Author + information
- Naoko Higashino1,
- Osamu Iida1,
- Shin Okamoto1,
- Takayuki Ishihara1,
- Kiyonori Nanto1,
- Takuya Tsujimura1,
- Shota Okuno1 and
- Masaaki Uematsu1
Patient initials or identifier number
Relevant clinical history and physical exam
A 68-year-old male with a history of bladder cancer (post-laparotomy) complained of sub-acute onset and intractable pain at rest in both lower limbs. The femoral arteries were not palpable, and the ankle brachial index was extremely low on both sides 0.37 right, 0.39 on the left. We strongly suspected severe peripheral artery disease (PAD).
Relevant test results prior to catheterization
CT angiography revealed complete occlusion of the infrarenal aorta complicated by the formation of a 35 mm an aneurysm. According to the Trans-Atlantic Inter-Society Consensus II guidelines, concomitant complete occlusion of the infrarenal aorta with an abdominal aortic aneurysm (AAA) defined as a D lesion, absolutely requiring surgical repair. However, as open surgery repair was a relatively high risk because of his several comorbidities, we planned an endovascular aneurysm repair.
Relevant catheterization findings:
The procedure performed under general anesthesia, and the common femoral arteries (CFA) were exposed via inguinal incisions. A 5Fr, 10 cm sheath was inserted from the right brachial artery for control of the angiogram. After the puncture of the right CFA, an 8Fr, long sheath inserted. A 0.035-inch Radifocus® guidewire successfully, an 18Fr, the 28 cm sheath inserted from the right CFA and an Excluder® aortic main body device was implanted in the renal artery. Next, we attempted to cannulate the contralateral gate for implantation into the contralateral leg. However, because optimal dilatation of the contra gate cannot obtain due to residual stenosis at the aortic lesions, the cannulation failed. Therefore, we switched the strategy to an antegrade approach. A 5Fr, 90 cm guiding catheter inserted from the right brachial artery. A 0.018-inch treasure wire accompanied by a 5Fr Judkins right guiding catheter was passed through a contra gate and a pull-through technique, from the left CFA to the right brachial artery, was used. After the wire crossing, a 14Fr sheath was put in place, and an Excluder® Contra Leg was implanted into the left common iliac artery. Finally, balloon-expandable stents (Assurant 10 mm × 60 mm, Medtronic) were implanted using the kissing balloon technique. The operation time (skin to skin) was 103 minutes, and the amount of contrast media used was 80 ml.
We conducted EVAR for a treatment of an aortic occlusion with AAA. After the procedure, the bilateral leg pain at rest immediately disappeared, and the ankle brachial index dramatically improved to 1.03 on the right side, and 1.04 on the left side. In this case, we successfully performed EVAR for concurrent PAD patients with AAA. Based on our experience in this case, in which a patient with severe symptoms successfully treated with a minimally invasive procedure, EVAR would be an attractive alternative to open surgery for concurrent PAD with AAA.