Using An Iliac Branch Endoprosthesis To Salvage A Kidney Transplant In A Symptomatic Aortic Aneurysm

The patient is an 84-year-old man with past medical history of chronic kidney disease status-post renal transplant 20 years ago, and an abdominal aortic aneurysm (AAA) status-post Gore Excluder endograft 10 years ago. The patient now presents with right lower quadrant abdominal pain for 3 days. On physical exam, he had a tender right lower quadrant (RLQ), and a pulsatile mass. Creatinine (Cr) was 1.61 mg/dL with glomerular filtration rate (GFR) 49 U. Computed tomography angiography (CTA) showed an expansion of the AAA to 10.4 cm and a type Ib endoleak with a 4.9 cm common iliac artery aneurysm with a transplanted renal artery. Due to the patient’s age and anatomic limitations, an endovascular intervention was planned. Under general anesthesia, a left brachial artery exposure was performed and an 8 Fr sheath was placed into the previous endograft. A right common femoral artery (CFA) open exposure was then performed, and a 16-French sheath was the placed for the iliac branch endoprosthesis (IBE). From the brachial sheath, a 12 mm Amplatzer plug was deployed at the origin of the right internal iliac artery. A 23 × 12 mm × 10 cm IBE device was advanced to the right common iliac artery. The IBE device was positioned with the gate opening laterally, and the transplanted kidney was catheterized via the brachial sheath and an 8 × 59 mm Gore VBX stent graft was deployed. The rest of the IBE device was deployed, and extended with a 12 × 10 cm Gore Excluder limb. Post deployment balloon inflations were performed, and completion angiogram showed complete exclusion of the aneurysms without evidence of endoleaks with perfusion to the transplanted kidney. Postoperatively, there was a resolution of the RLQ abdominal pain, urinary output was adequate, and there no changes in his baseline Cr. In the follow-up period, the patient had a non-contrasted CT scan with decreased AAA diameter to 8.2 × 9.0 cm with aorto-iliac duplex showing no endoleak and patent stents to the external iliac and transplant kidney (Fig 1; Fig 2). Fig 2A postoperative noncontrast-enhanced computed tomography (CT) scan of the iliac branch endoprosthesis (IBE) device that branches to the transplanted kidney.View Large Image Figure ViewerDownload Hi-res image Download (PPT)