Technique of reversed flared iliac stent graft for iliac aneurysms with discrepant size diameters

Purpose. Endovascular treatment of iliac artery aneurysms (IAAs) in patients with discrepancy in iliac artery diameters can be challenging because of limited availability of reversed flared stent graft limbs. The authors describe the technique of reversing a Cook Zenith (Bloomington, IN) iliac stent graft extension to accommodate for significant discrepancy in diameter between the common iliac artery (18 mm) and the external iliac artery (11 mm). Technique. A 75-year-old male patient with a 7.3-cm right internal IAA was treated with endovascular exclusion of distal internal iliac artery branches using Amplatzer plugs (AGA Medical Corp, Plymouth, MN) and coverage of the internal iliac artery origin using a reversed 12 × 20 mm Cook Zenith TLFE Iliac extension limb (Bloomington, IN). The 12 × 20 mm iliac extension limb was unsheathed on-site using a strict sterile technique, reversed within the introducer and resheathed. Following percutaneous bilateral femoral access and exclusion of the anterior and posterior divisional branches of the internal iliac artery, the reversed flared iliac limb device was deployed from the distal common to the external iliac artery. Completion angiography and follow-up computed tomography angiography revealed no endoleak. The patient was dismissed on postoperative day 1 without complications. Conclusion. The technique of reversed flared iliac stent graft limb is a feasible option in patients with iliac aneurysms and significant discrepancy in the diameter of the iliac arteries.