Unusual Endovascular Treatment of Iliac Occlusive Disease With a Physician-Modified Endograft to Preserve a Transplant Renal Artery

Purpose: We describe the feasibility and early results of iliac stenting using a physician-modified endograft (PMEG) to preserve a transplant renal artery in patient with iliac occlusive disease. Case Report: A 70-year-old male patient, with sub-occlusive left common iliac artery stenosis at the level of the transplanted kidney arterial anastomosis, presented with left critical limb ischemia (CLI) and pseudo-transplant renal artery stenosis (pseudo-TRAS) symptoms. He was treated with a physician-modified fenestrated covered stent introduced percutaneously via ipsilateral femoral artery after failure of simple angioplasty (percutaneous transluminal angioplasty, PTA). The modified graft was created by performing a square fenestration graftotomy on a Medtronic iliac limb stent graft (Medtronic Cardiovascular, Santa Rosa, CA, USA). The procedure was technically successful with no intraoperative complications. Procedural time was 110 minutes, including 35 minutes for device modification. On short-term follow-up, the patient had early improvement of renal function and resolution of CLI. The iliac and transplant renal artery remained patent with no sign of stent migration or kinking on 6 months surveillance computed tomography angiography and 1 year color Doppler ultrasonography. Conclusion: Use of PMEG to preserve visceral branches in occlusive iliac disease is a feasible endovascular technique with encouraging technical success and satisfying early results.