Novel Surgeon-Modified Hypogastric Branch Stent Graft to Preserve Pelvic Perfusion

Background: We describe the feasibility and early results of a novel approach to preserve pelvic perfusion during endovascular aortic aneurysm repair (EVAR) in patients with aortoiliac aneurysms extending to the iliac bifurcation. Methods: Three high-risk patients, aged 70 ± 7 years, with large aortoiliac aneurysms (mean 6.7 ± 0.5 cm) and inadequate distal common iliac artery landing zones were treated with a surgeon-modified hypogastric branch stent graft between June 2007 and July 2008. The modified device was created using a 73 mm iliac stent graft limb with a presewn 6-8 mm polyester side graft. The modified device was resheathed into a 20F sheath, and the side graft was preloaded with a wire and catheter. The resheathed device was introduced to the level of the aortic bifurcation via a 24F peel-away sheath, and using the preloaded catheter, a long wire was snared, establishing through-and-through femoral access. A 12F contralateral femoral sheath was advanced up and over the aortic bifurcation into the presewn side graft. The repair was bridged to the ipsilateral hypogastric artery using a matting self-expandable stent graft and extended distally to the external iliac artery, followed by standard EVAR. All patients were followed clinically and with computed tomography angiography prior to hospital discharge and every 3 months thereafter. Results: Mean procedural time was 172 ± 23 min, including 45 ± 22 min for device modification. Total fluoroscopy time, contrast load, and radiation dose were 78 ± 17 min, 180 ± 23 mL, and 3,890 ± 1,034 mGy, respectively. The procedure was technically successful in all cases. There were no aneurysm ruptures, deaths, conversions, or complications; and the mean length of hospitalization was 3.5 ± 1 days. At a mean follow-up of 9 ± 3 months, all branched hypogastric arteries remained patent without endoleak, migration, or loss of device integrity. Conclusion: Surgeon-modified hypogastric branch stent grafts to maintain perfusion to one or both hypogastric arteries is feasible and provides an alternative to hypogastric artery exclusion. Long-term follow-up is needed to evaluate stent-graft patency and failure rates.