In planning this operation, I broke it down into five parts.
The first was access to the aortic bifurcation via the right common iliac artery and to both common femoral arteries. This was done via a right retroperitoneal exposure and bilateral groin exposures.
The second step was anastomosis of a 10mm graft end to end to the endarterectomized, reopened proximal common iliac artery. This would allow for access to the aorta and to the left iliac system in an antegrade direction.
This along with left groin exposure for retrograde access allowed for the third step which was left external iliac artery recanalization.
The fourth step was EVAR, in this case with a AFX graft (Endologix). And the final step was revascularizing the right leg by anastomosing the conduit to the right common femoral artery.
Retroperitoneal access of the right common iliac artery is facilitated by use of a fixed retractor system. Figure 4 shows the three initial steps.
The conduit used was a PTFE graft (Propaten) which I anastomosed end to end to the common iliac artery which I endarterectomized to reestablish patency. Through the conduit, a sheath was placed and up and over access of the bifurcation was achieved.
Retrograde wire access allowed me to localize the external iliac artery origin, allowing for antegrade wire access (Figure 5).
This was then used to balloon the external iliac artery then deliver a large nitinol stent (Zilver 12x80) across the occlusion and post-dilate this to 8mm. This established access from the left groin (Figure 6).
Once this was done, EVAR with the AFX device was performed via the conduit and the recanalized left iliac system (Figure 7). The conduit was then used as a graft to deliver blood to the right leg by anastomosing it to the right common femoral artery. The final arteriogram showed successful exclusion of the aortic aneurysm with reestablished flows to both legs (Figure 8). She recovered well and was discharged several days after her procedure.