Dear Editor,
We appreciate the comments by Georgakarakos and Koutsoumpelis (1). We are glad that article on early results of ultra-low profile endografts has attracted attention from the readers of Diagnostic and Interventional Radiology. We agree with the Authors that ultra-low profile (ULP) endografts often lack radial strength in the iliac limbs, and this could represent a risk factor for either branch stenosis or occlusion, especially in case of a very tortuous and calcified iliac axis or a tight aortic bifurcation. The use of balloon-expandable stent (BES) may represent a solution to increase stability and durability of the implant. Prophylactic adjunctive proximal BES has been used with good results to support endovascular aortic repair (EVAR) in patients with hostile neck anatomy (2), as well as for chimneys during EVAR of juxtarenal aortic aneurysms with unfavorable anatomy (3). In a similar manner, BES could be used as a support to avoid compression of the iliac limbs in cases of tight aortic bifurcation or severe iliac angulation and tortuosity. In our experience with the use of ULP endografts, we also had a case of intraoperative iliac limb stenosis, in a patient with severely calcified and small iliac vessels. Several balloon angioplasties were repeated but the patient eventually required immediate conversion to open surgery and limb removal for persistent stenosis at the origin of the left limb, which appeared shrunk due to extrinsic compression by the contralateral limb (4). Before converting to open surgery, we hypothesized to put a BES to support the compressed leg. However, we encountered extreme difficulty with the ascent of the balloon and probably even a BES would not have fixed the problem, which may have been caused by the use of iliac limbs with excessive oversizing in a narrow aortic bifurcation. Therefore, we agree with the authors that BES can be used as a support for ULP endografts in case of challenging iliac anatomy, but bearing in mind that a careful preoperative patient selection is the most useful strategy to improve long-term durability of EVAR.
We appreciate the authors’ interest in this article.
References
- 1.Georgakarakos E, Koutsoumpelis A. Use of balloon-expandable stents to support the efficacy of ultra-low profile endografts in the treatment of abdominal aortic aneurysms with challenging iliac anatomy. Diagn Interv Radiol. 2018 doi: 10.5152/dir.2018.17465. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cox DE, Jacobs DL, Motaganahalli RL, Wittgen CM, Peterson GJ. Outcomes of endovascular AAA repair in patients with hostile neck anatomy using adjunctive balloon-expandable stents. Vasc Endovascular Surg. 2006;40:35–40. doi: 10.1177/153857440604000105. https://doi.org/10.1177/153857440604000105. [DOI] [PubMed] [Google Scholar]
- 3.Liu B, Pan H, Song X, Liu C, Wu W, Chen Y, Yang X. Chimney stents for endovascular repair of juxtarenal aortic aneurysms with unfavourable anatomy. Int Angiol. 2013;32:307–311. [PubMed] [Google Scholar]
- 4.Mazzaccaro D, Stegher S, Occhiuto MT, Malacrida G, Nano G. Immediate and late open conversion after ovation endograft. Ann Vasc Surg. 2015;29:1450.e5–9. doi: 10.1016/j.avsg.2015.04.062. https://doi.org/10.1016/j.avsg.2015.04.062. [DOI] [PubMed] [Google Scholar]