Interventional management of type Ia endoleak after endoluminal repair of bilateral internal iliac artery aneurysms - Vascular Surgery

In this case, exposure of the left groin was preferred over puncture because of severe scarring in the groin after previous surgery and the large caliber of the delivery system. After encircling the common femoral artery centrad and distad, puncture the artery in Seldinger technique. Introduce a 7 F sheath over the guidewire. Administer 5000 IU heparin saline locally into the vessel.

Tip:

To avoid vessel perforation, do not advance the stiff guidewire too far because of the severe kinking of the left iliac arteries and the paper-thin vessel walls.

Replace the stiff guidewire with a soft hydrophilic-coated guidewire (here:Terumo®)and advance it into the descending aorta. Now, introduce a pigtail catheter over the indwelling guide wire through which DSA is performed in road-mapping technique.  DSA demonstrates successful repair of the right internal iliac artery aneurysm and the migrated left endoluminal vascular graft, the endoleak, and the perfused left internal iliac artery aneurysm. Since the infrarenal aorta is aneurysmatic and dilated to around 35 mm, one alternative could have been an endoluminal Y-graft.

Tips:

1. It may be difficult to advance the Terumo® wire up because of the severe kinking of the iliac arteries. If a straight or tip-curved Terumo® wire does not slide along the vessel wall, it is often necessary to employ a guiding catheter since the latter is better able to pass the tortuosities of the vessel (Road Runner®, H-Stick®, RDC® or similar). Sometimes the maneuver also succeeds with a pigtail catheter, which must be used for exploratory angiography anyway.

2. Roadmapping („Pathfinder“): This involves the administration a small bolus of contrast agent to visualize the abdominal aorta and iliac arteries as a roadmap. This image is saved as a mask. Subsequent images are then acquired without contrast media and subtracted from the mask. In this way, for example, only the current position of a radiopaque catheter will be displayed. In the resulting subtraction images, the bright catheter will be visible against the dark vessels, and any background irrelevant to this study is hidden.

3. The endoluminal Y graft would have been a salvage procedure in case of failure of the unilateral procedure in the video clip.

After introducing a "superstiff" guidewire (e.g. Amplatz®, Backup Meier®, Lunderquist®), replace the indwelling 7F sheath with a 16F sheath remove the obturator and insert the delivery system with moistened, smooth surface via the common femoral artery into the external iliac artery.

Tips:

1. The paper-thin vessel walls may tear easily when introducing the delivery system. Therefore, perform this step of the procedure slowly and very delicately.

2. When introducing the system, also pay attention to the contralateral side. In the video clip, it is evident how the tip of the delivery system touches and moves the contralateral endograft. Do not dislocate the contralateral endograft with overly rough manipulations!

Since it can be expected that advancing the delivery systemn will compress the vessels, DSA must be repeated to ensure accurate graft deployment. Compression has indeed created a pseudostenosis of the left common iliac artery. The new endograft must be advanced until it abuts the contralateral endograft without later occluding it.