Single-Access Iliac Branched Device Implantation With Kissing-Balloon Technique

Purpose: The standard technique for iliac branch device (IBD) deployment involves bilateral femoral access and crossover wire, which may be challenging after previous endovascular aortic repair (EVAR). We present a technique for IBD deployment following EVAR using single femoral access and kissing-balloon angioplasty. Technique: An 83-year-old male patient with previous infrarenal bifurcated EVAR presented at 6-year follow-up with left common iliac dilatation and distal loss of seal, leading to type Ib endoleak and aortic aneurysm sac expansion of 13 mm (aortic diameter: 70 mm). A secondary intervention with an IBD was decided. Under general anesthesia, percutaneous left common femoral artery access was achieved. An IBD was successfully advanced and deployed above the left iliac bifurcation. A steerable sheath facilitated access to the hypogastric artery, allowing catheterization, delivery, and deployment of the bridging stent. Using this single access, simultaneous kissing-balloon angioplasty of the main IBD and branch ensured adequate expansion. Completion angiography confirmed patency without endoleak. The access site was secured using a closure device. The postoperative course was uneventful, and the pre-discharge computed tomography angiography confirmed proper device placement without endoleak. Conclusion: Single-access IBD deployment using a steerable sheath is feasible after EVAR and may reduce access-related complications. Clinical Impact Access site complications affect up to 10% of patients undergoing endovascular procedures and may be even more frequent in patients requiring large-bore sheaths. Single-access iliac branched device placement with a steerable sheath for branch catheterization and bridging stent advancement and deployment reduces the potential risk associated with secondary access site complications, without compromising the final result. With this technique, the performance of kissing balloon to assure adequate expansion of bilateral components is achievable.