Ancillary techniques to facilitate endovascular repair of aortic aneurysms

Purpose: The ability to treat abdominal aortoiliac aneurysms and thoracic a ortic aneurysms may be limited by coexisting arterial disease. Device deplo yment may be impaired by occlusive disease and tortuosity of the arteries u sed to access the aneurysm or by suitability of the implantation sites. In this study we describe the auxiliary procedures performed to circumvent the se obstacles and thereby enable endovascular aneurysm repair. Patients and Methods: Between January 1, 1993, and December 31, 1999, 390 p atients treated for aneurysm of the aorta with endovascular devices were en tered prospectively in a vascular registry. Fifty (12%) of the 390 patients required adjunctive surgical techniques to (1) create or extend the length of the proximal or distal device implantation site or (2) permit device na vigation through diseased iliac arteries. Auxiliary techniques used to exte nd or enhance implantation sites were elephant trunk graft (n = 2), the con struction of renovisceral bypass grafts (n = 1), and subclavian artery tran sposition (n = 2). Plication of the common iliac artery at its bifurcation was performed in conjunction with femorofemoral bypass graft in nine patien ts to allow preservation of pelvic circulation by avoiding internal iliac a rtery sacrifice. Construction of a bypass graft to transpose the internal i liac artery orifice was performed in one patient. The auxiliary techniques used to facilitate device navigation were iliac artery angioplasty or stent ing (n = 8), external iliac artery endovascular endarterectomy or straighte ning (n = 14), endoluminal iliofemoral bypass conduit (n = 5), and the cons truction of an open iliofemoral bypass conduit (n = 8). Results: Successful deployment of the endovascular devices was achieved in 49 (98%) of 50 patients. Auxiliary techniques were successful in providing access for endovascular device deployment in all 35 patients (100%). Mean f ollowup for techniques to facilitate device navigation is 26 months for end ovascular procedures and 42 months for the open bypass graft construction p atients; no occlusions were observed at this moment. There were five patien ts with incisional hematomas that did not necessitate intervention. Fourtee n (94%) of 15 patients underwent successful device implantation after the a uxiliary maneuvers to enhance implantation site. Mean follow-up for implant ation site manipulation is 28 months. One of the subclavian transpositions had a new onset of Horner's syndrome, two of nine patients who had common i liac artery ligated had retroperitoneal hematomas that did not necessitate interventions, and no colon ischemia was seen. The patient who underwent no nanatomic bypass grafting of viscero-renal arteries had a retroperitoneal h ematoma that necessitated reexploration. Conclusions: Significant coexisting arterial disease may be encountered in patients with aortic or iliac aneurysms. Identification of coexisting arter ial diseases is essential to help tailor the appropriate supplemental surgi cal procedure to allow the performance of endovascular aneurysm repair in p atients who would otherwise require open surgical repair.