Successful endovascular salvage of a maldeployed iliac limb extension during complex aortic reconstruction

The worst complication during cannulation of the contralateral gate during complex endovascular aortic repair is deployment of the limb extension behind the main graft body.A patient with a 5.7 cm juxtarenal abdominal aortic aneurysm was taken to the operating room for fenestrated endovascular aortic repair and iliac branch device. Percutaneous femoral access was used to deploy a Gore Iliac Branch Endoprosthesis, followed by a physician modified Cook Alpha thoracic stent graft with four fenestrations. Next a Gore Excluder was deployed to bridge the fenestrated component to the iliac branch and native left common iliac artery creating distal seal. Due to the severe tortuosity, a buddy wire technique, using a stiff lunderquist wire, was used to cannulate the contralateral gate. Unfortunately, after cannulation, the limb was advanced over the buddy lunderquist wire instead of the luminal wire. We used a backtable modified guide catheter to provide the necessary pushability to navigate wires between the aberrantly deployed limb extension and the iliac branch device. Using through-and-through access, we then successfully deployed a parallel flared limb in the correct plane.Careful communication, wire marking, and attention to intraoperative flow can minimize risks of complication, but knowledge of bail out techniques remains imperative.