complex treatment of a type 1b endoleak aer evar and an ... · our soluon for type 1b endoleak in...

Complex treatment of a type 1b endoleak a3er EVAR and an internal iliac aneurysm Michel Bosiers, MD Vascular and Endovascular Surgeon Department of Vascular Surgery St. Franziskus-Hospital Münster, Germany

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Page 1: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

Complextreatmentofatype1bendoleaka3erEVARandaninternaliliacaneurysm

MichelBosiers,MDVascularandEndovascularSurgeonDepartmentofVascularSurgerySt.Franziskus-HospitalMünster,Germany

Page 2: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

Case presenta*on

•  76ymalepaKent

•  EVAR+singlechimney2009

•  OverstenKngandocclusionrightinternaliliacarteryduetotype1bendoleak2010

•  Cuff-ImplantaKon+triplechimney+embolisaKonusingonyxduetotype1aendoleak2013

•  Now:Type1bendoleakonthele3side+internaliliacarteryaneurysm

ComorbidiKes:•  CAD•  NYHA2•  Hypertension•  COPD

Page 3: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

Problems:

•  Only1patentinternaliliac(IIA)

•  IIAisaneurysmaKc(5cm)

•  Stenosedglutealartery

•  IMAisoccluded

Solu4ons:

•  Donothing?

•  Iliacsidebranch?

•  OverstenKngIIAandembolisaKon?

•  Openconversion

•  Other?

Our solu*on for type 1b endoleak in this case:

1.  Wedidn´twanttoriskbowelischemia(occlusionrightIIA,IMA),thereforeIIAshouldbepreserved

2.  IIAaneurysmshouldbetreatedinthiscase(5cm)

3.  Inouropinionnotfitforopenkonversion(keepinmind,hehas3chimneystentgra3s)

4.  OpensurgeryforIIAaneurysmisverydifficultinthiscase:largeanddeepinthepelvis

Iliacsidebranchdevice

Page 5: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

•  Transfemoralpercutaneousapproach•  Cutdownaxillarartery

1.  IliacsidebranchfromCOOK:ZBIS-12-61-412.  proximalextensionusingEndurantlimb(Medtronic)3.  Closingofthegrointorestorebloodflowtothele3limb

Page 6: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

Transaxillaryapproachfortheiliacsidebranch

Advancing8FsheaththroughthebranchintotheIIA

AlreadyimplanKngabridgingballoonexpandablecoveredstentgra3(VBX8x59,Gore)togetamorestabilPosiKoninsidetheIIA

Page 7: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

•  VeryinstableposiKonofthewire

intheglutealartery

•  Wecouldn´tadvanceanycatheters

WewerethenabletoadvanceaLP6x100Viabahn(Gore)overa14inchSpartacorewire(Abbok)HowevernotlongenoughtoreachthealreadyimplantedVBX

SointryingtoakachthemwithanotherStentgra3....DislocaKonoftheviabahn

Page 8: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

Wemanagedtostraigthentheviabahn Andconnectthemwithashort

VBX8x39mm

However:typeIIIendoleak

Page 9: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

AdvancinganAdvanta8x59

dislocatedtheviabahn...again

Butnowa„stable“connecKonwasmade

withsKllsometypeIIIendoleak

Welinedallofitwitha8x100mm

Viabahn

Page 10: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

FinalResult

Page 11: Complex treatment of a type 1b endoleak aer EVAR and an ... · Our soluon for type 1b endoleak in this case: 1. We didn´t want to risk bowel ischemia (occlusion right IIA, IMA),

•  Intheend:goodresult

•  Dischargeatpostopday5

•  NocomplicaKons

•  Nobowelischemia

Ques4onstoVascupedians:1.  Worththemoney?

2.  Whatwouldyouhavedonedifferently?

3.  Whatisyourtrickinveryinstable

wireposiKonstoadvanceacatheterorstent

4.  Doyouhaveexperiencewithiliacside

branchdevices?Whichoneandwhatisyour

opinionaboutthem?

5.  Whodoesn´tcareabouttheIIAandwould

haveembolisedit?

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