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Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by : Salman Mapara
Contributed by : Salman Mapara
Endovascular Aneurysm Repair with an Aorto-Uni-Iliac Device.
Endovascular Aneurysm Repair with an Aorto-Uni-Iliac Device.
Introduction:
Introduction:
Abdominal aortic aneurysms (AAA) remain one of the leading causes of morbidity and mortality in patients over the age of 65 years. Endovascular repair has become the preferred therapy for the management of infrarenal AAAs and accounts for upto 80% of repairs in some institutions - due to the decreased preoperative morbidity and mortality as well as faster initial recovery times
Abdominal aortic aneurysms (AAA) remain one of the leading causes of morbidity and mortality in patients over the age of 65 years. Endovascular repair has become the preferred therapy for the management of infrarenal AAAs and accounts for upto 80% of repairs in some institutions - due to the decreased preoperative morbidity and mortality as well as faster initial recovery times
Case presentation:
Case presentation:
A 66-year-old man came with complaints of dull aching abdominal pain in the umbilical region since 25 days. He was a known hypertensive on antihypertensive medications. There was no significant history of any past medical illness. Clinical examination of his respiratory and cardiovascular system was normal.
A 66-year-old man came with complaints of dull aching abdominal pain in the umbilical region since 25 days. He was a known hypertensive on antihypertensive medications. There was no significant history of any past medical illness. Clinical examination of his respiratory and cardiovascular system was normal.
On abdominal examination, a pulsatile mass was palpable in the left lumbar region. On ultrasonography, there was a medium sized saccular aneurysm in the infrarenal aorta. A CT aortogram showed a large saccular aneurysm arising from the left side of the infrarenal aorta measuring approx. 6.2 x 4.6 cm . There was tortuous anatomy of the descending infrarenal abdominal aorta (Figure 1 and video 1).
On abdominal examination, a pulsatile mass was palpable in the left lumbar region. On ultrasonography, there was a medium sized saccular aneurysm in the infrarenal aorta. A CT aortogram showed a large saccular aneurysm arising from the left side of the infrarenal aorta measuring approx. 6.2 x 4.6 cm . There was tortuous anatomy of the descending infrarenal abdominal aorta (Figure 1 and video 1).
VIDEO 1.mp4Fig 1:3D Volume rendered image of the CT aortogram showing left sided saccular infrarenal aortic aneurysm.
Video 1 Axial contrast enhanced CT video showing fusiform suprarenal aortic aneurysm and saccular left sided infrarenal aortic aneurysm.
Another fusiform aneurysm was seen in the suprarenal aorta involving the celiac trunk in close relation to the SMA. (Figure 2 and video 2)
Another fusiform aneurysm was seen in the suprarenal aorta involving the celiac trunk in close relation to the SMA. (Figure 2 and video 2)
VIDEO 2.mp4Fig. 2 -Axial contrast enhanced CT image showing left sided infrarenal saccular aortic aneurysm.
Video 2- Coronal contrast enhanced computed tomography (CT) video showing fusiform suprarenal aortic aneurysm and saccular left sided infrarenal aortic aneurysm.
With the saccular aneurysm on left side and a tortuous aorta. aorto biliac stenting was not planned. We anticipated the risk of stent kinking as well. Therefore the patient was planned for an aorto-uni-iliac (AUI) stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femoro femoral bypass.
With the saccular aneurysm on left side and a tortuous aorta. aorto biliac stenting was not planned. We anticipated the risk of stent kinking as well. Therefore the patient was planned for an aorto-uni-iliac (AUI) stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femoro femoral bypass.
Through a right femoral access, a glidwire was used to negotiate the aneurysm but was not possible (figure 3a and 3b). Therefore, brachial artery access was used.
Through a right femoral access, a glidwire was used to negotiate the aneurysm but was not possible (figure 3a and 3b). Therefore, brachial artery access was used.
Fig. 3- Showing failure of glidewire to cross through the aneurysm with curling around of it
Stent Graft Deployment:
Stent Graft Deployment:
Bilateral brachial artery access and right common femoral artery access with right femoral arteriotomy were performed. A 7F sheath was placed in the right common femoral artery and 5F sheath was placed in both brachial artery accesses. A 5F pigtail catheter was placed through the left brachial access, for angiographic control during the deployment of the stent graft (Video 3).
Bilateral brachial artery access and right common femoral artery access with right femoral arteriotomy were performed. A 7F sheath was placed in the right common femoral artery and 5F sheath was placed in both brachial artery accesses. A 5F pigtail catheter was placed through the left brachial access, for angiographic control during the deployment of the stent graft (Video 3).
Video 4a.mp4Video 4b .mp4Video 3 Angiogram performed with 4F cobra catheter showing the tip at the level of the aneurysm (left) . Angiogram showing fusiform suprarenal aortic aneurysm and saccular left sided infrarenal aortic aneurysm (right)
Through this access, a J tip AES guidewire is advanced from right brachial artery access and was snared from right common femoral artery access (Video 4). After this the 5F H1 catheter was advanced from the right common femoral artery access. The J-tip AES wire was exchanged for a Lunderquist wire and was positioned in the descending thoracic aorta. A 5F pigtail catheter was placed through the left brachial access,for angiographic runs during the deployment of the stent graft (Video 4).
Through this access, a J tip AES guidewire is advanced from right brachial artery access and was snared from right common femoral artery access (Video 4). After this the 5F H1 catheter was advanced from the right common femoral artery access. The J-tip AES wire was exchanged for a Lunderquist wire and was positioned in the descending thoracic aorta. A 5F pigtail catheter was placed through the left brachial access,for angiographic runs during the deployment of the stent graft (Video 4).
Video 3 .mp4Video 3b .mp4Video 4 –Angiogram showing the J tip AES guidewire advanced from left brachial artery access and snared from right common femoral artery access.
Based on preoperative measurements and aortic morphology, the main body of the stent graft was chosen of a of length 10 cm; proximal diameter 23 mm, distal diameter 14 mm was selected and advanced over the Lunderquist wire. The covered segment of stent graft was deployed in the infrarenal aorta after precise confirmation of the location of both renal orifices; the cranial end of the covered portion of the main body stent-graft was placed below the lower-most renal artery orifice. (Videos 5 and 6)
Based on preoperative measurements and aortic morphology, the main body of the stent graft was chosen of a of length 10 cm; proximal diameter 23 mm, distal diameter 14 mm was selected and advanced over the Lunderquist wire. The covered segment of stent graft was deployed in the infrarenal aorta after precise confirmation of the location of both renal orifices; the cranial end of the covered portion of the main body stent-graft was placed below the lower-most renal artery orifice. (Videos 5 and 6)
Video 5 .mp4video 6.mp4Video 5 Angiogram showing deployment of aortic stent graft over the Lunderquist stiff wire.
Video 6- Angiogram showing deployment of aortic and right common iliac artery stent graft over The Lunderquist wire.
The caudal end of the stent was placed at the level of the proximal right common iliac artery. Another stent graft was placed in the right common iliac artery with its length 8 cm, proximal diameter of 16 mm and distal diameter of 13 mm.(Video 7 and 8). After this, through a left femoral access, with 8F cordis sheath and through this a Cera Amplatz plug of 14 mm was deployed at origin of left CIA. (Video 9)
The caudal end of the stent was placed at the level of the proximal right common iliac artery. Another stent graft was placed in the right common iliac artery with its length 8 cm, proximal diameter of 16 mm and distal diameter of 13 mm.(Video 7 and 8). After this, through a left femoral access, with 8F cordis sheath and through this a Cera Amplatz plug of 14 mm was deployed at origin of left CIA. (Video 9)
video 7.mp4VIDEO 8 O UNILIAC .mp4Video 9 plug dep.mp4Video 7-Angiogram showing post aortic stent graft deployment with exclusion of aneurysm from main circulation.
Video 8- Angiogram showing post aortic stent graft deployment and right common iliac artery stent with exclusion of aneurysm from main circulation.
Video 9- Angiogram showing deployment of Amplatz plug at left common iliac artery at bifurcation.
Post-stent graft deployment, completion angiography was performed to confirm proper graft position, assess endoleaks, and verify exclusion of the aneurysm. It showed adequate placement of the stent graft (Video 10 ).
Post-stent graft deployment, completion angiography was performed to confirm proper graft position, assess endoleaks, and verify exclusion of the aneurysm. It showed adequate placement of the stent graft (Video 10 ).
VIDEO 10 FINAL.mp4Video 10, Angiogram after aortic stent graft, right common iliac artery stent and left common iliac origin Amplatz plug deployment status with exclusion of aneurysm from main circulation.
Following the procedure, the patient was shifted under general anaesthesia to the operating room and a femoro-femoral bypass procedure was performed. The patient was transferred to recovery room for 48 hours. At this time, a CT angiogram of the abdomen and pelvis with thigh region was performed. Both lower limb Doppler examinations were also performed.. The Doppler studies showed no abnormality. The CT scan of the abdomen and pelvis with the thigh showed exclusion of the infrarenal pseudoaneurysm from circulation with no filling in any phase (figure 4). Good opacification of both lower limb arterial system with normal femoro- femoral artery bypass was seen. (Video 11a and 11b).
Following the procedure, the patient was shifted under general anaesthesia to the operating room and a femoro-femoral bypass procedure was performed. The patient was transferred to recovery room for 48 hours. At this time, a CT angiogram of the abdomen and pelvis with thigh region was performed. Both lower limb Doppler examinations were also performed.. The Doppler studies showed no abnormality. The CT scan of the abdomen and pelvis with the thigh showed exclusion of the infrarenal pseudoaneurysm from circulation with no filling in any phase (figure 4). Good opacification of both lower limb arterial system with normal femoro- femoral artery bypass was seen. (Video 11a and 11b).
VIDEO 11a.mp4VIDEO 11b.mp4Figure 4-3D Volume rendered image of computer tomography (CT) aortogram of the postprocedure scan showing exclusion of saccular left sided infrarenal aortic aneurysm with aorto-uniliac stent graft placement status with left common iliac artery plugging and femoro-femoral artery bypass status.
Video 11 -Axial and coronal reconstructed videos of computer tomography (CT) aortogram of post procedure scan showing exclusion of saccular left sided infrarenal aortic aneurysm with aorto-uniliac stent graft placement status with left common iliac artery plugging and femoro-femoral artery bypass status.
Figure 5-Fluoroscopic spot film of the abdomen showing endovascular stent graft in the infrarenal aorta (orange arrow) and left sided plug- at the origin of the left common iliac artery region (green arrow).
Discussion:
Discussion:
Abdominal aortic aneurysms remain one of the leading causes of morbidity and mortality in patients over the age of 65 years. Despite increased evidence supporting the utility of screening for AAAs in high-risk patient populations, the most common way that these are detected is incidentally while undergoing an ultrasound, radiography of the back orabdomen, CT scan, or MRI for the evaluation of another problem. Endovascular repair habecome the preferred therapy for the management of infrarenal AAAs and accounts for upto 80% of repairs in some institutions due to decreased preoperative morbidity and mortality as well as faster initial recovery times [ 1 ].
Abdominal aortic aneurysms remain one of the leading causes of morbidity and mortality in patients over the age of 65 years. Despite increased evidence supporting the utility of screening for AAAs in high-risk patient populations, the most common way that these are detected is incidentally while undergoing an ultrasound, radiography of the back orabdomen, CT scan, or MRI for the evaluation of another problem. Endovascular repair habecome the preferred therapy for the management of infrarenal AAAs and accounts for upto 80% of repairs in some institutions due to decreased preoperative morbidity and mortality as well as faster initial recovery times [ 1 ].
Katsikas et al. [ 3 ] had documented through meta-analysis that the main advantages of the AUI endograft are its simplicity and versatility. An aorto-uni-iliac (AUI) graft with occlusion of the contralateral common iliac and a femoro-femoral bypass has been performed to treat an abdominal aortic aneurysm (AAA), not suitable for bifurcated stent graft system, isolated iliac artery aneurysms, complex iliac anatomy, or large aneurysms which seldom have a distal neck as well as ruptured AAA or AAA having iliofemoral artery disease or in the treatment of complications of previous applied endovascular bifurcated devices for the treatment of AAA.[ 2,4 ].We report a successful case of endovascular repair of saccular infrarenal AAA with AUI device, femoral to femoral bypass with graft, and occlusion of the contralateral common iliac artery with a review of the literature.
Katsikas et al. [ 3 ] had documented through meta-analysis that the main advantages of the AUI endograft are its simplicity and versatility. An aorto-uni-iliac (AUI) graft with occlusion of the contralateral common iliac and a femoro-femoral bypass has been performed to treat an abdominal aortic aneurysm (AAA), not suitable for bifurcated stent graft system, isolated iliac artery aneurysms, complex iliac anatomy, or large aneurysms which seldom have a distal neck as well as ruptured AAA or AAA having iliofemoral artery disease or in the treatment of complications of previous applied endovascular bifurcated devices for the treatment of AAA.[ 2,4 ].We report a successful case of endovascular repair of saccular infrarenal AAA with AUI device, femoral to femoral bypass with graft, and occlusion of the contralateral common iliac artery with a review of the literature.
In patients with AUI stent graft, complete occlusion of the contralateral iliac artery is required to seal the aneurysm associated with a femoro-femoral bypass to re-establish perfusion to the contralateral limb.[ 4,5 ] Early critics pointed to poor long-term patency rates of the femoro-femoral bypass; fortunately, the patency of crossover femoro-femoral bypass is very high in recent published literature.[ 4,6 ]
In patients with AUI stent graft, complete occlusion of the contralateral iliac artery is required to seal the aneurysm associated with a femoro-femoral bypass to re-establish perfusion to the contralateral limb.[ 4,5 ] Early critics pointed to poor long-term patency rates of the femoro-femoral bypass; fortunately, the patency of crossover femoro-femoral bypass is very high in recent published literature.[ 4,6 ]
Lipsitz et al., [ 5 ] showed that crossover bypasses for aneurysmal disease are durable procedures either for pure aneurysmal disease or aneurysmal disease with aortoiliac occlusive pathology. Hinchliffe et al.[ 4 ] and Yilmaz et al.[ 6 ] have proven that fem-fem crossover for AUI offers durable and encouraging long-term patency. Ng et al. reported a cumulative patency rate at 6 years of 92% for femoro-femoral crossover procedures and a low early mortality rate of 1.3%.[ 7 ] Furthermore, despite these procedures might be complicated by the development of graft infection, graft occlusion, false aneurysm formation, seromas in the groin, their incidences are very low.[ 7 ]
Lipsitz et al., [ 5 ] showed that crossover bypasses for aneurysmal disease are durable procedures either for pure aneurysmal disease or aneurysmal disease with aortoiliac occlusive pathology. Hinchliffe et al.[ 4 ] and Yilmaz et al.[ 6 ] have proven that fem-fem crossover for AUI offers durable and encouraging long-term patency. Ng et al. reported a cumulative patency rate at 6 years of 92% for femoro-femoral crossover procedures and a low early mortality rate of 1.3%.[ 7 ] Furthermore, despite these procedures might be complicated by the development of graft infection, graft occlusion, false aneurysm formation, seromas in the groin, their incidences are very low.[ 7 ]
Outcomes of aorto-uni-iliac and bifurcated devices:
Outcomes of aorto-uni-iliac and bifurcated devices:
Moore et al. in 2001 compared the AUI stent-graft with the tube, the bifurcated graft, and open control series in regard to patient demographics, medical comorbidity, 30-day morbidity/mortality, and outcome at 1 year.[ 8 ] The trial results showed that the AUI configurations outcomes are competitive with the results by tube or bifurcated graft systemsand are associated with lower morbidity than open surgery repair.[ 8 ]. Pereira et al., in 2002, concludes AUI system is a simple and safe technique alternative to bifurcated systems for high-risk patients.[ 9 ]. Saratzis et al. in 2005, states in high surgical risk patients with complex iliac anatomy AUI endograft are feasible and efficacious. Patency of the crossover femoro-femoral bypass graft also appears satisfactory.[ 10 ]
Moore et al. in 2001 compared the AUI stent-graft with the tube, the bifurcated graft, and open control series in regard to patient demographics, medical comorbidity, 30-day morbidity/mortality, and outcome at 1 year.[ 8 ] The trial results showed that the AUI configurations outcomes are competitive with the results by tube or bifurcated graft systemsand are associated with lower morbidity than open surgery repair.[ 8 ]. Pereira et al., in 2002, concludes AUI system is a simple and safe technique alternative to bifurcated systems for high-risk patients.[ 9 ]. Saratzis et al. in 2005, states in high surgical risk patients with complex iliac anatomy AUI endograft are feasible and efficacious. Patency of the crossover femoro-femoral bypass graft also appears satisfactory.[ 10 ]
Dalainas et al. in 2007, compares the outcome between a bifurcated and an AUI stent-graft in the short- and mid-term period for the treatment of aneurysmal aortic disease. The results showed that treating AAAs with AUI endoprosthesis is as safe and effective as treating them with bifurcated endografts.[ 11 ]. Baptisteab et al., in 2009, reports the midterm results following the use of bifurcated and AUI endovascular devices in the treatment of AAAs in a population of patients deemed to be at high risk for open surgery. The results of this study demonstrates that bifurcated devices were associated with better results than AUI devices.[ 12 ]
Dalainas et al. in 2007, compares the outcome between a bifurcated and an AUI stent-graft in the short- and mid-term period for the treatment of aneurysmal aortic disease. The results showed that treating AAAs with AUI endoprosthesis is as safe and effective as treating them with bifurcated endografts.[ 11 ]. Baptisteab et al., in 2009, reports the midterm results following the use of bifurcated and AUI endovascular devices in the treatment of AAAs in a population of patients deemed to be at high risk for open surgery. The results of this study demonstrates that bifurcated devices were associated with better results than AUI devices.[ 12 ]
Lazaridis et al., in 2009, demonstrate that AUI endografts are simpler, more rapidly placed and permits treatment of more patients who need EVAR due to associated comorbidities because of fewer restrictions according to the morphological criteria of feasibility, such as the narrow terminal aorta and tortuous, narrow, calcified, or occluded iliac axis.[ 13 ]
Lazaridis et al., in 2009, demonstrate that AUI endografts are simpler, more rapidly placed and permits treatment of more patients who need EVAR due to associated comorbidities because of fewer restrictions according to the morphological criteria of feasibility, such as the narrow terminal aorta and tortuous, narrow, calcified, or occluded iliac axis.[ 13 ]
Hynes and Sultan [ 14 ] reported that AUI EVAR with a fem-fem crossover is a safe and effective alternative as bifurcated endografts in high-risk patients with AAA. This is explained by the fact that AUI EVAR requires less preoperative planning, less operative time, and less trauma for those patients.
Hynes and Sultan [ 14 ] reported that AUI EVAR with a fem-fem crossover is a safe and effective alternative as bifurcated endografts in high-risk patients with AAA. This is explained by the fact that AUI EVAR requires less preoperative planning, less operative time, and less trauma for those patients.
Carrafiello et al.[ 15 ] reported a high mortality rate with AUI grafts, but a deeper look in this study design demonstrates that precious time was wasted in preoperative analysis and preoperative CT angiography in these unstable patients. Clouse et al.[ 16 ] had proven that AUI with fem-fem crossover graft is a safe, effective option with a satisfactory midterm result.
Carrafiello et al.[ 15 ] reported a high mortality rate with AUI grafts, but a deeper look in this study design demonstrates that precious time was wasted in preoperative analysis and preoperative CT angiography in these unstable patients. Clouse et al.[ 16 ] had proven that AUI with fem-fem crossover graft is a safe, effective option with a satisfactory midterm result.
Conclusion:
Conclusion:
The decision to treat AAA is based on patient's clinical presentation and aneurysm status. According to the society for vascular surgery practice guidelines, anatomical treatment such as open surgical repair or EVAR is indicated with strong recommendation level in case of ruptured AAA, symptomatic unruptured AAA, increasing size of the aneurysm on serial documentation and large AAA > 5.5 cm in diameter. Anatomical suitability is an essential factor for successful EVAR. Some of the anatomical considerations include: -
The decision to treat AAA is based on patient's clinical presentation and aneurysm status. According to the society for vascular surgery practice guidelines, anatomical treatment such as open surgical repair or EVAR is indicated with strong recommendation level in case of ruptured AAA, symptomatic unruptured AAA, increasing size of the aneurysm on serial documentation and large AAA > 5.5 cm in diameter. Anatomical suitability is an essential factor for successful EVAR. Some of the anatomical considerations include: -
1) Aortic Neck Anatomy: The length, angle, presence of calcification or thrombus, and the diameter and shape of aortic neck should be carefully considered. The aortic neck length is defined as the distance from the lowest renal artery to the top of the aneurysm.
1) Aortic Neck Anatomy: The length, angle, presence of calcification or thrombus, and the diameter and shape of aortic neck should be carefully considered. The aortic neck length is defined as the distance from the lowest renal artery to the top of the aneurysm.
2) Anatomy of Aneurysm: The aneurysmal angle, presence of intraluminal mural thrombus, and branching vessels from the aneurysm must be taken into consideration.
2) Anatomy of Aneurysm: The aneurysmal angle, presence of intraluminal mural thrombus, and branching vessels from the aneurysm must be taken into consideration.
3) Access Vessels: The tortuosity and diameter of the iliac artery, presence of atherosclerotic lesion along the iliac artery, and length of the common iliac artery should be considered for adequate EVAR.
3) Access Vessels: The tortuosity and diameter of the iliac artery, presence of atherosclerotic lesion along the iliac artery, and length of the common iliac artery should be considered for adequate EVAR.
The stent-graft is made up of a self-expanding Nitinol stent that uses radial force for fixation, and a polytetrafluoroethylene (PTFE) fabric that creates a new conduit for blood flow and prohibits the blood from entering the aneurysm sac. Stent grafts used for infrarenal AAA are bifurcated, giving them the ability for a limb extension to extent the graft inferiorly. (aortic stent graft image).
The stent-graft is made up of a self-expanding Nitinol stent that uses radial force for fixation, and a polytetrafluoroethylene (PTFE) fabric that creates a new conduit for blood flow and prohibits the blood from entering the aneurysm sac. Stent grafts used for infrarenal AAA are bifurcated, giving them the ability for a limb extension to extent the graft inferiorly. (aortic stent graft image).
Complications such as stent-graft infection, pelvic ischemia, pseudoaneurysm and graft occlusion can occur with both EVAR and open repair. Complications more commonly seen in EVAR include post-implantation syndrome, limb thrombosis, migration of stent-graft, enlargement of sac and rupture, and endoleaks.
Complications such as stent-graft infection, pelvic ischemia, pseudoaneurysm and graft occlusion can occur with both EVAR and open repair. Complications more commonly seen in EVAR include post-implantation syndrome, limb thrombosis, migration of stent-graft, enlargement of sac and rupture, and endoleaks.
Patients require life-long imaging surveillance to monitor for endoleaks, aneurysm expansion and for graft integrity. This is most performed via CTA.
Patients require life-long imaging surveillance to monitor for endoleaks, aneurysm expansion and for graft integrity. This is most performed via CTA.
In conclusion, a safe and technically precise implantation requires management of anticoagulation, blood pressure regulation in general anaesthesia. Modern endograft implantation involves highly technical resources, including guide wires or catheters.
In conclusion, a safe and technically precise implantation requires management of anticoagulation, blood pressure regulation in general anaesthesia. Modern endograft implantation involves highly technical resources, including guide wires or catheters.
Beside patient selection, an optimal procedure planning, graft model choice and endovascular skills are mandatory aspects to prevent complications In patients with anatomical limitations for the use of a bifurcated endograft, the deployment of an AUI stent graft followed by a femoro-femoral crossover bypass can exclude the aortic pathology with similar immediate and mid-to-long-term compared to standard bifurcated graft, avoiding, therefore, an open abdominal surgery. The main advantages of the AUI endograft are its simplicity and versatility.
Beside patient selection, an optimal procedure planning, graft model choice and endovascular skills are mandatory aspects to prevent complications In patients with anatomical limitations for the use of a bifurcated endograft, the deployment of an AUI stent graft followed by a femoro-femoral crossover bypass can exclude the aortic pathology with similar immediate and mid-to-long-term compared to standard bifurcated graft, avoiding, therefore, an open abdominal surgery. The main advantages of the AUI endograft are its simplicity and versatility.
References:
References:
1. May J, White G, Waugh R, Yu W, Harris J. Treatment of complex abdominal aortic aneurysms by a combination of endoluminal and extraluminal aortofemoral grafts J Vasc Surg. 1994;19:924–33
1. May J, White G, Waugh R, Yu W, Harris J. Treatment of complex abdominal aortic aneurysms by a combination of endoluminal and extraluminal aortofemoral grafts J Vasc Surg. 1994;19:924–33
2. Delle M, Lönn L, Wingren U, Karlström L, Klingenstierna H, Risberg B, et al Preserved pelvic circulation after stent-graft treatment of complex aortoiliac artery aneurysms: A new approach J Endovasc Ther. 2005;12:189–95
2. Delle M, Lönn L, Wingren U, Karlström L, Klingenstierna H, Risberg B, et al Preserved pelvic circulation after stent-graft treatment of complex aortoiliac artery aneurysms: A new approach J Endovasc Ther. 2005;12:189–95
3. Katsikas VC, Dalainas I, Martinakis VG, Xiromeritis K. The role of aortouniiliac devices in the treatment of aneurysmal disease Eur Rev Med Pharmacol Sci. 2012;16:1061–71
3. Katsikas VC, Dalainas I, Martinakis VG, Xiromeritis K. The role of aortouniiliac devices in the treatment of aneurysmal disease Eur Rev Med Pharmacol Sci. 2012;16:1061–71
4. Yilmaz LP, Abraham CZ, Reilly LM, Gordon RL, Schneider DB, Messina LM, et al Is cross-femoral bypass grafting a disadvantage of aortomonoiliac endovascular aortic aneurysm repair? J Vasc Surg. 2003;38:753–7
4. Yilmaz LP, Abraham CZ, Reilly LM, Gordon RL, Schneider DB, Messina LM, et al Is cross-femoral bypass grafting a disadvantage of aortomonoiliac endovascular aortic aneurysm repair? J Vasc Surg. 2003;38:753–7
5. Lipsitz EC, Ohki T, Veith FJ, Rhee SJ, Gargiulo NJ 3rd, Suggs WD, et al Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease J Endovasc Ther. 2003;10:1061–5
5. Lipsitz EC, Ohki T, Veith FJ, Rhee SJ, Gargiulo NJ 3rd, Suggs WD, et al Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease J Endovasc Ther. 2003;10:1061–5
6. Hinchliffe RJ, Alric P, Wenham PW, Hopkinson BR. Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair J Vasc Surg. 2003;38:498–503
6. Hinchliffe RJ, Alric P, Wenham PW, Hopkinson BR. Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair J Vasc Surg. 2003;38:498–503
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8. Moore WS, Brewster DC, Bernhard VM. Aorto-uni-iliac endograft for complex aortoiliac aneurysms compared with tube/bifurcation endografts: Results of the EVT/Guidant trials J Vasc Surg. 2001;33:S11–20
9. Pereira AH, Sanvitto PC, de Souza GG, Costa LF, Grudtner MA. Aortomonoiliac stent-grafts for abdominal aortic aneurysm repair: Association with iliofemoral crossover grafts J Endovasc Ther. 2002;9:765–71
9. Pereira AH, Sanvitto PC, de Souza GG, Costa LF, Grudtner MA. Aortomonoiliac stent-grafts for abdominal aortic aneurysm repair: Association with iliofemoral crossover grafts J Endovasc Ther. 2002;9:765–71
10. Saratzis N, Melas N, Lazaridis J, Ginis G, Antonitsis P, Lykopoulos D, et al Endovascular AAA repair with the aortomonoiliac endofit stent-graft: Two years' experience J Endovasc Ther. 2005;12:280–7
10. Saratzis N, Melas N, Lazaridis J, Ginis G, Antonitsis P, Lykopoulos D, et al Endovascular AAA repair with the aortomonoiliac endofit stent-graft: Two years' experience J Endovasc Ther. 2005;12:280–7
11. Dalainas I, Moros I, Gerasimidis T, Papadimitriou D, Saratzis N, Gitas CG, et al Midterm comparison of bifurcated modular endograft versus aorto-uni-iliac endograft in patients with abdominal aortic aneurysm Ann Vasc Surg. 2007;21:339–45
11. Dalainas I, Moros I, Gerasimidis T, Papadimitriou D, Saratzis N, Gitas CG, et al Midterm comparison of bifurcated modular endograft versus aorto-uni-iliac endograft in patients with abdominal aortic aneurysm Ann Vasc Surg. 2007;21:339–45
12. Baptisteab EJ, Batta M, Azzaoui R, Koussa M, Khodja RH, Haulon S. A comparison of the mid-term results following the use of the bifurcated and aortouniiliac devices in the treatment of abdominal aortic aneurysms Eur J Vasc Endovasc Surg. 2009;38:298–304
12. Baptisteab EJ, Batta M, Azzaoui R, Koussa M, Khodja RH, Haulon S. A comparison of the mid-term results following the use of the bifurcated and aortouniiliac devices in the treatment of abdominal aortic aneurysms Eur J Vasc Endovasc Surg. 2009;38:298–304
13. Lazaridis J, Melas N, Saratzis A, Saratzis N, Sarris K, Fasoulas K, et al Reporting mid- and long-term results of endovascular grafting for abdominal aortic aneurysms using the aortomonoiliac configuration J Vasc Surg. 2009;50:8–14
13. Lazaridis J, Melas N, Saratzis A, Saratzis N, Sarris K, Fasoulas K, et al Reporting mid- and long-term results of endovascular grafting for abdominal aortic aneurysms using the aortomonoiliac configuration J Vasc Surg. 2009;50:8–14
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