Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
The 80-year-old female patient referred from a local doctor indicating the abnormal shadow in chest X-ray.
She had no symptoms and no medical history but had hypertension and dyslipidemia. Her height was 165 cm and weight was 55 kg. There was no other arteriosclerotic disease including coronary artery disease and carotid artery disease.
Relevant test results prior to catheterization
The contrast-enhanced CT scan showed the hairpin curve of descending aorta that shown as an abnormal shadow in chest X-ray, abdominal aortic aneurysm (AAA) (45 mm), left common iliac artery aneurysm (CIAA) (51 mm) and internal iliac artery aneurysm (IIAA) (28 mm). The proximal neck was angulated ver 90 degrees and the length was 19 mm.
Relevant catheterization findings
The angle between left subclavian artery and aortic arch angulated that it was difficult to let the pigtail catheter go through the ascending aorta. In the angiography from a common femoral artery, the neck of AAA was very angulated and the length was short.
The both sides of the internal artery were embolized via each contralateral femoral artery using Vascular Plugs. The main body ofEndurant II was deployed just distal to the left renal artery (RA) and the contralateral limbs were deployed on each side. While deploying the main body of the stent graft, we pushed the delivery shaft of Endurant II up in order to align the first ring of the main body coaxial to the angulated neck. The distal landing points were the external iliac artery on both sides.
After touching up the stent graft using the Reliant balloon, we found that the stent graft jailed the left RA. It was impossible to approach the left RAbecause of the angulated proximal neck, and therefore, we had to approach it from the left brachial artery. An ultra-stiff wire deployed into the descending aorta in order to advance a 6 French guiding sheath through the descending aorta from the left brachial artery. A 0.014” Guidewire was able to cross the left RA, however, the acute angle of the aortic arch prevented a 6 French guiding catheter from approaching left RA. Therefore, we chose GuideLiner PV to solve this problem. GuideLiner PV could enter into the left RA and a 6 mm balloon successfully delivered into the left RA. A balloon anchoring technique allowed the tip of the 6 French guiding catheter passes the ostium of the left RAcovered by the stent graft. After the stent implantation in the ostium of the RA, no endoleaks and excellent blood flow of the left RA observed.
It is difficult to bail out an unexpected side branch occlusion during a stent graft implantation. The reason for the difficulty includes a torturous access route and artificial occupying objects. GuideLiner PV is an effective option to clear these difficulties.