Use of an endovascular graft converter for primary repair of a complex right aortoiliac aneurysm

Abstract

An 84-year-old man presented with an enlarging 6.8-cm right common iliac aneurysm (A). He was previously deemed too high-risk for open aneurysm repair secondary to comorbidities, and he was not a candidate for a standard endovascular approach due to a severe infrarenal aorta stenosis and massive right inguinal hernia (B). We used the Zenith Renu Ancillary Graft (Cook Medical Inc, Bloomington, Ind), indicated for rescuing migrating stent grafts previously placed for aortic aneurysm repair, to primarily repair the aneurysm. Because this endograft tapers to a smaller-diameter stent designed to fit inside a failing endograft, the patient's aortic stenosis was not prohibitive to its use. The patient consented to the publication of the details of his case.The patient's right internal iliac artery was embolized with an Amplatzer plug (St. Jude Medical Inc, St. Paul, Minn) 3 weeks before the definitive operation to allow for collateralization. We then placed an aortouniiliac Renu endograft, such that the tapered part of the endograft fit the severely stenotic aorta (C). Because of the size of the patient's aneurysm and severe right external iliac artery tortuosity, we placed the graft through the contralateral (left) side and placed a second Amplatzer plug into the distal right external iliac artery. A completion angiogram demonstrated complete exclusion of the aneurysm sac (D).Next, we performed a right superficial femoral-to-left common femoral artery bypass to perfuse the right leg. Because of his massive inguinal hernia, we tunneled the graft laterally from the right side around the hernia and then turned medially at a high level just below the umbilicus.At 1-year postoperatively, the patient was fully functional. Follow-up imaging demonstrated complete aneurysm exclusion and a patent femoral-femoral artery bypass. Thus, in cases of anatomy prohibitive to standard endograft use, an endograft converter may be used for primary repair of a complex aortoiliac aneurysm.