Department of Surgery, University of Oklahoma, College of Medicine -Tulsa, Tulsa, OK

Endovascular aneurysm repair (EVAR) has become the treatment of choice for most surgeons and patients with an infrarenal abdominal aortic aneurysm (AAA). In 2007 67% of all aneurysm were repaired by an endovascular approach5. Several anatomic parameters determine patients’ suitability for EVAR including existence of appropriate landing-sealing zone proximally and distally and adequate ilio-femoral access5. Patients that lack femoral access secondary to atherosclerotic disease may require recanalization of the occlusion for implantation of a bifurcated graft or a unilateral graft with femoral to femoral bypass or finally an open reconstruction. We report for the first time the use of the axillary artery during EVAR for contralateral iliac limb deployment in a patient with chronic external iliac artery occlusion and a symptomatic 5.7 cm AAA suffering.

INTRODUCTION

BackgroundThe axillary artery has been used for complex endovascular aortic procedures such as Thoracic Endovascular Aortic Repair (TEVAR) with poor anatomy for traditional deployment as well as fenestrated and branched endografts. We report the first case where an iliac graft limb was deployed through the axillary artery during an EVAR case for maintenance of anterograde internal iliac flow on a patient with chronic ipsilateral occlusion of the external iliac and femoral artery.Case Report:A 65 years old male patient with a previous history of coronary artery disease, heart failure, hypertension and COPD was referred to our institution for a symptomatic Abdominal Aortic Aneurysm (AAA) with a maximum diameter of 57mm (Fig.1, 2). Anatomically, this AAA was not suitable for EVAR as the proximal neck had an angulation superiorly of 90 degrees. A bifurcated graft was also not indicated as the aortic bifurcation measured 11x14mm and there was occlusion of the left femoral and external iliac arteries. Nonetheless, due to patient’s symptomatic status and multiple comorbidities, we decided to proceed with endovascular treatment. Furthermore, we judged the patient’s left hypogastric artery as crucial for the viability of his bowel and left lower extremity (Fig. 3). Therefore, we attempted to treat him with a bifurcated graft and deployment of the left iliac limb through the left axillary artery. The operation lasted 7 hours and was successful with good sealing of the aneurysm after the addition of a proximal aortic cuff (Fig. 9). The patient required an axillo-unifemoral left bypass for worsening leg ischemia on day 2. At two months’ follow up the patient is doing well. On clinical examination there is no abdominal pulsatility and on CT scan the AAA has a reduced diameter (Fig. 10). Conclusion:The axillary artery can be used in selected cases of complex endovascular treatment of aortic pathology. This is the first reported case of successful deployment of the iliac limb from the axillary artery during EVAR. It provided a good solution for a patient that otherwise would have had a dismal prognosis.

ABSTRACT

A 65 year old male with significant history of congestive heart failure, coronary artery disease and myocardial infarction with coronary artery bypasses 6 years prior, presented with left sided chest and abdominal pain for approximately 1 week. Abdominal ultrasound revealed a 5.7 cm aneurysm. (Fig.1, 2) Patient vitals remained stable. Physical exam yielded a pulsatile masse. Given clinical exam, history, and imaging results, the patient was believed to be having symptoms related to his abdominal aortic aneurysm and a procedure was indicated. After a complete cardiac workup the patient was found to have an ejection fraction of 24%. Computed Tomography Angiography (CTA) revealed a conical neck with high degree of angulation (>90 degrees, Fig. 1). The area just proximal to the bifurcation tapered down to the 1.1-1.4 cm in diameter. The left external iliac and left common femoral arteries were occluded. The left internal iliac (IIA) was patent, and the main source for collateral flow for the left leg. (Fig. 3) Patients workup for peripheral vascular disease, yielded ABIs of .5 and .4 for right and left extremities respectively. The operation began with attempts of recanalizing the chronically occluded left common iliac artery via the left common femoral artery. Negotiation of the occlusion was unsuccessful after multiple attempts with several guide wires. Main graft was deployed from the right femoral artery while left axillary was used for the left iliac limb. (Fig. 4&5). The graft dimensions were 36 mm proximal diameter, 16 mm distal graft diameter, and a length of 16.6 cm. A stiff guidewire allowed for the negotiation of the thoracic vasculature into the abdominal aorta. Next using a Bernstein catheter entry was made into and through the opening of the proximal gate of the stent graft. Once in the lumen, the wire was advanced but cannulation of the left common iliac was unsuccessful. The right iliac limb was then deployed. After deployment access was gained into the L common iliac. A “kissing balloon” dilation of the aortic bifurcation via right femoral and left axillary artery was necessary in order to permit passage of the graft delivery system (Fig. 6) After dilation a super-stiff guide-wire was passed into the left common iliac artery and this allowed the deployment of the contralateral iliac limb (Fig. 7). A post deployment angio revealed a type I endoleak (Fig. 8) that was resolved by placement of proximal cuff (Fig. 9). After a 7 hour case a bifurcated graft was in place and flow into the internal iliac was preserved. (Fig. 8). The patient required an axillo-unifemoral left bypass after exhibiting signs and symptoms of acute left lower extremity ischemia on postoperative day 2. Two month follow up revealed no pulsatile masses on physical exam. Duplex US and CT revealed no endoleaks and a reduction in the size of the AAA (Fig. 10).

CASE REPORT

Preservation of the IIA is of particular importance during EVAR.6 The use of the axillary artery has been described before for complex endovascular procedures.3 The use of the axillary artery in our case allowed for use of a bifurcated graft although one femoral artery was not available for access. Although axillary artery access confers higher risk from a standard femoral access, it remains less invasive than an open surgery especially in patients with such multiple comorbidities5 .

Internal iliac artery arises at the bifurcation of the common iliac artery, anterior to the sacroiliac joint, posterior to the ureter at the pelvic brim. Several branches of the internal iliac artery, including the lateral sacral, superior gluteal, and middle rectal are important in perfusing roots of sacral nerves, buttock musculature, and rectum and upper anal canal respectively. Pelvic ischemia has an occurrence rate of 1-2% in open cases vs. 3-10% in endovascular approaches.2

In this patient, use of unilateral device would cause occlusion of the internal iliac artery as no retrograde or anterograde flow would be available for the vessel. A bilateral stent was not feasible as the left common femoral artery was chronically occluded and not amenable to recanalization. However, the axillary artery may be accessed id required for precise antegrade graft deployment3. This technique was used to deploy an iliac limb during an EVAR. This allowed for bilateral limb deployment, thus preserving patients vascular status and flow into the internal iliac artery .

In our patient, endovascular approach was ideal given his significant cardio and pulmonary comorbidities. The benefit to EVAR is justified by less hospital stay and faster recovery times, however the ischemic complication have remained equivalent.2 Significant iliac artery stenosis is a relevant contraindication for EVAR.4 However the morbidity of open Surgery is increased in these patients, who usually have multiple comorbidities as well as multilevel disease. A common iliac artery conduit can be used in patients with external iliac artery occlusion, however, complications are more common as compared to those who have an EVAR with femoral access.1

DISCUSSION

Internal Iliac Artery Flow Preservation During Endovascular Aneurysm Repair (EVAR) with Deployment of Iliac Leg from the Axillary Artery

Robert Brown MD, Denis Budrevich MD, Alexandros MalliosMD, John Blebea MD, MBA

This is the first report of anterograde deployment of an iliac limb through the axillary artery during EVAR. The axillary approach allowed for completion of the operation endovascularly and obviated the need for an open operation in a patient with significant comorbidities. This technique requires careful preoperative planning and can be useful in selected patients.

CONCLUSION

Figure 1. 3D reconstruction of preoperative CT angiogram. Note the extreme proximal angulation (red arrow), left external iliac artery occlusion (blue arrow) and distal tapering of the aortic lumen (green arrow)

Figure 2. Preoperative measurement of maximum AAA diameter of 5.7cm

5.7 cm Figure 3. Narrowing of the aortic bifurcation to 14 mm (yellow arrow). Most grafts require 18 to 20 mm.

(14x11mm)

Figure 4. Bilateral femoral access (blue arrows) and left axillary access (green arrow) was gained with short 3cm long incisions.

Figure 6. A “kissing balloon” dilatation was required in order to permit passage of the graft. Red arrow is pointing at balloon coming from right femoral and blue arrow the balloon coming from the left axillary artery.

Figure 7. After insertion of the main graft from the right femoral artery (red arrows), the left iliac limb was deployed from the left axillary artery (blue arrow).

Figure 9. Final arteriogram showing good proximal sealing after placement of a proximal cuff (red arrow) and no longer any abnormal flow into the aneurysm sac.

c.

Figure 8. Arteriogram at completion showed patent iliac vessels (red arrows) but a proximal endoleak (fillling of the aneurysm sac (blue arrows). This was caused from the high proximal neck angulation and required the placement of an extra cuff (aortic graft extension).

Figure 10. Postoperative measurement of the AAA at the same level on 3 month follow up. Diameter has now decreased from reduction from 5.7 to 5.2cm without the intraluminal pressure.

5,2 cm

1.Lee WA, Bercelli SA, Huber TS, Ozaki CK, Flynn TC, Seeger JM. Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair. J Vasc Surg 2003;38:459-63;discussion:464-5.2.Maldonado, T, Rockman C, Riles E, Douglas D, Adelman M, Jacobwitz, G, Gagne P, Nalbandian M, Cayne, N, Lamprello P, Salzeberg S, Riles T. Ischemic complications after endovascular abdominal aortic aneurysm repair. Journal of Vascular Surgery [2004, 40(4):703-9; discussion 709-10]3.Mallios A, Boura B, Combes M. Precision in distal graft deployment as additional indication for anterograde TEVAR through the axillary artery. European Journal of Vascular and Endovascular Surgery, Volume 45, Issue 5, May 2013, Page 535.4.Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASCII). J Vasc Surg 2007;45(Suppl S):S5-67.5.Vallabhaneni R, Sorial E, Jordan W, Minion D, Farber M. Iliac artery recanalization of chronic occlusions to facilitate endovascular aneurysm repair. J Vasc Surg. 2012 Dec;56(6):1549-54; discussion 1554. doi: 10.1016/j.jvs.2012.05.089. Epub 2012 Sep 7.6.Yano O, Morrisey N, Eisen L, Faries P, Soundararajan K, Wan S, Teodorescu V, Kerstein M, Hollier L, Marin M. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg. 2001 Aug;34(2):204-11.

REFERENCES

Figure 5. Guidewire (red arrows) advanced from the left axillary artery into the left subclavian and the descending thoracic aorta, projecting here behind the heart.