons (radiation therapy, corticosteroids, small external iliac arteries, calcified femoral arteries, obesity). Indication for ISF was (1) an abdominal aortic aneurysm (AAA) with a narrow distal aorta (<14mm), (2) bilateral severely calcified AOID and (3) ruptured AAA in 10 (50%), 8 (40%) and 2 (10%) patients, respectively. The punctured graft was made of Dacron in 14 cases (70%) and a PTFE in 6 cases (30%). Technical success was 90%. The two failures were patients who had prior iliac ligation. Fluoroscopy time was 28 minutes (range, 15-46) and 90 cc (range, 70-140) of contrast product were necessary. There was no death or systemic complication, especially no postoperative bleeding. Hospitalization duration was 6 days (2-14). With a follow-up of 12 months (range, 1-20), all repairs were patent on last CT-scan. No endoleak was observed at the ISF site. Conclusion - This technique represents another application of ISF. Although it remains an off-label technique, it provides a bifurcated repair in cases where it is usually considered at risk. ISF use in other aortic sites, such as the visceral aorta, remains to be evaluated.

Morphology and Hemodynamics in Isolated Common Iliac Artery Aneurysms Impacts Proximal Aortic Remodeling.

Objective- Isolated common iliac artery aneurysms (CIAA) are rare. Their prognosis and influence on aortoiliac blood flow and remodeling are unclear. We evaluated the hypotheses that morphology at and distal to the aortic bifurcation, together with the associated hemodynamic changes, influence both the natural history of CIAA and proximal aortic remodeling. Approach and Results- Twenty-five isolated CIAAs (15 intact, 10 ruptured), in 23 patients were reconstructed and analyzed with computational fluid dynamics: all showed abnormal flow. Then we studied a series of 24 hypothetical aortoiliac geometries in silico with varying abdominal aortic deflection and aortic bifurcation angles: key findings were assessed in an independent validation cohort of 162 patients. Wall shear stress in isolated unilateral CIAAs was lower than the contralateral common iliac artery, 0.38±0.33 Pa versus 0.61±0.24 Pa, inversely associated with CIAA diameter ( P<0.001) and morphology (high shear stress in variants distal to a sharp kink). Rupture usually occurred in regions of elevated low and oscillatory shear with a wide aortic bifurcation angle. Abdominal aortas deflected towards the CIAA for most unilateral isolated CIAAs (14/21). In silico, wider bifurcation angles created high focal regions of low and oscillatory shear in the common iliac artery. The associations of unilateral CIAA with aortic deflection and common iliac artery diameter with bifurcation angle were confirmed in the validation cohort. Conclusions- Decreasing wall shear stress is strongly associated with CIAA progression (larger aneurysms and rupture), whereas abnormal blood flow in the CIAA seems to promote proximal aortic remodeling, with adaptive lateral deflection of the abdominal aorta towards the aneurysmal side.

A novel application of the culotte stent technique to bail out a jailed common iliac artery

Implanting a self-expandable stent at the ostium of the common iliac artery (CIA) may lead to coverage of the orifice of the contralateral CIA. Here, we describe a novel application of the culotte stent technique using a balloon-expandable stent to bail out an ostial stenotic legion of a jailed CIA due to prior self-expandable stent placement. The bilateral CIAs were revascularized by culotte stenting, and patency of the stents was confirmed 3 years after the procedure. The culotte stent technique was successfully applied to an ostial stenotic lesion of a jailed CIA.

A comparison of hemodynamic metrics and intraluminal thrombus burden in a common iliac artery aneurysm

Aneurysms of the common iliac artery (CIAA) are typically found in association with an abdominal aortic aneurysm (AAA). Isolated CIAAs, in the absence of an AAA, are uncommon. Similar to AAAs, CIAA may develop intraluminal thrombus (ILT). As isolated CIAAs have a contralateral common iliac artery for comparison, they provide an opportunity to study the hemodynamic mechanisms behind ILT formation. In this study, we compared a large isolated CIAA and the contralateral iliac artery using computational fluid dynamics to determine if hemodynamic metrics correlate with the location of ILT. We performed a comprehensive computational fluid dynamics study and investigated the residence time of platelets and monocytes, velocity fields, time-averaged wall shear stress, oscillatory shear index, and endothelial cell activation potential. We then correlated these data to ILT burden determined with computed tomography. We found that high cell residence times, low time-averaged wall shear stress, high oscillatory shear index, and high endothelial cell activation potential all correlate with regions of ILT development. Our results show agreement with previous hypotheses of thrombus formation in AAA and provide insights into the computational hemodynamics of iliac artery aneurysms.

Outcomes of the single-stent versus kissing-stents technique in asymmetric complex aortoiliac bifurcation lesions

This study investigated the outcomes of single-stent vs kissing-stents techniques in asymmetric complex aortoiliac bifurcation (ACAB) lesions. We retrospectively investigated 80 consecutive patients (69 males, 66.6 ± 8.7 years) treated with a single stent and 30 patients (26 males, 67.1 ± 7.7 years) treated with kissing stents for ACAB between January 2005 and December 2012 from a single-center cohort. A ACAB lesion was defined as a symptomatic unilateral common iliac artery stenosis (>50%) combined with intermediate stenosis (30%-50%) in the contralateral common iliac artery ostium. The primary end point was the primary patency of the ACAB. The baseline clinical characteristics did not differ significantly between the single-stent and the kissing-stents group. Technical success was achieved in all patients. The single-stent group required fewer stents (1.3 ± 0.5 vs 2.3 ± 0.8; P < .001) and less bilateral femoral access (55% vs 100%; P < .001). Two patients in the single-stent group (3%) required bailout kissing stents because of plaque shift to the contralateral side. The major complication rates were 8% in single-stent vs 13% in the kissing-stent group, which was similar (P = .399). At 3 years, the single-stent and kissing-stents group had similar rates of primary patency (89% vs 87%; P = .916) and target lesion revascularization-free survival (93% vs 87%; P = .462). The single-stent technique in ACAB was safe and showed midterm outcomes comparable with those of kissing stents. Considering the benefits, such as fewer stents, less bilateral femoral access, and the availability of contralateral access for future intervention, the single-stent technique may be an advantageous treatment option in ACAB.

In Situ Fenestration Through the Contralateral Iliac Artery to Convert an Aortouni-iliac Into a Bifurcated Endograft

Purpose: To present a technique of in situ fenestration that allows conversion of an aortouni-iliac endograft into a bifurcated endograft, thereby avoiding crossover femorofemoral bypass and its complications. Technique: Following conventional deployment of an aortouni-iliac endograft, in situ fenestration through the contralateral common iliac artery is performed with a transjugular intrahepatic access set. The fabric hole is enlarged using a cutting balloon and a high-pressure noncompliant balloon. Kissing iliac-covered stents are then positioned at the level of the bifurcation to convert the aortouni-iliac endograft into a bifurcated repair. To date, this technique has been successfully used in 4 patients with satisfactory short-term results. Conclusion: This technique represents another application of endograft in situ fenestration. This strategy provides a bifurcated repair in cases where bifurcated stent-grafts are usually precluded, such as a narrow distal aorta, ruptured abdominal aortic aneurysm, or combined aortoiliac occlusive disease.

A rare case of May-Thurner-like syndrome in an elderly lady

An elderly lady presented with decreased mobility, sputum production and intermittent confusion. She was treated for chest sepsis, fast atrial fibrillation, and acute kidney injury, and also noted to have a swollen left leg. Venous duplex imaging showed extensive thrombus within the left common iliac, left external iliac and left common femoral veins. A CT Venogram showed compression of the left common iliac vein between an osteophyte at L5 and a calcified ipsilateral common iliac artery. It also showed a pelvic kidney with an extra renal pelvis and large renal cyst which was indirectly contributing to venous compression by splinting the left iliac artery. A decision was made after discussion at the Vascular MDT that the patient was not fit enough for surgery and to manage her medically with anticoagulation. Discussion: Proximal DVT’s are rarer than distal thrombosis, but have similar causes. One of the rarer causes of proximal DVT is May-Thurner syndrome and its variants known collectively as non-thrombotic iliac vein lesions. May-Thurner originally described DVT formation caused by extrinsic compression of the left common iliac vein between the overriding contralateral (right) common iliac artery and adjacent lumbar vertebrae. The best imaging modality is a CT Venogram. Duplex ultrasonography can be used, although it can be difficult to visualize the iliac veins. The mainstay of management is surgical thrombectomy, or thrombolysis, followed by stenting of the affected vessel. However, if intervention is not appropriate, then it can be managed medically with anticoagulation.

Abstract 18309: Outcomes of Single Versus Kissing Stenting Technique in Lateralized Complex Aortoiliac Bifurcation Lesion

Backgrounds: Kissing stenting technique has been frequently performed even in the cases of unilateral aortoiliac diseases in order to protect contralateral common iliac artery (CIA) with intermediate plaque burden. However, kissing stenting is associated with loss of access from contralateral side for future revascularization. We compared the outcomes of single versus kissing stenting technique in lateralized complex aortoiliac occlusive disease. Methods: From Jan. 2006 to Dec. 2012, we retrospectively enrolled 86 consecutive patients (73 males, 67±9 years) treated with a single stenting technique and 33 patients (29 males, 68±8 years) treated with a kissing stenting technique for lateralized complex aortoiliac bifurcation lesions. A lateralized complex aortoiliac bifurcation lesion was defined as a significant unilateral CIA ostial stenosis (&gt;70%) combined with an intermediate (30~50%) stenosis of contralateral CIA. Results: Single stenting and kissing stenting was successfully performed in all patients without procedure-related major complications. However, in the single stenting group, bailout stenting in contralateral CIA was required in two (2.3%) cases due to unfavorable plaque shift. Median follow up duration of the single and the kissing stenting group was 24 (3~88) and 14 (3~82) months, respectively. The primary patency of the ipsilateral CIA in the single stenting group was 93.9% comparable with 94.9% in the kissing stent group (OR 0.823, 95% CI 0.157-4.298). Target lesion revascularization occurred in 5 (6%) cases of the single stenting group and in 2 (6.1%) cases of the kissing stenting group. Progression of the contralateral un-stented CIA requiring additional revascularization was observed in only 2 (2.4%) cases of the single stenting group during follow up. Conclusions: Single stenting technique in lateralized complex aortoiliac bifurcation lesion was relatively safe and showed comparable outcomes as the kissing stenting technique.

Crossover Chimney Technique to Preserve the Internal Iliac Artery in Abdominal Aortic Aneurysm With Common Iliac Artery Aneurysms

To report a new technique to preserve the internal iliac artery (IIA) in cases of aortoiliac aneurysms. Under bilateral common femoral artery (CFA) exposure, a crossover sheath was inserted from the contralateral CFA to the ipsilateral IIA involved in the common iliac artery (CIA) aneurysm. A Viabahn stent-graft was positioned 2 cm inside the IIA. The main body abdominal stent-graft was inserted through the ipsilateral CFA with distal sealing in the external iliac artery (EIA). The gate was cannulated, and the limb extension was positioned in the contralateral CIA near the IIA orifice. After the first Viabahn deployment, a second device was deployed with a minimum 1-cm overlap inside the first Viabahn and 2 mm distal to the limb extension. For bilateral CIA aneurysms, the Viabahn and extension limb were landed in the EIA with IIA embolization. In the past year, this technique has been used in 5 patients with success. There was no acute branch occlusion or type I endoleak from the IIA or chimney graft gutters on imaging studies up to 6 months. This technique is easy to use and avoids the brachial access of the sandwich technique and the additional cost of an iliac branch device.

Balloon Occlusion of the Contralateral Iliac Artery to Assist Recanalization of the Ipsilateral Iliac Artery in Total Aortoiliac Occlusion: A Technical Note

Endovascular recanalization of chronic total aortoiliac occlusion is technically challenging. Inability to reenter the true aortic lumen, following retrograde iliac recanalization, is one of the most common causes of failure. We describe a case of a total aortoiliac occlusion where balloon occlusion of the right common iliac artery, following its recanalization from a brachial approach, was used to facilitate antegrade recanalization of the occluded contralateral left common iliac artery.

Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: The Albany Vascular Group approach

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today, endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality compared with the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help vascular surgeons deal with not just the technical aspects of these procedures but also address some of the challenges, including the availability of preoperative computed tomography, the choice of anesthesia, the percutaneous vs femoral cutdown approach, use of aortic occlusion balloons, need for bifurcated vs aortouniiliac stent grafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Endovascular approach for isolated common iliac aneurysm and severe kyphoscoliosis

We report the case of a 72-year-old patient presenting with an isolated common iliac aneurysm with occlusion of contralateral common iliac artery and severe kyphoscoliosis. Because of high risk for open surgery due to chronic obstructive pulmonary disease, this patient was treated with an endovascular approach using an aortomonoiliac stent graft, followed by a femoro-femoral crossover bypass. This report illustrates the usefulness of a minimally invasive approach, and feasibility even for patients with difficult anatomy.