Endovascular Repair of Aortoiliac Aneurysm Using Bifurcated Stent Grafts with Sandwich Technique for Preserving the Internal Iliac Artery
A 76-year-old man with a history of hypertension, diabetes mellitus, benign prostate hypertrophy and tobacco use was presented with right flank pain. A retrograde pyelography revealed an extrinsic indentation of the right pelvic ureter. Computed tomography (CT) angiography demonstrated an AAA with bilateral CIA involvement (). The maximal diameter of the distal abdominal aorta was 34 mm and the diameter of the aorta at renal artery level measured 19.2 mm. The right CIA was 55 mm and the left CIA was 24 mm in their maximal diameters. The diameter of the right CIA at its ostium was 27 mm, whereas that of the left CIA was 11 mm.\nIn this patient, we decided to perform EVAR using a bifurcated stent graft. In order to preserve at least one IIA for pelvic perfusion, we planned to apply the sandwich technique. The right IIA was embolized using a 14 mm Vascular Plug (Amplatzer, St. Jude Medical, St. Paul, MN, USA) after the engagement of a 7 Fr sheath into the right IIA from the left common femoral artery. The main body of the bifurcated stent graft (Excluder 23-14-160 mm, Gore, Newark, DE, USA) was introduced through the left common femoral artery and deployed below the left renal artery origin.\nThereafter, a tubular-type stent graft (Viabahn 8×150 mm, Gore, Newark, DE, USA) was inserted into the left IIA through a 8 Fr Shuttle sheath from the left brachial artery. An iliac extender stent graft (Excluder 12×140 mm, Gore, Newark, DE, USA) was inserted through the left common femoral artery. The two distal stent grafts were deployed in parallel with the overlapping of the proximal main body stent graft and dilated synchronously by a kissing balloon method (). A contralateral limb (Excluder 12-140 mm, Gore, Newark, DE, USA) and an iliac extender (Excluder 12-100 mm, Gore, Newark, DE, USA) were inserted through the right CFA in order to cover the right CIA and the proximal segment of the right EIA sheath.\nAfter the procedure, angiography showed proper positions of the deployed stent grafts with good blood flow to the left IIA and minimal endoleaks (types Ib and III). Follow-up aorta CT scans taken at 3 days () and 8 months after the procedure showed patent stent grafts without significant endoleak. During the 8-month follow-up, the patient remained uneventful.