What question did this study set out to answer?

This research explores salvage direct transabdominal aortic access as a solution when iliac artery spasm obstructs thoracic endovascular aortic repair delivery.

March 30, 2026Open Access

Salvage Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making (Salvage Direct Transabdominal Aortic Access-TEVAR)

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Symptomatic thoracic aortic pseudoaneurysm (n=1). Intervention: Salvage direct transabdominal aortic access. Primary outcome: Successful stent graft deployment and pseudoaneurysm exclusion.

Key Result

Salvage direct transabdominal aortic access enabled successful TEVAR stent graft deployment and complete pseudoaneurysm exclusion at 1 month in a patient with severe iliac artery spasm.

Key Points

This research explores salvage direct transabdominal aortic access as a solution when iliac artery spasm obstructs thoracic endovascular aortic repair delivery.
Described a case of TEVAR with failed bilateral femoral access due to iliac artery spasm.
Utilized direct transabdominal aortic puncture via midline laparotomy for device delivery.
Executed preprocedural planning with multiple bailout strategies and immediate surgical expertise.
Successful deployment of a stent graft through the transabdominal aortic access after iliac access failure.
Postoperative recovery without complications and confirmation of pseudoaneurysm exclusion at one month follow-up.
Highlighting the importance of surgical preparedness in addressing TEVAR failures due to vascular spasms.

Study Design

Type

Case Report (n=1)

Structured PICO

Population

A 58-year-old woman with a symptomatic thoracic aortic pseudoaneurysm undergoing TEVAR with failed bilateral femoral access due to severe iliac artery spasm.

Intervention

Salvage direct transabdominal aortic access via midline laparotomy for TEVAR device delivery using a 21-French sheath.

Outcome

Successful stent graft deployment and pseudoaneurysm exclusion.

Salvage direct transabdominal aortic access serves as an effective and definitive bailout strategy for TEVAR when severe iliac artery spasm prevents conventional femoral device delivery.

Limitations

Longer-term follow-up is recommended to assess the durability of aortic puncture sites.

Abstract

• Although rare, iliac artery spasms can prevent femoral TEVAR device delivery, particularly with large-bore sheaths. • Salvage direct transabdominal aortic access is effective when pharmacological and endovascular measures fail, particularly in vessel injury. • Preprocedural planning should include a hierarchy of bailout strategies with immediate surgical expertise required. • Multidisciplinary coordination is critical for the timely recognition of access failure and safe conversion to an open access. : To describe salvage direct transabdominal aortic access as a bailout strategy for thoracic endovascular aortic repair (TEVAR) when bilateral iliac artery spasm precludes device delivery and to contextualize this approach among contemporary access techniques. A 58-year-old woman with a symptomatic thoracic aortic pseudoaneurysm underwent TEVAR. Bilateral femoral surgical cut-downs failed because of severe iliac artery spasm with >50% luminal narrowing and contrast extravasation despite maximal vasodilators and balloon angioplasty attempts. After recognizing definitive access failure, conversion to direct transabdominal aortic access was performed via midline laparotomy. A 21-French sheath (outer diameter ∼7.8 mm) was inserted under direct vision, which enabled successful stent graft deployment. Postoperative recovery was uneventful, and one-month CTA confirmed complete pseudoaneurysm exclusion and healed iliac access sites. However, a longer-term follow-up is recommended to assess the durability of aortic puncture sites. : Iliac artery spasm is a dynamic and under-recognized cause of TEVAR failure. When conventional measures fail, salvage direct transabdominal aortic puncture offers a definitive solution, underscoring the importance of surgical preparedness and structured bailout algorithms in complex endovascular therapy.