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469
Annals of Vascular Diseases Vol.5, No.4 (2012)
Case Report
Two Cases of Endovascular Abdominal Aortic
Aneurysm Repair with Iliac Aneurysm
Using a Zenith Iliac Bifurcation Graft
Kei Kazuno, MD, Norifumi Ohtani, MD, and Sentaro Nakanishi, MD
We report on treatment of an abdominal aortic aneurysm with common iliac artery aneurysm using an iliac
branch device. We performed 2 cases because of a large common iliac artery aneurysm or a complication
of an internal iliac artery aneurysm. Both cases had a good postoperative course and progressed without
embolizing the iliac branch device during follow-up period. Though there is a drawback, it is not covered
by the national insurance program in Japan and cannot be used in all applicable cases. However, use of
a unilateral or bilateral iliac branch device allows us to maintain the bloodstream of the internal iliac
artery, thus suggesting it to be effective in such cases.
Keywords: endovascular surgery, iliac branch device, aortic aneurysm, abdominal iliac aneurysm
IntroductIon
Treatment of an abdominal aortic aneurysm (AAA)
using endovascular abdominal aortic replacement
(EVAR) was rst reported in 1991.1) However, there are
cases in which there is a short and/or sharp angle proximal
ne ck or tho s e in whic h access is di f cult , due to cal cica -
tion of the iliac artery region; therefore, not all cases may
be treated with EVAR.2) Coil embolization on the internal
iliac artery (IIA) with an extension of the stent graft leg
to the external iliac artery (EIA) is a common technique
when treating AAA with common iliac artery aneurysm
(CIAA). In the report by Cochennec et al., they warn that
ischemia symptoms, such as intermittent claudication
of the buttocks, etc., are prone to occur due to the blood
ow of IIA being interrupted.3) Furthermore, it is said
that coil embolization of the bilateral IIA should not be
carried out on bilateral CIAA cases because the possi-
bility of intestinal ischemia increases. We herein report
on treatments utilized in our department, in which the
iliac branch device (IBD) manufactured by Zenith Co.,
Ltd.. was used on not all, but in some cases, when there
was no other option for the patient, except to undergo
bilateral iliac aneurysm and bilateral internal iliac artery
embolization.
case report
Case 1
The case pertains to a 59-year-old man. He underwent
thoracoabdominal aortic graft replacement by a former
institute due to DeBakey type III aortic dissection. Sub-
sequently, the patient was followed up as an outpatient
accompanying relocation to our department. He had a
past history of an untreated renal tumor, but this was
followed up by periodic CT scanning. AAA and bilateral
CIAA enlargement were observed during follow-up.
Furthermore, stricture of the origin of the right external
iliac artery, believed to be caused by a past aortic dissec-
tion, was observed along with intermittent claudication
of the right lower extremity. A mild decline in cardiac
function was observed during preoperative testing. The
past surgery was conducted via the retroperitoneum;
Depart ment of Cardiovascular Surgery, Steel Memorial Muroran
Hospital, Muroran, Hokkaido, Japan
Received: August 19, 2012; Accepted: October 14, 2012
Corresponding author: Kei Kazuno, MD. Department of Cardio-
vascular Surgery, Steel Memorial Muroran Hospital, 1-45 Chir ibet-
su-cho, Muroran, Hokkaido 050- 0076, Japan
Tel: +81-143-44-4650, Fax: +81-143-47-4354
E-mail: kazuno@asahikawa-med.ac.jp
Ann Vasc Dis Vol.5, No.4; 2012; pp 469–473
©2012 Annals of Vascular Diseases doi: 10.3400/avd.cr.12.00071
Kazu no K, et al.
470 Annals of Vascular Diseases Vol.5, No.4 (2012)
however, adhesion of the surroundings of the abdominal
aorta below the renal artery was expected, so we planned
treatment by EVAR. Upon preoperative 3D-CT, the maxi-
mum diameter of the AAA was found to be 60 mm, the
right CIAA was 35 mm, and the left CIAA was 33 mm
(Fig. 1a and 1b). In regards to surgical policy, the external
iliac artery was strictured on the right, and symptoms of
intermittent claudication of the lower limb appeared, so
the right IIA was embolized using a coil, while the stent
graft was extended to EIA. The left CIAA had a large
maximum diameter of 33 mm, thus satisfying the treat-
ment indications in our department, so the stent graft
needed to be extended to the EIA in the same manner.
Accordingly, regarding the treatment using EVAR with
the purpose of preventing intermittent claudication of
the buttocks and ischemia of the digestive tract, after the
IBD was inserted into the left iliac artery and blood ow
of the IIA was ensured, the leg was extended to the EIA
regarding the right. While the patient was under general
anesthesia, we exposed the femoral artery and a Branch
Endovascular Graft-Iliac Bifurcation (COOK Medi-
cal Inc. Bloomington IN USA) manufactured by Cook
Co., Ltd.. was inserted and unfolded in the iliac artery.
Then, a guide wire was inserted from the contralateral
femoral artery and inserted into the IIA over the IBD.
Subsequently, insertion of the covered stent (ATRIUM
MEDICAL CORP. Hudson NH USA) manufactured by
ATRIUM Co., Ltd.. was antegrade and completely sealed
by connecting the IBD and IIA periphery (Fig. 2). Next,
coil embolization was conducted on the right IIA and a
Zenith Flex (COOK Medical Inc. Bloomington IN USA)
main-body manufactured by Cook Co., Ltd.. was inserted
from the right femoral artery. The leg was extended to
the EIA on the right, and the leg was placed so as to con-
nect to the IBD on the left. The postoperative course was
uneventful. There was good blood ow in the lower limb
and pelvis, as shown by 3D-CT, 6 days following surgery
(Fig. 1c) with no endoleak, and impeded blood ow of the
right lower limb was also released. There was no problem
with the wound, and the patient left the hospital 8 days
following recovery from surgery.
Case 2
The case pertains to an 80-year-old man. He was fol-
lowed up as an outpatient regarding AAA, right CIAA,
Fig. 1 Cas e1
a: Preoperative 3DCT: thoraco-abdominal graft replacement is carried out below the renal ar tery. The origin of the
right EIA is observed with narrowing of the true lumen due to dissection.
b: AAA with a maximum diameter of 60 mm is observed accompanying the mural thrombus below the renal artery.
c:Imag ing CT followi ng EVAR The blo od ow if the rig ht II A is go ne , and blo o d ow of the IBD to th e IIA is ensu r ed.
Report of EVAR with Zenith Bif urcation Graft
471Annals of Vascular Diseases Vol.5, No.4 (2012)
and left IIAA, but an enlarging tendency was observed
during follow-up, so the patient was admitted to hospital
for surgery. The patient was observed to have low cardiac
function accompanying congestive cardiac insufciency,
chronic renal failure without the introduction of dialysis,
and pancytopenia (MDS), after placement of a pacemaker
due to bradycardia-atrial-brillation. It was determined
that there was low anti-surgery capability, so we de-
cided to be treated with EVAR with the concomitant
use of IBD. The maximum diameter in preoperative
3D-CT was 52 mm; right CIAA, 32 mm; andleft IIAA,
35 mm (Fig. 3a). The operation was performed in the
same manner as in case 1. It was completed because there
was no endoleak upon nal contrast radiography follow-
ing ballooning. Imaging CT was not conducted because
temporary worsening of renal function was observed
following surgery (Fig. 3b and 3c); however, there was no
apparent endoleak upon abdominal blood vessel echoing.
Moreover, there was no worsening of general conditions
and the patient left the hospital 7 days following recovery
from surgery.
There were no problems in the postoperative course re-
garding both cases mentioned above, with each observed
as having aneurysm reduction as of the present, one
year and 6 months following surgery, and complications
related to EVAR have not been observed. Moreover, the
IBD was persistent in both cases upon an imaging CT/
abdominal blood vessel echo, and blood ow to the IIA
was maintained. Radiation exposure times of IBD cases
were 130 minutes and 117 minutes, respectively, and vol-
umes of contrast medium were 205 mL and 325 mL each.
dIscussIon
Complications of AAA and CIAA are not so common,
being found in 20% of all AAA cases.4) Treatment is often
conducted with the present EVAR, with safety of EVAR
to AAA established. However, a suitable treatment strat-
egy for iliac aneurysms has not yet been claried, and if
the diameter of the CIAA is small, to some extent, then
the leg of the bell bottom is inserted into the EVAR. If
the CIAA is large, there is a method of conducting coil
embolization on the IIA and extending the leg to the EIA,
etc. Furthermore, there is a method of bypassing from the
EIA to the IIA for the purpose of maintaining blood ow
of IIA after ligation of the orice of IIA. However, there
are no clear adaptations or policies for any of these.5) In
this manner, it is said that the leg is extended to the EIA
in 15% to 30% of EVAR, conducted on complicated cases
of AAA and CIAA.5) Moreover, carrying out coil embo-
lization on the IIA and conducting EVAR are common
and effective, in order to prevent a postoperative type II
endoleak. However, they may sometimes cause compli-
cations.6, 7) According to the literature, postoperative,
subjective symptoms were observed in approximately
1/3 of cases of coil embolization of the IIA, even on one
Fig. 2 IBD inser tion technique
a: An IBD is inserted, the outer sheath is slightly lowered, and the pre-load catheter
is taken out. A guide wire is inserted inside the pre-load catheter, maintained with a
snare catheter from the iliac arter y from the opposite side, and removed from the body.
b: The IBD outer sheath is partially developed until the inner iliac region is developed.
c: A Balkin sheath is inserted inside the IBD via the guide wire of the opposite side and
the sheath is inserted into the internal iliac artery.
d: A covered stent is inserted from the balkin sheath and developed. The IBD and inner
ileum are completely sealed. Finally, the IBD is completed.
(diagram used with permission of COOK medical Inc.)
a b c d
Kazu no K, et al.
472 Annals of Vascular Diseases Vol.5, No.4 (2012)
side, with claudication of the gluteus muscles, which is
the ischemia of gluteus muscles, being the most common,
observed in 80% of cases with symptoms. Furthermore,
it is said that erectile dysfunction was observed in 10%,
though it depended on the degree of symptoms, and
intestinal ischemia was observed in 6%–9%.6, 8) So it
is said that coil embolization of the bilateral IIA should
not be carried out on bilateral CIAA cases, because of
these reasons.
In our institute, the maximum leg peripheral diameter
is 24 mm in the case of Zenith; therefore, EVAR is deter-
mined to be extended up to the CIA if the CIA diameter
is under 20 mm while the leg is extended in two stages
if enlargement is observed during the postoperative
course. If the common iliac artery diameter is 25 mm
or more, the leg is extended to the EIA after carrying
out coil embolization on the IIA. Complications such as
intestinal necrosis are not observed in cases that under-
went coil embolization on the unilateral IIA; however,
intermittent claudication of the buttocks is observed in
approximately 10% of cases. In regards to the 2 cases
presented in this study, treatment using IBD was selected
because the treatment is halfway by extending the leg to
a unilateral IIA coil embolization/EIA, and because the
iliac aneurysm diameter is too big to conduct treatment in
two stages. IBD is a new treatment method with a device
to maintain the orthodromic bloodstream in endovascular
repair of abdominal and iliac aneurysm without adding
laparotomy.
However, there are only 2 types of lengths for IBDs,
with various adaptations regarding the insertion thereof.
The sheath diameter of the IBD body is 20Fr, so access
allowing the insertion of a 20Fr sheath is necessary. Re-
garding IBDs, the common iliac artery has a diameter
of 12 mm, with lengths of only 45 mm and 61 mm. On
the relationship of the leg of the stent graft body and the
overwrap, as well as the relationship of providing a 10-
mm gap between the IIA and the inner iliac region of
the IBD, when the central IBD and aortic bifurcation are
matched, and the covered stent in this space is inserted,
the common iliac artery cannot be used unless it is at least
50 mm in length. The ideal sealing zone of the internal
iliac artery is 7–9 mm in diameter, when at least 15 mm
or more in length is required. The inner ilium opening
of the IBD has an inner diameter of 8 mm, so a covered
stent that is 8 mm or longer is required.
Fig. 3 Case2
a: Preoperative 3DCT: AAA•rtCIAA•ltIIAA were observed
b/c: Postoperative CT: enhance wasn’t performed due to renal dysfunction. AAA don’t enlarge
and cover stent inserted into right internal iliac artery.
b
a
c
Report of EVAR with Zenith Bif urcation Graft
473Annals of Vascular Diseases Vol.5, No.4 (2012)
Regarding cases in which the IBD is not adapted, there
is a method of carrying out EVAR using an aortouniiliac
graft if it were CIAA, by concomitantly using a femoro-
femoral bypass (F-F bypass). Moreover, when there is a
stenosis lesion or enlargement in the EIA, a bypass must
be selectively conducted on IIA. When such treatments
are carried out, not only does patient invasion become
high due to the addition of a lower abdominal incision
but the internal iliac artery is also pushed deeply into
the pelvis when there is a CIAA; therefore, the tech-
nique becomes complicated and may cause unexpected
complications. Furthermore, the risk of graft infection
also increases.9)
Furthermore, Karthikesalingam et al. also used IBDs
on 195 cases, reporting that occlusion of the IBD and
claudication of the buttocks only occurred in 6.1% cases;
it was reported that the incidence of claudication of the
buttocks was lower compared to open surgery, so IBD
was useful.10) Fabio et al. mentioned that occlusion of the
IIA following insertion of an IBD is caused due to kink-
ing of the IBD from secular changes, and discussed that
thrombus removal was successful in all cases in which
occlusion was conducted. However, occlusion following
insertion of IBD is only conducted on about 6% of cases,
and it is mentioned that because there are not many cases
observed with symptoms, these cases should be further
treated while observing the symptoms.6)
In this manner, IBDs are observed with a complication
of occlusion of IIA at a longterm stage, and may be said
to be useful devices upon maintaining the orthodromic
bloodstream of the IIA region with respect to AAA
complicated with CIAA; however, it is not applicable to
insurance in Japan, and there is no other choice but to
privately import the IBD in order to use it. The IBD itself
is $2870, ATRIUM of the covered stent costs $1400, and
furthermore, there is a problem that approval from the
hospital is required for the use thereof, so it is believed
that more time is required for it to become widespread
in Japan.
conclusIon
Though there are problems, such as the fact that the
IBD needs to be privately imported, it was believed that
this is a device useful in maintaining the orthodromic
bloodstream of the IIA region with respect to AAA with
a complication of CIAA. Moreover, IIA may be occluded
over the long term in some cases, so it was believed that
close follow-up is required following the surgery thereof.
FundIng
This re search received no specic gr a nt from any fu nd-
ing agency in the public, commercial, or not-prot sectors.
dIsclosure statement
None declared.
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