Iliac Conduit for Deploying Aortic Endografts: An All-Autogenous Option
John F. Eidt, MD, and Ahsan T. Ali, MD
Vascular and Endovascular Surgery Volume X Number X
Month 2007 1-3
© 2006 Sage Publications
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Unfavorable iliac anatomy, such as small caliber or circumferential calcification, can cause problems dur- ing delivery of aortic endografts and lead to potential complications. An iliac artery conduit “chimney” has been used to deliver the large caliber endoprosthesis using a Dacron graft sewn onto the iliac bifurcation.
An all-autogenous revascularization option allows for hypogastric bypass while limiting the use of synthetic graft.
Keywords: Aortic endograft Autogenous graft Aortic aneurysm
U nfavorable iliac anatomy, such as small cal- iber or circumferential calcification, can cause problems during delivery of aortic endografts and can lead to potential complications.1 Similarly, if the common iliac artery is aneurysmal, the endograft has to be landed into the external iliac artery covering the origin of the hypogastric artery. While coil emboliza- tion is an option, there is a trend toward hypogastric revascularization and preservation of pelvic flow. 2 In these situations, a separate bypass is required to the hypogastric artery. An iliac artery conduit “chimney” has been used to deliver the large caliber endoprosthesis using a Dacron graft sewn on to the iliac bifurcation. The “chimney” is used as an ilio-femoral bypass.1,2
This paper describes a technique for deploying endografts when treating aortic and common iliac artery aneurysm. This can be used when revasculariza- tion of the internal iliac artery is necessary. An all-auto- genous revascularization option allows for hypogastric bypass while limiting the use of synthetic graft. It also saves the patient from having a separate groin incision for an ilio-femoral bypass.
The patient presented with an aneurysm of the infrarenal aorta and the left common iliac artery.
From the Division of Vascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas (JFE, ATA).
Address correspondence to: Ahsan T. Ali, MD, Assistant Professor of Surgery, Division of Vascular Surgery, 4301 West Markham Street, Slot # 520, Little Rock, AR 72205; tel: 501- 686-6176; fax: 501-686-5328; email: firstname.lastname@example.org.
Figure 1. Abdominal aneurysm with large left common iliac aneurysm.
The left external and the internal iliac artery were not involved. He was scheduled for an endograft repair. In order to exclude the common iliac artery aneurysm, it was necessary to land the endograft in the ipsilateral external iliac artery. At the same time it was important not to sacrifice the hypogastric artery and preserve the blood supply of the pelvis (Figure 1).
The iliac bifurcation was exposed through a left lower quadrant curvilinear incision. The hypogastric
2 Vascular and Endovascular Surgery / Vol. X, No. X, Month 2006
Figure 2. The internal iliac artery transected at its origin. The external iliac artery is transected after 2 cm from its origin.
Figure 4. A prosthetic conduit is anastomosed to the external iliac artery distally for delivery of the graft.
Figure 3. The transected ends of the internal iliac and the external iliac artery are transposed.
Figure 5. Once the graft is deployed, the conduit is removed and the external iliac artery is anastomosed to its distal end in an end-to-side fashion.
artery was mobilized to its first branch. Then the external iliac artery was dissected out down to the inguinal ligament.
The internal iliac artery was controlled distally and then divided at its origin. Next it was oversewn flush at the origin, the common iliac bifurcation. The external iliac artery was divided distally, leaving a 2-3 cm proximal stump still in continuity with the common iliac artery (Figure 2).
The distal end of the external iliac artery was then transposed on to the hypogastric artery
(Figure 3). This established an all-autogenous anastomosis for the pelvic circulation. It also allowed some blood flow to the extremity during the procedure.
A 10-12 mm Dacron tube graft was anasto- mosed to the proximal stump of the external iliac artery, which protected it from catheter and sheath related trauma during introduction and deployment (Figure 4).
The endograft was landed into the proximal exter- nal iliac artery and once the procedure was completed,
Iliac Conduit for Aortic Endografts / Eidt, Ali 3
the Dacron conduit was removed. Now a primary anastomosis was performed between the proximal external iliac artery stump and the distal external iliac artery (Figure 5). Thus an autogenous configuration was achieved. The common iliac bifurcation essen- tially was moved distally while flow to the internal iliac artery was preserved.
This technique can be used when there is a redundant external iliac artery without concomitant occlusive disease.
1.Lee AW, Berceli SA, Huber TS, Ozaki CK, Flynn TC, Seeger JM. Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2003;38:459-465.
2.Arko FR, Lee AW, Hill BB, Fogarty TJ, Zarins CK. Hypogastric artery bypass to preserve pelvic circulation: improved outcome after endovascular abdominal aneurysm repair J Vasc Surg. 2004:39:404-408.