SS10. Endovascular Treatment of Failed Open Surgical and Bifurcated Stent Grafts and Short-Length Infrarenal Aortic Aneurysms Using Fenestrated-Branched Endografts With Distal Inverted Iliac Limbs

Objectives: Open aortoiliac grafts have been constructed with a short aortic bifurcation sewn near or to the visceral vessels to avoid limb kinking. Similarly, the majority of endovascular bifurcated stent grafts have short aortic main body ranging from 4 to 5 cm. In these patients and in those with short infrarenal aortic lengths, endovascular salvage with fenestrated-branched stent grafts is technically challenging because of the short distance between the renal arteries and the flow divider of the graft. Custom-manufactured fenestrated-branched stent grafts can be extended into the prior open surgical graft or stent graft using a short distal bifurcated stent graft with inverted iliac limb (Fig) for the contralateral gate. The aim of this study was to evaluate outcomes of patients treated with fenestrated-branched stent grafts coupled with inverted iliac limbs for salvage of failed open surgical and endovascular stent grafts. Methods: The clinical data of three high-volume, complex aortic referral centers using fenestrated-branched stent grafts were entered into prospectively maintained databases from January 2011 to June 2014. All patients had investigational manufactured devices under physician-sponsored investigational device exemption protocols. In addition to the proximal fenestrated-branched component, all patients received custom-manufactured distal bifurcated devices constructed with a main body<70 mm and an inverted iliac limb to dock the contralateral gate. End points were technical success, 30-day or in-hospital mortality, type I or III endoleak, limb occlusion, and secondary reintervention. Results: There were 56 patients, 41 males (73%) and 15 females (27%), with mean age of 75 years (range, 5986 years) treated by fenestrated-branched stent grafts using distal bifurcated devices with inverted iliac limbs. Fortyseven patients (84%) had a previous aortic repair with a short main body device and nine had short distances between the native renal artery and aortic bifurcation requiring inverted limbs. A total of 184 visceral arteries were targeted by fenestrations or branches (mean, 3.3 vessels/patient). Technical success was 96.4%, with no 30-day or in-hospital deaths. At a mean follow-up of 11 months, six patients developed endoleaks; however, there were no device migration, occlusions, or complications associated with the inverted limb. On the inverted limb side there were three complications. Two patients developed type IB endoleaks treated by limb extension and angioplasty, and one patient developed distal limb ischemia treated by thrombectomy. Reintervention was successful in all of these patients. Conclusions: Patients with a short distance between the renal arteries and the aortic bifurcation can be challenging for endovascular treatment using currently available devices. The use of inverted limb custom-manufactured devices avoids the need for aortouniiliac repair, with femoralfemoral bypass preserving antegrade contralateral limb perfusion. The device was associated with no migration, component separations, or type III endoleaks. In the short-term, rates of type III endoleak or limb occlusion are similar to what has been reported for universal bifurcated devices with noninverted iliac limbs.