Teaching Case

Endoluminal exclusion of an common iliac artery aneurysm complicated by dislodgement of the stentgraft during delivery

A 74-year-old presented with a right blue-toe syndrome. Transbrachial arteriography revealed a large aneurysm of the right common iliac artery which was regarded as a source for embolism. Due to its size it was also regarded to be prone to rupture and endoluminal exclusion by use of a balloon-expandable stentgraft was planned (Fig. 1). Firstly, a long 9 F introducer sheath was placed across the lesion with its proximal tip across the aortic bifurcation. Then, a balloon-expandable stentgraft (Large stentgraft, Jomed Inc.), mounted on an 8 mm balloon, was inserted through the sheath. Due to the kinking of the iliac artery at the level of the orifice of the internal iliac artery, it turned out that it was not possible to advance the stentgraft further without being pushed back from the balloon. Thus the long sheath together with the stent were pulled back and the long sheath was reinserted. Then, after removing the stent graft, an 8F guiding catheter was backloaded over the balloon catheter and its proximal end was placed at the distal end of the balloon. Then the stentgraft was remounted on the balloon (Fig.2). Thus, the balloon catheter together with the stent graft and the guiding catheter were reinserted through the sheath and the stent graft was advanced to the desired position. After retrieval of the long sheath the stent graft was delivered by balloon inflation. The intervention was terminated by an additional stent placement of a noncovered stent - using the same delivery technique (Fig.3) at the orifice of the common iliac artery which was also stenosed (Fig. 4 A and B).

Endoluminal exclusion of iliac aneurysms is feasible by use of self-expanding and balloon expandable stentgrafts. Balloon-expandable stent grafts allow a more flexible policy of stocking since a single device may be used from 5 mm to 9 mm in diameter while self-expanding stentgrafts are fixed to its dedicated diameter at length which means to have a large variety of different stents in stock in order to be prepared for all diferent situations and cases. Due to the covering and its increased stiffness, balloon-expandable stent grafts are more difficult to be crimped safely onto the balloon compared to bare stents. Especially if kinking of the artery causes compression of the delivery sheath, dislodgement of the stentgraft during advancement of the delivery system is a risk. Therefore, use of a protecting long sheath is mandatory. Combing the delivery balloon with a suiting guiding catheter allows to protect the stent graft from being dislodged backwards while being advanced. As an alternative, a kink-resistant sheath such as the Arrow superflex sheath or a Balkov sheath (Cook Inc.) could be used.