Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report

Abstract

Introduction: Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients.

Patient concerns: A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup.

Diagnoses: Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length.

Interventions: After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD.

Outcomes: The stent grafts were patent without endoleak at the 6-month follow-up.

Lessons: In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Figure 1.

(A) Preoperative computed tomography angiography image with 3-dimensional reconstruction that shows a left common iliac artery aneurysm (LAO 35, CAU 15) and (B) a drawing using Paint 3D application in Accessories with detailed numerical values (unit, mm).

Figure 2.

Preoperative planning with the equipment from 3 different manufacturers expected to be used. It was drawn in Paint 3D application (yellow, Cook IBD; blue, reversed Endurant iliac limb; red, Covera Plus stent-graft; black, Concerto microcoils). “Print color requested”.

Figure 3.

Benchwork steps of the preparation for proximal aortic extension with an Endurant iliac limb in an upside-down configuration. (A) Deploying a stent graft on a separate table aseptically. (B) Relocating the deployed stent graft in the opposite direction so that the released stent tapers downward with a proximal end of 24 mm and a distal end of 16 mm in diameter. (C) After half-mounted in the reverse direction. (D) Inserting the reversed endograft into the initially peeled sheath with the aid of nylon tape. One person collects the struts as much as possible by wrapping them with nylon tape, while the other holds both ends of the gathered struts with both hands and puts them one by one into the sheath so that the struts would not get caught in the tip. On the bottom right, the schematic drawing shows how the nylon tape is arranged. (E) After reloading a reversed limb in a 16 Fr delivery system.

Figure 4.

Endovascular procedure. (A) The advancement of the Cook iliac branch device (IBD) along the extrastiff wire from the right side and the placement of the side branch at approximately 10 mm above the aortic bifurcation. The left internal iliac artery (IIA) had just been embolized with microcoils. (B) The deployment of a 10 × 100 mm self-expanding covered stent from the left common femoral artery with an adequate overlapping zone, proximal to the IBD and distal to the external iliac artery, which was subsequently molded with a balloon catheter 10 mm in diameter. (C) After the proximal aortic extension to IBD with a reversed iliac limb, completion angiography shows a contrast filling defect in the right common iliac artery (partial) and the IIA (complete), suggesting thrombosis but no type I or III endoleak.

Figure 5.

Follow-up computed tomography image after a 1-month anticoagulation with warfarin (target INR 2–2.5) shows (A) complete resolution of the thrombosis in the right common iliac artery and (B) no evidence of endoleak on maximum intensity projection with 3-dimensional reconstruction.