Balloon-oriented puncture for creating an access for endovascular aortic aneurysm repair in a case of iliac and femoral artery occlusion

BACKGROUND: Abdominal aortic aneurysms (AAA) with iliac artery occlusive diseases are not uncommon. When an occlusion extends from iliac artery to common femoral artery (CFA), adjunctive procedures such as endareterectomy of CFA and angioplasty of iliac artery are performed prior to endovascular aneurysm repair (EVAR). Alternatively, aorto-uni-iliac stentgrafting with femoro-femoro bypass surgery could be performed. If run off vessels such as superficial femoral artery (SFA) and profunda femoris artery (PFA) are both occluded in addition to the CFA, surgical procedures may become extremely complex, with much longer procedure time. We present an unusual case of AAA with arterial occlusion ranging from external iliac artery (EIA) to superficial and profunda femoris arteries, which was fully managed with endovascular means. CASE PRESENTATION: The patient was a 76 year old male who was found incidentally to have a fusiform infrarenal AAA, the size of which was 55 mm in maximal transverse diameter. Despite the occlusions of left EIA, CFA and proximal parts of SFA and PFA, he did not have ischemic symptoms in his left leg due to the development of abundant collateral networks from left internal iliac artery. The patient had a past history of endarterectomy of left CFA. Since a repeated endarterectomy or interposition grafting of the CFA were deemed extremely difficult, without any patent runoff vessel, EVAR was performed using the occluded vessel simply as a conduit for the delivery of the endograft, without revascularizing the vessel. An angioplasty balloon was delivered from right CFA to the occluded left CFA through a subintimal space. A percutaneous puncture of the expanded balloon was done at the occluded left CFA under fluoroscopy, inserting the guidewire into the punctured balloon, finally establishing the through and through wire. EVAR was successfully performed using AFX unibody stentgraft without any complication. CONCLUSION: AAA with access vessel occlusions from EIA to SFA was successfully treated with EVAR with the aid of the balloon oriented percutaneous puncture technique. Having the technique as an armamentarium can broaden the application of EVAR for AAA with the complicated access.