MIAMI BEACH – A novel, trifurcated, endovascular stenting procedure allowed preservation of blood flow through the internal iliac artery of patients undergoing repair of a thoracoabdominal aortic aneurysm or an aortoiliac aneurysm.
Dr. Armando C. Lobato
Dr. Armando C. Lobato, who developed the technique, has successfully used it on 34 patients, including 7 patients who required bilateral repairs, he said at the International Symposium on Endovascular Therapy. He performed his first trifurcation procedure – which he also calls the Brazilian Sandwich procedure – in August 2008. He has had 100% technical success using the procedure, with no operative deaths and no need to convert to an open procedure.
During a median follow-up of 5 months (range, 2-24 months), no patient experienced colonic or buttock necrosis, no patient had ischemic colitis, and there were no type III endoleaks. In all, 39 (95%) of the 41 treated internal iliac (hypogastric) arteries maintained primary patency. As a result of the procedure, occlusions also occurred in one contralateral iliac limb and in one ipsilateral external iliac artery. Secondary patency was maintained in 38 of the 41 treated arteries and their associated vessels, said Dr. Lobato, medical director of the Vascular and Endovascular Surgery Institute in São Paulo, Brazil.
About 20%-30% of patients with abdominal aortic aneurysm also have aneurysms in one or both of their common iliac arteries. Endovascular repair in these patients is harder because of the difficulty in finding an adequate landing zone for the stent-graft limbs and because the iliac aneurysm is a potential site for an endoleak. In addition, some patients have short common iliac arteries, an anatomy that is especially prevalent in patients of Asian descent and on the right side of the body. Dr. Lobato said that he developed the trifurcation technique to overcome these anatomical problems so that endovascular aneurysm repair could expand in a safe and cost-effective way via a method that was easy to perform.
Dr. Lobato broke the trifurcation technique into the following five steps:
• First, he inserts the main, bifurcated stent graft using an ipsilateral femoral approach. He positions the graft so that the distal end of the iliac limb is 1 cm above the origin of the internal iliac artery.
• Second, he inserts a long, 5-Fr multipurpose catheter into the ipsilateral internal iliac artery using left brachial access and a 0.035-inch, extra-stiff guide wire with a floppy tip.
• In the third step, he places a covered, self-expanding stent 2 cm into the internal iliac artery with a 6-cm overlap into the iliac limb. He also then positions an iliac limb extension 1 cm below the proximal end of the covered stent. He deploys the iliac limb extension first, followed by deployment of the covered stent.
• Fourth, he models the iliac limb stents with a latex balloon and dilates the covered stent with an angioplasty balloon.
• For the final, fifth step, he deploys the graft within the contralateral iliac limb.
In patients with bilateral aneurysms in their common iliac artery, he repeats steps 2-4 on the second side.
Dr. Lobato said that he had no disclosures.