Successful Bailout of Intraoperative External Iliac Artery Rupture by Aorto-Uni-Iliac Stent Grafting and Femoral-Femoral Crossover Bypass in a Patient With a Giant Common Iliac Artery Aneurysm.

Common iliac artery aneurysms (CIAAs) are typically asymptomatic and difficult to detect. As they enlarge and are identified at later stages, the risk of perioperative complications increases. Endovascular aortic repair (EVAR) is often a viable option for managing giant CIAAs. It is crucial to keep the tip of the guidewire in the descending aorta to ensure adequate torque transmission, to streamline the access pathway, and to address emergency situations such as aneurysm rupture or other access-related issues. Careful manipulation is essential, particularly in cases of severe tortuosity. However, complications may still occur. Here, we describe a fatal access-related complication involving the severance of the external iliac artery (EIA) and guidewire deviation into the retroperitoneal cavity during EVAR for a giant CIAA. This report is the first to document a bailout strategy for such an access-related complication in a patient with a giant CIAA. We present the case and our recovery approach with a literature review. An 88-year-old man presented with worsening left back pain. Contrast enhanced computed tomography (CT) revealed a giant left CIAA measuring 69 mm, with significant calcification extending from the abdominal aorta to both EIAs. EVAR was planned using a bifurcated Excluder® device. During the procedure, angiography of the left CIAA revealed a looped and tortuous EIA. While advancing a left DrySeal® sheath with a Lunderquist® stiff wire into the terminal aorta, the Lunderquist® slipped into the terminal aorta, causing the diameter of the DrySeal® loop to enlarge. As we attempted to retract the DrySeal® sheath to the distal EIA to avoid CIAA rupture, the loop enlarged further, and the patient suddenly went into shock. Assuming a CIAA rupture, we removed the stiff wire to the distal EIA to release the enlarged loop. However, angiography confirmed a rupture of the left EIA. Attempts to access the left EIA from the CIAA side using a through-and-through technique were unsuccessful. Consequently, we performed Excluder® aorto-right uni-iliac (AUI) stent grafting combined with a common femoral artery crossover prosthetic bypass using the upside-down technique. The patient's postoperative course was uneventful, and he was transferred to a referral hospital on postoperative day (POD) 15. Unfortunately, three months after discharge, the patient succumbed to sepsis caused by methicillin-resistant (MRSA). In cases of severe tortuous access arteries that do not straighten despite the use of stiff wires, it is advisable to implement an early through-and-through technique between the brachial and femoral arteries. Additionally, proactive perioperative infection control, particularly for conditions like MRSA, is essential to improving postoperative survival and life expectancy.