Indian Journal of Vascular and Endovascular Surgery

CASE REPORT
Year
: 2020  |  Volume : 7  |  Issue : 3  |  Page : 302--305

Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery


B Nishan, K Sivakrishna, Hudgi Vishal, VP Ahsan, Vivek Anand 
 Department of Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Correspondence Address:
B Nishan
Department of Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India

Abstract

We present a patient requiring aorto-uni-iliac (AUI) endovascular aneurysm repair with a review of indications and outcomes of this procedure. A 72-year-old male presented at Jain Institute of Vascular Sciences due to infrarenal saccular abdominal aortic aneurysm with a maximum diameter of 4.5 cm. A low-lying, the dominant left accessory renal artery with inadequate length from the origin of the left accessory renal artery to aortic bifurcation (50 mm) precluded the deployment of a bifurcated device (since the length of the aorta from the origin of the left accessory renal artery to aortic bifurcation was inadequate for the contralateral limb to open). Hence, AUI stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femorofemoral bypass was performed.



How to cite this article:
Nishan B, Sivakrishna K, Vishal H, Ahsan V P, Anand V. Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery.Indian J Vasc Endovasc Surg 2020;7:302-305


How to cite this URL:
Nishan B, Sivakrishna K, Vishal H, Ahsan V P, Anand V. Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Dec 3 ];7:302-305
Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/302/294904


Full Text



 Introduction



An aorto-uni-iliac (AUI) graft with occlusion of the contralateral common iliac and a femorofemoral bypass has been performed to treat an abdominal aortic aneurysm (AAA), not suitable for bifurcated stent graft system, isolated iliac artery aneurysms, complex iliac anatomy, or large aneurysms which seldom have a distal neck as well as ruptured AAA or AAA having iliofemoral artery disease or in the treatment of complications of previous applied endovascular bifurcated devices for the treatment of AAA.[1],[2]

We report a successful case of endovascular repair of saccular infrarenal AAA with AUI device, femoral to femoral bypass with graft, and occlusion of the contralateral common iliac artery with a review of the literature.

 Case Report



A 72-year-old male, smoker, diabetic and hypertensive, underwent a routine general medical check-up, including ultrasound of the abdomen, which revealed an incidental finding of 4.5 cm infrarenal saccular AAA. Contrast-enhanced computed tomography (CT) angiogram confirmed a saccular aneurysm arising from the left lateral wall of the infrarenal abdominal aorta measuring 4.5 cm × 3.3 cm (ap × tr) over a length of about 6.2 cm, arising 7 cm below the left lowermost renal artery, which is more than adequate for the deployment of any standard endovascular aneurysm repair (EVAR) device. However, a large left accessory renal artery, perfusing most of the left kidney, arising 50 mm below the left renal artery, and 50 mm above aortic bifurcation and 20 mm above saccular AAA [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

After workup, the patient was planned for the endovascular repair of AAA.

Operative procedure

Under general anesthesia, bilateral groin opened, and common femoral artery retrograde access taken. Angiogram showed patent bilateral renal arteries, left accessory renal artery, superior mesenteric artery, and saccular aneurysm around 4.5 cm × 4 cm, the distance between the origin of the left accessory renal artery to the saccular aneurysm and aortic bifurcation is around 20 mm and 50 mm, respectively [Figure 3]. The low lying left accessory renal artery with inadequate length from the origin of the left accessory renal artery to aortic bifurcation (50 mm) precluded deployment of the bifurcated device, since the length of aorta distal to the origin of the left accessory renal artery was inadequate for the contralateral limb to open. Hence, a “uni-graft [Figure 4]” (Endurant stent graft) was deployed just below the accessory left renal artery, maintaining its perfusion and a crossover femoral to femoral bypass with graft was performed. The left common iliac artery was occluded with a vascular plug. Intraoperative angiogram showed complete exclusion of the aneurysm without any evidence of any retrograde flow [Figure 5].{Figure 3}{Figure 4}{Figure 5}

The aneurysm was “excluded” with no flow in the sac [Figure 5] and perfusion of both lower limbs well maintained with excellent distal pulses. He was discharged on the 3rd postoperative day with a return to normal activities in about 2 weeks.

 Discussion



Indications [Table 1] for the treatment of AAA by EVAR with the AUI configuration.[3]{Table 1}

In patients with AUI stent graft, complete occlusion of the contralateral iliac artery is required to seal the aneurysm associated with a femoro-femoral bypass to re-establish perfusion to the contralateral limb.[4],[5] Early critics pointed to poor long-term patency rates of the femoro-femoral bypass; fortunately, the patency of crossover femoro-femoral bypass is very high in recent published literature.[4],[6]

Lipsitz et al.,[5] showed that crossover bypasses for aneurysmal disease are durable procedures either for pure aneurysmal disease or aneurysmal disease with aortoiliac occlusive pathology.

Ng et al. reported a cumulative patency rate at 6 years of 92% for femoro-femoral crossover procedures and a low early mortality rate of 1.3%.[7] Furthermore, despite these procedures might be complicated by the development of graft infection, graft occlusion, false aneurysm formation, seromas in the groin, their incidences are very low.[7]

Outcomes of aorto-uni-iliac and bifurcated devices

Moore et al. in 2001 compared the AUI stent-graft with the tube, the bifurcated graft, and open control series in regard to patient demographics, medical comorbidity, 30-day morbidity/mortality, and outcome at 1 year.[8] The trial results showed that the AUI configurations outcomes are competitive with the results by tube or bifurcated graft systems and are associated with lower morbidity than open surgery repair.[8]

Pereira et al., in 2002, concludes AUI system is a simple and safe technique alternative to bifurcated systems for high-risk patients.[9]

Saratzis et al. in 2005, states in high surgical risk patients with complex iliac anatomy AUI endograft are feasible and efficacious. Patency of the cross over femoro-femoral bypass graft also appears satisfactory.[10]

Dalainas et al. in 2007, compares the outcome between a bifurcated and an AUI stent-graft in the short- and mid-term period for the treatment of aneurysmal aortic disease. The results showed that treating AAAs with AUI endoprosthesis is as safe and effective as treating them with bifurcated endografts.[11]

Baptisteab et al., in 2009, reports the midterm results following the use of bifurcated and AUI endovascular devices in the treatment of AAAs in a population of patients deemed to be at high risk for open surgery. The results of this study demonstrates that bifurcated devices were associated with better results than AUI devices.[12]

Lazaridis et al., in 2009, demonstrate that AUI endografts are simpler, more rapidly placed and permits treatment of more patients who need EVAR due to associated comorbidities because of fewer restrictions according to the morphological criteria of feasibility, such as the narrow terminal aorta and tortuous, narrow, calcified, or occluded iliac axis.[13]

Hynes and Sultan[14] reported that AUI EVAR with a fem-fem crossover is a safe and effective alternative as bifurcated endografts in high-risk patients with AAA. This is explained by the fact that AUI EVAR requires less preoperative planning, less operative time, and less trauma for those patients.

Carrafiello et al.[15] reported a high mortality rate with AUI grafts, but a deeper look in this study design demonstrates that precious time was wasted in preoperative analysis and preoperative CT angiography in these unstable patients.

Katsikas et al.[3] had documented through meta-analysis that the main advantages of the AUI endograft are its simplicity and versatility.

Clouse et al.[16] had proven that AUI with fem-fem crossover graft is a safe, effective option with a satisfactory midterm result.

Hinchliffe et al.[6] and Yilmaz et al.[4] have proven that fem-fem crossover for AUI offers durable and encouraging long-term patency.

 Conclusion



In patients with anatomical limitations for the use of a bifurcated endograft, the deployment of an AUI stent graft followed by a femoro-femoral crossover bypass can exclude the aortic pathology with similar immediate and mid-to-long-term compared to standard bifurcated graft, avoiding, therefore, an open abdominal surgery. The main advantages of the AUI endograft are its simplicity and versatility.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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