Percutaneous endovascular abdominal aortic aneurysm repair.

In this prospective, nonrandomized study, we compared outcome with percutaneous femoral artery closure to that with open femoral arteriotomy in 95 patients who underwent endovascular AAA repair. Devices were introduced using 22 Fr and/or 16 Fr sheaths. The 8 Fr/10 Fr Perclose devices (Perclose Inc., Redwood City, CA) were used in an off-label "preclose technique." Thirty-three patients had bilateral open femoral arteriotomies, 44 patients had bilateral attempted percutaneous closure, and 18 patients had open femoral arteriotomy on one side and attempted percutaneous closure on the other side. Percutaneous closure was successful in 85% (47/55) of 16 Fr sheaths and 64% (29/45) of 22 Fr sheaths (p < 0.027). Bilateral percutaneous closure was successful in 63% (28/44) of patients. Conversion to open femoral arteriotomy due to bleeding occurred in 24 of 106 percutaneous attempts. There were no dissections, arterial thromboses, or pseudoaneurysms associated with percutaneous arterial closure. Wound complications were seen in 3.6% (3/84) of open arteriotomies and 0.9% (1/106) of all percutaneous attempts and arterial closures (p > 0.05). Gender, previous femoral access, obesity, and iliac occlusive disease were not predictive of percutaneous failure. Procedural success for percutaneous AAA repair is affected by sheath size. Devices delivered through 16 Fr or smaller sheaths will have successful femoral artery closure rates of at least 85%.

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.