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.


Background
Endovascular aneurysm repair (EVAR) is a less invasive therapeutic option for abdominal aortic aneurysm (AAA) compared to open surgery and is being increasingly performed worldwide (Chadi et al. 2012). The feasibility and outcomes of EVAR are highly dependent on various anatomic factors, including diameter or patency of the iliac access route. In previous studies, AAA with coexisting iliac occlusive disease reportedly precluded EVAR in 6-15.4% of patients (Arko et al. 2004). Nevertheless, an advancement of medical devices and increased operators' experiences have lead to high technical success rates even in AAA with occlusive iliac access (Uchiyamada et al. 2013;Vallabhaneni et al. 2012;Takeuchi et al. 2019). In cases of iliac artery occlusion extending to the common femoral artery (CFA), an ancillary endarterectomy/ interposition grafting of CFA is generally required. However, such an ancillary surgery is difficult when runoff vessels, i.e. superficial femoral artery (SFA) or profunda femoris artery (PFA), are occluded. Herein a case of AAA with a coexisting access route occlusion from the external iliac artery (EIA) to the SFA is presented where a technique of percutaneous puncture of angioplasty balloon was utilized to establish the through and through wire prior to EVAR.

Case presentation
The case was a 76-year-old man affected by a 55 mm infrarenal AAA (Fig. 1). All of the left EIA, CFA and SFA were totally occluded. He had a past history of undergoing endarterectomy of the left CFA. The collateral circulation was well developed from the left internal iliac artery (IIA) through the PFA, and the patient did not complain of any ischemic symptom in his leg, corresponding to the Rutherford grade 0. Since a repeated endarterectomy or interposition grafting of the CFA was deemed extremely difficult, without any patent runoff vessel, it was decided to perform an EVAR using the occluded vessel simply as an endovascular conduit for the delivery of the endograft, without revascularizing the vessel (Fig. 2). First, the occluded left CFA was punctured under ultrasound guidance. Initially, an attempt was made to advance a guidewire (0.014 in. Astato XS 9-40, Asahi Intec, Nagoya, Japan) retrogradely, however the guidewire went outside of the occluded EIA. After another access was obtained from the contralateral (right) CFA, another guidewire (0.014 in. Gradius, Asahi Intecc, Nagoya, Japan) was finally able to be advanced down to the occluded left CFA antegradely via subintimal lumen of the occluded left EIA. An angioplasty balloon (JADE 2.5 mm/40 mm, OrbusNeich, Hong Kong) was subsequently delivered to the occluded left CFA and dilated. A percutaneous puncture of the expanded balloon with a 21 gage needle (Micropuncture access set: COOK Medical, Bloomington, IL, USA) was performed at the occluded left CFA under fluoroscopy, followed by the insertion of a guidewire (0.014 in. Cruise, Asahi Intecc, Aichi, JAPAN) into the punctured balloon. The punctured balloon was slowly retracted into the sheath advanced from the contralateral CFA, finally establishing the through and through wire. A 8F sheath was advanced from the occluded left CFA to the left common iliac artery (CIA) over the through and through wire. While the main body of the AFX 2 endograft (Endologix Inc., Irvine, CA, USA) was being delivered to the aorta via the right iliac artery, the contralateral wire attached to the endograft was caught by a snare catheter (Indy OTW Vascular Retriever, COOK medical, Bloomington, CT 1 week after EVAR showed the successfully sealed AAA without sacrificing collateral channels from left IIA (Fig. 3).

Discussion
The EVAR was successfully performed for AAA with unilateral iliac access occlusion extending to the SFA using the percutaneous balloon puncture technique. With this technique, as long as the balloon can be advanced down to the CFA, the through and through wire can be reliably established by simply puncturing the balloon under fluoroscopic guidance. This technique was reported for the insertion of tunneled hemodialysis catheters (Too et al. 2016). Too et al. reported ten cases of the catheter insertion via occluded veins using the technique, with a technical success rate of 100%. A snare catheter can be utilized instead of balloons to be punctured, followed by grabbing the guidewire inserted via needle. Testi et al. reported that a balloon which was advanced subintimally from distal anterior tibial artery was puncture at CFA to revascularize the occluded SFA (Testi et al. 2019). The current case was the first one using the technique prior to EVAR. The biggest advantage of the technique is that it can be performed even when the puncture site is occluded. Technical successes of the EVAR for AAA with coexisting iliac artery occlusion are reportedly high with a success rate of 87-100% (Uchiyamada et al. 2013;Vallabhaneni et al. 2012;Takeuchi et al. 2019). For occlusions extending from the iliac artery to the CFA, endovascular revascularization plus concomitant endarterectomy of the CFA can be performed (Takeuchi et al. 2019). However, in cases like the one reported here, revascularization can be difficult due to the past history of endarterectomy and the lack of distal patent vessels. Additionally, ischemic symptom of the limb was not observed owing to the abundant collateral channels via IIA and PFA. On the other hand, use of an aorto-uniiliac graft, which could be an alternative option for the occluded iliac access, might sacrifice the arterial flow into left IIA and could lead to sever limb ischemia in this case.
There could be a debate as to whether the embolization of the tract at the end of the procedure was necessary. Although manual compression of the CFA with/without the usage of a vascular closure device might have been sufficient for closing the channel, further experience is needed on which method is more suitable to prevent the hemorrhagic complication from the groin.

Conclusions
AAA with access vessel occlusions from EIA-SFA was successfully treated with the balloon oriented percutaneous puncture technique at the occluded CFA. The puncture of the expanded balloon is very simple and can be performed at any occluded vessel. Having the technique as an armamentarium can broaden the application of EVAR for AAA with the complicated access such as occluded CFA.