Vascular Access and Reparative Surgery

**61**

**Chapter 3**

**Abstract**

in patients undergoing EVAR.

endoconduit

**1. Introduction**

Occlusive Disease

Endovascular Aortic Aneurysm

*Kevin D. Mangum, Arash Fereydooni and Naiem Nassiri*

Repair in Patients with Aortoiliac

Although endovascular aortic aneurysm repair (EVAR) has become an attractive, minimally invasive option for patients with abdominal aortic aneurysms (AAA), significant challenges in arterial access exist in patients with concomitant aortoiliac occlusive disease (AIOD), particularly for more advanced TASC C and D lesions. Under these circumstances, endograft delivery is possible but requires extensive preoperative planning and intraoperative techniques including but not limited to surgical conduit creation, plain balloon angioplasty, endoconduit placement, and subintimal recanalization. Newer generation aortic endografts have also shown promise in accommodating compromised access vessels. Concomitant AIOD and compromised access vessels complicate EVAR and increase operative time and complexity. Therefore, extreme caution, meticulous preoperative planning, familiarity and facility with the various surgical and endovascular options needed to circumvent these obstacles are essential for safe and effective delivery of EVAR in this high-risk subset of patients. The purpose of this chapter is to present standard approaches for access in patients undergoing EVAR; discuss how advanced AIOD precludes routine access; and present various methods to overcome difficult access

**Keywords:** abdominal aortic aneurysm, endovascular aortic aneurysm repair, aortoiliac occlusive disease, endograft, aorta, iliac artery, femoral artery, access,

Endovascular aortic aneurysm repair (EVAR) has expanded to more than 75% of elective abdominal aortic aneurysm (AAA) repairs due to its lower perioperative complication and high technical success rate [1, 2]. Despite its advantages, however, there are specific limitations that preclude EVAR delivery, making open AAA repair a more suitable option for select patients. In general, patient age and overall health are important considerations in deciding between EVAR versus open repair. Anatomic factors may also limit use of EVAR in select patients, and one of the single most important of these is proximal neck anatomy [3]. Unsuitable, hostile proximal neck features include angulation of ≥60°, neck length ≤ 10 mm, focal bulge in the neck >3 mm, and thrombus involving ≥50% of the aortic diameter—all common EVAR limiting factors [4]. In addition, access related issues due to atherosclerotic occlusive disease remain major barriers to EVAR as up to 36% of patients with AAA

## **Chapter 3**
