Southern Association for Vascular Surgery
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Transaxillary EVAR using a reverse mounted Gore Excluder endograft for a patient with AAA and severe iliofemoral occlusive disease
Carla K Scott, Andres V Figueroa, Jacqueline L Babb, Carlos H Timaran, Mirza S Baig
UT Southwestern Medical Center, Dallas, TX

Objective: Patients with Abdominal Aortic Aneurysm and severe iliofemoral occlusive disease present a unique challenge for endovascular repair. We present a technique for transaxillary totally percutaneous endovascular repair of an infrarenal aortic aneurysm complicated by occlusive disease of bilateral iliofemoral arteries. Methods: A 75-year-old male with hypertension, tobacco use and a 5.5 cm infrarenal AAA with severe bilateral external iliac and common femoral artery occlusive disease that was previously recommended to undergo open aortofemoral bypass or bilateral femoral endarterectomy, iliac conduit and EVAR, the patient refused any open procedure and was referred for a total percutaneous option. Results: Under general anesthesia, the left axillary artery was accessed under ultrasound guidance, two Perclose devices were deployed and an 18Fr x 65cm sheath was advanced to the level of the infrarenal aorta. The left common iliac artery demonstrated >90% stenosis with calcified plaque, successful lithoangioplasty was performed of the left common and external iliac and common femoral arteries followed by stenting. Next, a 23mm x 14.5mm x 12cm Gore Excluder Graft was dismounted from the delivery system, then the graft was reverse mounted on a 6mm x 150mm balloon catheter to allow transaxillary delivery in the same orientation as a transfemoral delivery. The graft was placed in the infrarenal aorta from above and an aortogram was performed and the renals were marked. The graft was successfully deployed, starting with the ipsilateral limb into the left common iliac stent followed by the main body. The contralateral gate was cannulated. The right external iliac was occluded at the origin. Antegrade crossing proved difficult. A micropuncture catheter was placed in the right common femoral and a .018 wire used to cross retrograde. The wire was snared from the axillary access. Lithoangioplasty was again performed to treat the right common and external iliacs stenosis. Then, a bridging stent was placed from the contralateral gate to the right common iliac. The Right external and common femoral arteries were stented. Completion angiogram demonstrated an excellent result with widely patent bilateral iliac arteries and no evidence of endoleak. Conclusion: Total percutaneous transaxillary delivery of a remounted bifurcated endoprosthesis is a feasible technique for repair of aortic pathology in patients with high mobidity and mortality risk with open repair and no viable femoral access for endovascular repair.

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