Endovascular Left Common Iliac Aneurysm Repair Using Intraoperative Positioning System Technology for 3D Device Guidance
Quang Le1, Behzad Farivar2
1University of Virginia School of Medicine, CHARLOTTESVILLE, VA;2University of Virginia Health System, CHARLOTTESVILLE, VA
OBJECTIVES: The development of endovascular aneurysm repair (EVAR) has delivered major changes to the practice of vascular surgery, providing a safe and effective treatment modality for aneurysms of the abdomen and pelvis. However, one notable drawback of endovascular repair is the exposure of patients to radiation and nephrotoxic dye. The Intraoperative Positioning System (IOPS) is a new endovascular navigation system currently in development that uses electromagnetic tracking to provide three-dimensional simulated vascular guidance. A recent update has also allowed the system to incorporate endograft into real-time visualization of the vasculature. We are reporting an early case of common iliac aneurysm repair using IOPS with an endoprosthesis overlay.
METHODS: Our patient is an 87-year-old male with an incidentally found, asymptomatic aneurysm measuring 37.1 mm just proximal to the left common iliac artery bifurcation. This patient is an active smoker with a notable history of hypertension and descending penetrating aortic ulcer that was being monitored. His preoperative workup was reassuring with a Creatinine of 1.2 mg/dL. The patient was taken for an endovascular repair of his aneurysm using a Gore Excluder Iliac Branch Endoprosthesis (IBE) measuring 23x12x10 mm. Bilateral percutaneous femoral artery access was obtained. We then establish through and through access across the aortic bifurcation. The endograft was delivered into position and partially deployed. At this point, an intraoperative computed tomography (CT) was performed to fuse the patient’s position was preoperative CT. The patient’s vascular anatomy was subsequently simulated with an overlay of the endograft. Using IOPS compatible wire and sheath, the posterior branch of the left internal iliac was cannulated in 50 seconds. No contrast or fluoroscopy was used during cannulation. A Viabahn VBX 8x59 mm stent was used to extend the internal iliac gate. The IBE was then fully deployed. A 12x60 mm Protégé stent was then used to extend left external iliac coverage due to tortuosity. A final aortogram was performed which showed the proper placement of endografts and no endoleak. Overall, the case lasted 166 minutes with 25 minutes of fluoroscopy, 1309 mGy of radiation, and 110 mL of Omni350.
RESULTS: The case was a technical success. There was no endoleak. The patient’s hospital course was uneventful, and he was discharged on postoperative day 1. Maximal creatinine during admission was 1.2 mg/dL. At one month follow-up, the patient is stable clinically and radiologically. Aneurysm size is stable with no notable endoleak.
CONCLUSIONS: Our case represents the initial experience with intraoperative 3D visualization of the endograft with endovascular navigation using IOPS catheters. The patient’s positive outcome points to the feasibility of using a fusion imaging overlay to direct EVAR. This approach combines the proven favorable outcomes of EVARs with the reduced radiation and contrast use facilitated by IOPS.
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