Mertens Renato A, Bergoeing Michel P, Mariné Leopoldo A, Valdés Francisco, Krämer Albrecht H
Departamento de Cirugía Vascular y Endovascular, División de Cirugía, Pontificia Universidad Católica de Chile, Santiago, Chile.
Ann Vasc Surg. 2010 Feb;24(2):255.e9-12. doi: 10.1016/j.avsg.2009.07.009. Epub 2009 Nov 8.
Anatomy has been the major challenge to overcome to increase safe and durable applicability of endografting for the treatment of abdominal aortic aneurysm. Bilateral iliac aneurysm preventing an appropriate distal landing zone for the endograft is a common condition and can be managed by (a) increasing the diameter of the endograft, with limitations in available sizes, (b) bilateral hypogastric embolization, accepting an increased morbidity, (c) the use of a branched device, increasing the cost and currently with limited availability, (d) combined surgical hypogastric revascularization by the retroperitoneal approach, or (e) retrograde revascularization from the ipsilateral external iliac artery using an endograft. We describe the use of widely available devices to obtain stable antegrade revascularization of one hypogastric artery during aortic endografting. We report the case of a 68-year-old man, at high risk for an open procedure, who presented with bilateral iliac aneurysm and minor aortic ectasia; no iliac landing zone was available. A regular bifurcated graft was deployed and extended into one of the external iliac arteries, preceded by ipsilateral hypogastric embolization. Through an upper extremity approach, an endograft was deployed from the remaining bifurcated graft branch into the other hypogastric artery, followed by ipsilateral external iliac occlusion. Finally a femorofemoral crossover bypass was performed. The patient recovered event free, and patency of the endograft and absence of endoleak were demonstrated on computed tomography. Minor unilateral buttock claudication resolved in 6 weeks and sexual function was preserved. This technique is a reasonable alternative to consider in the endovascular treatment of patients with bilateral iliac aneurysm, allowing preservation of pelvic perfusion, limiting cost, and using available devices.
为提高腹主动脉瘤腔内修复术的安全性和耐用性，解剖结构一直是需要克服的主要挑战。双侧髂动脉瘤导致腔内修复术缺乏合适的远端锚定区是一种常见情况，可通过以下方法处理：（a）增加腔内修复器械的直径，但现有尺寸有限；（b）双侧髂内动脉栓塞，这会增加发病率；（c）使用分支型器械，这会增加成本且目前供应有限；（d）通过腹膜后途径进行联合手术性髂内动脉血运重建；或（e）使用腔内修复器械从同侧髂外动脉进行逆行血运重建。我们描述了在主动脉腔内修复术中使用广泛可用的器械实现一侧髂内动脉稳定的顺行血运重建。我们报告了一例68岁男性患者，其开放性手术风险高，患有双侧髂动脉瘤和轻度主动脉扩张，无髂动脉锚定区。先进行同侧髂内动脉栓塞，然后植入常规分叉型移植物并延伸至一侧髂外动脉。通过上肢入路，将腔内修复器械从剩余的分叉型移植物分支植入另一侧髂内动脉，随后闭塞同侧髂外动脉。最后进行股-股交叉旁路移植术。患者顺利康复，计算机断层扫描显示腔内修复器械通畅且无内漏。轻微的单侧臀部间歇性跛行在6周内缓解，性功能得以保留。该技术是双侧髂动脉瘤患者血管内治疗中值得考虑的合理替代方案，可保留盆腔灌注，降低成本，并使用现有器械。
