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• Angulated neck
• Reverse conical neck
• Short neck
• Aortic mural thrombus
• Narrow aortic bifurcation
• Severe tortuosity of iliac artery
• Thoracoabdominal aortic aneurysm (TAAA)
Difficult cases : Out of IFU
Technical success was achieved in all cases.
Similar mortality, morbidity, technical success, clinical
success, complications, and reinterventions rates.
Estimated 1-year freedom from type I endoleak was
100% in the IFU group vs 93.3% in the OL patients
(P=0.01) @ 1 year.
• thoracoabdominal aneurysm
• persistent type Ιa endoleak (previous standard
EVAR)
• aortoenteric fistula
• adequate distal landing zone
How to select the chimney graft?
More chimney grafts, more gutters and more chance of type Ia endoleak
Sandwich technique
Aortic mural thrombus
(>50%)
Balloon dilatation
(neck)
Narrow aortic bifurcation
The problems of narrow aortic
bifurcation and narrow aorta ??
• Arterial dissection and disruption
• Stent graft compression and collapse
• Iliac limb occlusion
• Difficult to advance the wire into the contralateral
gate
• Open repair
• Aortouniiliac stent graft (AUI)
• Bifurcated stent graft
(off-label technique)
• 231 AUI-EVAR patients
• Patency@3 yr : 91%
• Patency@5 yr : 83%
• Wound complications : 11%
(groin hematoma4%, seroma3%, superficial wound
infection3%)
• Fem-fem bypass graft occlusion : 4%
J Vas Surg2003;38:498-503
• Aortic bifurcation diameter < 18mm
• Early mortality rate =1.8% , morbidity rate =11%
• Bifurcated stent grafts(106) : diameter : 16±3mm
• Stent graft primary patency@1,5 yr : 99%, 96%
J Vas Surg2015;62:1140-7
A B C
Up and over
technique
J Vas Surg2015;62:1140-7
Narrow aortic bifurcation
Kissing balloon and bare BES
Kissing balloon and bare BES
AAA with AIOD
PTA and partially deployed MB
Iliac limb compression; kissing balloon
Iliac limb compression; kissing bare BES
Severe tortuosity of iliac artery
• Open repair
• Hybrid repair
• Totally endovascular repair
o T-branch
o Sandwich technique
Review of the literature
• Operative mortality and morbidity of standard open repair for
TAAA have improved significantly at selected centers, but the
overall national data of mortality rate approaching 20%.
PTFE, 8mm
Rt CIA
Left common iliac artery-to-
left renal artery-to-SMA
bypass
No endoleak
CHA
Lt renal a.
Rt renal a. SMA
SMA
• CTA at one month
showed
• no endoleak
• no bypass grafts
occlusion
• dissection of right
external iliac artery.
• The patient denied for
iliac stenting. dissection
Sandwich tech : TAAA
Sandwich tech : TAAA
Thank you for your attention