Complex aortoiliac occlusions

The patient was a 72-year-old man

• Comorbidities: hyperlipidemia and hypertension
• 2010: prostate cancer → hormone therapy + radiation therapy
• 2011: rectal cancer → laparotomy, rectum amputation + terminal colostomy 
• 29.04.2015: Rutherford III → kissing stents CIA
• 21.05.2015: occlusion stents CIA → recanalisation failure
• 24.06.2015: surgical aorto bi-iliac prosthesis 

On 27/09/2022, the patient presented with acute bilateral claudication (Rutherford III) and a walking distance of 90 meters, leading to a CT angioscan being performed.

Here are the images from the CT angioscan: can you tell us what you see?

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• After explaining the different options to the patient and their risks, the decision was made to opt for conservative therapy.
• The patient was admitted and placed under observation, receiving heparin.
• He was then discharged home after 2 days with anti-platelet medication.
• Supervised walking therapy was then provided.

On 10 December 2022, the patient presented again with rest pain and ischaemic wounds.

• Rutherford V – bilateral ischemic ulcers and worsening clinical status
• Multidisciplinary meeting 

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Procedure: Chimney CERAB

• General anesthesia
• Surgical cutdown of the axillary artery
• 12Fr sheath advanced to the suprarenal aorta
• Ultrasound-guided bilateral CFA puncture
• Two 9Fr sheaths inserted

• Recanalisation of both limbs:
  • Right limb: antegrade approach with snare
  • Left limb: retrograde approach
• Antegrade placement of BECS (Advanta® V12 5 x 39) in the RRA and LRA
• Retrograde placement of Advanta® V12 LD 12 x 29 with Cristal® balloon (distal 16 mm)

The UF catheter used for the angiogram broke due to excessive rotation.

Two Scitech Solaris 7 x 100 mm EIA grafts were used for the recanalisation.

• 2x Advanta V12 7 x 59 graft limbs
• 2x Advanta V12 8 x 38 were added in the main body for proximal extension

Post-operative

• Uncomplicated
• No rest pain
• Discharged after 1 night
• Medication: dual antiplatelet therapy (DAPT) for one year
• Return visit after 6 weeks with CT angio scan
• Wounds were healing: no amputation
• Initially, conservative therapy was proposed due to Fontaine IIB claudication. 
  An open intervention would have been challenging given the patient's history of two prior laparotomies.
  Eventually, the patient progressed to Fontaine IV, prompting the decision to pursue an endovascular approach.