Internal iliac artery aneurysm repair using an iliac branch endoprosthesis in the setting of aortic endograft limb occlusion and chronic limb-threatening ischemia

An 83-year-old gentleman with multiple cardiovascular comorbidities presented in clinic with short-distance left calf claudication and toe ulceration 6 weeks after transurethral prostate resection for BPH. He had a history of AAA open repair with a tube graft 21 years ago and EVAR with a Zenith endograft for a 6.4cm left common iliac artery aneurysm with coil embolization of a 3cm left internal iliac artery aneurysm (IIAA) 8 years prior. Lower extremity pulses were absent on the left (ABI 0.38) and palpable on the right (ABI 0.99). CTA revealed occlusion of the endograft left limb and external iliac artery, a 4.6cm right IIAA, and a 2cm left common femoral artery aneurysm (CFAA) (Figure 1). Bilateral infrainguinal run-off was patent. The flow divider encroached on the proximal right limb, causing stenosis (Figure 2). Under general anesthesia, through a 22Fr right femoral sheath and left brachial cutdown, through-and-through access was obtained. The 11mm segment of the endograft right limb was ballooned to 18mm, and a 23mm by 14.5mm by 10cm Gore IBE was introduced and deployed. The reconstruction was extended from brachial access into the IIA posterior division using a 9mm by 10cm Viabahn stent and a 13mm IBE internal iliac limb as bridging stent. Coaxially, a 5Fr sheath was introduced into the right IIA anterior division (AD), two 8mm Amplatzer plugs and coils were placed distally to occlude the AD branches and the reconstruction was completed from the arm. The IBE external iliac component was deployed, followed by kissing balloon angioplasty. Two 10 by 38 mm iCast stents were placed in the stenosed proximal right limb and post-dilated to 14mm. Cone beam CT confirmed technical success. Finally, right-to-left femoral-femoral bypass was performed with 8mm Dacron, excluding the left CFAA (Figure 3). Procedural duration was 390 minutes, requiring 1.37Gy of radiation. Postoperative course was uneventful, left ABI normalized (0.97) and symptoms resolved. After 6 years, the patient is asymptomatic, with a patent reconstruction and right IIAA shrinkage (Figure 4). He consented to publication. This case demonstrates long-term patency of an IBE placed within a previous EVAR limb to preserve IIA flow (1D'Oria M. Mastrorilli D. DeMartino R. Lepidi S. Current Status of Endovascular Preservation of the Internal Iliac Artery with Iliac Branch Devices (IBD).Cardiovasc Intervent Radiol. 2019 Jul; 42: 935-948Crossref PubMed Scopus (28) Google Scholar, 2Wang S.K. Miladore J.N. Yee E.J. Liao J.L. Donde N.N. Motaganahalli R.L. Combined transbrachial and transfemoral strategy to deploy an iliac branch endoprosthesis in the setting of a pre-existing endovascular aortic aneurysm repair.J Vasc Surg Cases Innov Tech. 2019 Jun 29; 5: 305-309Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar) in the setting of an occluded Zenith endograft limb (3Urlings T.A. de Vries A.C. de Mol van Otterloo J.C. Eefting D. van der Linden E. Thromboembolic complications after Zenith® Low Profile Endovascular Graft for infrarenal abdominal aneurysms.Cardiovasc Intervent Radiol. 2015; 38: 600-605Crossref PubMed Scopus (12) Google Scholar).