Kansai Rosai Hospital Cardiovascular Center
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1 Successful internal iliac aneurysm exclusion by using coil embolization and upside down Gore Excluder contralateral leg with extracorporeal predeployment Kansai Rosai Hospital Center Shota Okuno, Osamu Iida, Shin Okamoto, Daigo Kanamori, Kiyonori Nanto, Takuma Iida, Tatsuya Shiraki and Masaaki Uematsu
2 74 y/o male Right internal iliac artery aneurysm History of present illness Mar Open repair for abdominal aortic aneurysm (Y-graft) Mar Follow-up CT angiogram incidentally revealed right internal iliac artery aneurysm (30 mm in maximal diameter) Comorbidities Hypertension Dyslipidemia Aortic regurgitation treated with aortic valve replacement Atrial fibrillation treated with catheter ablation
3 Preoperative computed tomography angiogram 3D VR MIP Outflow vessels Rt.EIA Rt.IIA & aneurysm
4 Challenges Challenges 1: Short length of aneurysm neck = We couldn t repair the aneurysm only by coil embolization. Rt.CIA Diameter: 20mm Stent graft deployment from Y-graft limb to EIA was necessary to block inflow. Rt.EIA Diameter: 12mm Rt.IIA aneurysm neck Length: 5mm
5 Challenges Challenges 1: Short length of aneurysm neck = We couldn t repair the aneurysm only by coil embolization. Rt.CIA Diameter: 20mm Y-graft limb Diameter:9mm Length:10mm Stent graft deployment from Y-graft limb to EIA was necessary to block inflow. Challenges 2: Small diameter and short length of Y-graft limb = Any stent graft available in Japan didn t fit the Y-graft limb. Rt.EIA Diameter: 12mm Upside down technique using Gore Excluder contralateral leg was necessary to fit the graft and prevent endoleak.
6 Gore Excluder <proximal> 16mm 100mm 120mm 140mm 12mm 14.5mm <distal>
7 EVT strategy 1 st step: Coil embolization for outflow vessels Y-graft 2 nd step: Stent graft deployment from graft limb to EIA Stent graft Lt.EIA Lt.IIA Rt.EIA Rt.IIA aneurysm
8 Coil embolization A B C D Products used Sheath: Parent plus 4.5Fr, 90cm (Madikit, Tokyo) Wire: 0.035inch Radifocus J-tip (Terumo, Tokyo) Cruise (ASAHI intec, Tokyo) Catheter: 5Fr JR4.0 (Goodman, Nagoya) Microcatheter: Prowler (Cordis, Miami Lakes, FL) Coil: Micrus (Cook Medical, Bloomington, IN) 3.0mm 6cm, 4.0mm 8cm 2, 4.0mm 6cm, 5.0mm 12cm, 6.0mm 15cm 2, 10.0mm 25cm, 12mm 30cm Torunado (Cook Medical, Bloomington, IN) 3mm 5mm 1, 3mm 6mm 7, 4mm 8mm 5
9 Angiogram after coil embolization
10 Aortogram before EVAR
11 Stent graft preparation A The tip of catheter B Cut! A, B: Removal of the tip at the end of the catheter from delivery catheter by cut with scissors
12 Stent graft preparation A The tip of catheter B C Cut! 12Fr sheath Stent graft A, B : Removal of the tip at the end of the catheter from delivery catheter by cut with scissors C : Upside down introduction of Gore Excluder contralateral leg (12mm 10cm) into 12Fr sheath
13 Stent graft preparation A The tip of catheter D B C Cut! 12Fr sheath Stent graft E A, B : Removal of the tip at the end of the catheter from delivery catheter by cut with scissors C : Upside down introduction of Gore Excluder contralateral leg (12mm 10cm) into 12Fr sheath D, E : Predeployment of stent graft in the 12Fr sheath
14 Stent graft deployment A PULL! 12Fr sheath 18Fr sheath Insertion of 18Fr sheath via right femoral artery A : Predeployment of stent graft in 18Fr sheath
15 Stent graft deployment A PULL! C PULL! B 12Fr sheath 18Fr sheath PUSH! By the cut dilator Insertion of 18Fr sheath via right femoral artery A : Predeployment of stent graft in 18Fr sheath B, C : Stent graft deployment by using cut dilator as pusher Cut the dilator
16 Stent graft deployment A PULL! C PULL! B 12Fr sheath 18Fr sheath D PUSH! By the cut dilator Insertion of 18Fr sheath via right femoral artery A: Predeployment of stent graft in 18Fr sheath 18Fr sheath B, C, D: Stent graft deployment by using cut dilator as pusher Cut the dilator
17 Stent graft introduction and deployment Y-graft Stent graft Rt.EIA Product used Sheath: sheath introducer 8Fr, 25cm (Terumo, Tokyo), 18Fr sheath (Medikit, Tokyo) Wire: 0.035inch Radifocus J-tip (Terumo), 0.035inch Amplaz super stiff (Boston Scientific, Natick, MA) Catheter: 5Fr JR4.0 (Goodman, Nagoya), 5Fr PIG 100 (Goodman) Stent Graft: Excluder 12mm 10cm (W.L. Gore & Associates Inc, Flagstaff, Ariz) Ballon: ADMIRAL 12 20mm (Medtronic, Minneapolis, MN), Equalizer 20mm (Boston Scientific) Rt.IIA aneurysm
18 Final aortogram before after
19 Postoperative computed tomography angiogram 3D VR Stretched CPR Proximal landing diameter 9mm Proximal landing length 10mm Distal landing diameter 14mm Distal landing length 20mm
20 Summary We treated a case with internal iliac aneurysm using an endovascular approach because of the patient s hostile abdomen. To overcome the anatomical challenges, we embolized outflow vessels and deployed Gore Excluder contralateral leg by using upside down technique. In postoperative CT angiogram, endoleak was not detected, and right internal iliac aneurysm was completely excluded.
21 Conclusion We achieved successful internal iliac aneurysm exclusion by using coil embolization and upside down technique with Gore Excluder contralateral leg.
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