Initial experience with the CERAB technique : case series

Open surgical repair with aorto-bifemoral bypass grafting is considered as the standard of care for the aorto-iliac occlusive disease involving the abdominal aorta, at least in fit patients. On the other hand, substantial risk of peri-operative morbidity and mortality may tarnish the good technical outcomes in higher risk patients. The covered endovascular reconstruction of aorto-iliac bifurcation (CERAB) is a novel minimal invasive approach for aorto-iliac occlusive disease treatment, offering good earlyand mid-term outcomes so far. The procedure consists of the implantation of a wide diameter aortic stent graft and the expansion of two iliac covered stents according to the kissing-technique inside the aortic graft. We report an initial case series of 4 patients treated with the CERAB technique for aorto-iliac occlusive disease treatment. 166 Hellenic Journal of Vascular and Endovascular Surgery | Volume 1 Issue 4 2019 Patients Pre-operative anatomic characteristics Access sites Stent grafts No 1 Severe infrarenal aortic & bilateral CIA and right CFA artery stenosis Percutaneous LCFA RCFA endarterectomy 14x57mm aortic stent-graft & 8x38mm covered balloon expandable at CIAs (Be-Graft, Bentley, Innomed, Germany) No 2 Occlusion of the aorto-iliac bifurcation extending to bilateral CIAs & right EIA and CFA stenosis Bilateral CFA endarterectomy Pre-dilatation of REIA with 7x80mm angioplasty balloon; 16x38mm aortic stent-graft & 9x57mm & 8x57mm balloon expandable covered stents at the right and left CIA, respectively (Be-Graft, Bentley, Innomed, Germany) No 3 Occlusion of the aorto-iliac bifurcation extending to bilateral CIA & unilateral CFA stenosis Percutaneous LCFA RCFA endarterectomy 16x38mm aortic stent-graft & 8x57mm balloon expandable covered stents at CIAs (Be-Graft, Bentley, Innomed, Germany) No 4 Occlusion of the infrarenal aorta, bilateral CIA & right EIA and CFA artery; diffused severe atheromatosis Percutaneous RCFA LCFA endarterectomy 14x38mm aortic stent-graft & 8x57mm balloon expandable covered stents at CIAs (Be-Graft, Bentley, Innomed, Germany); sub-intimal re-canalization of right EIA with self-expanding stents 8x60mm& 8x40mm (E-Luminexx, Bard Peripheral Vascular, Arizona, USA) Table III. Pre-operative anatomical and intra-operative patients’ characteristics. CFA: common femoral artery; CIA: common iliac artery; EIA: external iliac artery atherosclerotic plaque in the common femoral artery, which was considered as a contraindication for percutaneous access. A hydrophilic 0.035’’ or/and 0.014’’ and 0.018’’ guidewire was inserted to overcome bilateral iliac occlusions or stenoses and it was exchanged with a standard PTFE guidewire after accessing the abdominal aorta. A 0.014’’ and 0.018’’ guidewire was initially used as a step of the standard procedure in order to achieve intra-luminal access. In case where a sub-intimal access was demanded to complete the intervention, a hydrophilic 0.035’’ was preferred. An upper access site from the left brachial artery was also available in all patients, in case of failure of passage the lesion through femoral access. After the insertion of an 8Fr x 45cm sheath (Arrow, Teleflex, USA) into the aorta, a diagnostic arteriography was accomplished. A balloon expandable aortic stent graft (Be-Graft, Aortic, Bentley, Innomed, Germany) was, then, deployed into the infrarenal aorta down to the bifurcation through a 12Fr x 33cm sheath over a stiff guidewire (Gore, W.L. Gore & Associates Inc. Delaware, USA). Two balloon-expandable covered stents (Be-Graft, Aortic, Bentley, Innomed, Germany) were then deployed with the kissing stent technique starting 10-20mm into the aortic stent graft, creating a new aortic bifurcation. In case of extended disease, down to the external iliac arteries, self-expandable stents or just balloon angioplasty was used to complete the procedure. Final angiography was used to confirm adequate placement and patency intra-operatively. Post-operative surveillance and follow-up Double anti-platelet therapy was initiated the day of the procedure. Clinical evaluation and ankle-brachial pressure index (ABPI) measurements were assessed the first post-operative day. 30-day, 6-month and 1st-year follow-up was undertaken with CTA at the first instance and duplex ultrasonography in subsequent ones in order to evaluate the flow and any stentgraft malformation or other complication (Figures 3 and 4).