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384 Hybrid procedures
When open exposure has been performed, it is
usually best to puncture the artery and keep the
opening in the artery as small as possible, just
enough to accommodate the sheath (Fig ure 27.4).
is assists in hemostasis. is is usually more
hemostatic than when an open surgical arteriot-
omy is placed along the artery as the rst step and
the sheath is then inserted through the arteriot-
omy. When the sheath is inserted through an open
surgical arteriotomy, in order to maintain hemo-
stasis, all branches must be clamped and ow must
be stopped. When the sheath is inserted into the
artery directly by enlarging a needle puncture and
surgical arteriotomy has not yet been performed,
some ow can oen be maintained in the artery.
When a sheath is placed retrograde through an
open surgical arteriotomy, the operator does not
have the benet of a guidewire having already been
passed to provide a rail for the sheath. Passing a
guidewire in this situation would cause substantial
blood loss since the arterial clamp would have to
be removed to allow the wire to pass. An example
of this is when an open common femoral surgical
arteriotomy has already been performed and the
operator decides that a proximal lesion requires
treatment. In this case, it is usually better to nish
A B
Patch
C
D
Fig. 27.3 Avoid crossing a fresh endarterectomy endpoint, if possible. (A) This patient requires a com-
mon femoral endarterectomy. (B) A femoral endarterectomy has been performed and a patch angio-
plasty has been placed. Along the posterior wall inside the artery, the plaque has been transected in
a transverse manner to allow for removal of the bulky portion of the plaque. This maneuver creates an
endpoint for the plaque. It usually remains stable but can be inadvertently disrupted with mechanical
maneuvers. (C) This demonstrates the view of the endarterectomized artery from a lateral direction. It is
apparent that the proximal endpoint is a place where a flap could form if the plaque were undermined.
(D) In this example, a wire is passed through a needle puncture in the patch located on the anterior wall
of the artery. The wire is naturally directed posteriorly since the puncture site is on the anterior wall and
directs the needle posteriorly. The tip of the wire may go directly into a subintimal plane.
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Technical points for performing hybrid procedures 385
the common femoral artery repair and then to
puncture the artery for wire access in a separate
location, usually more proximally to where the
surgical repair has been performed.
If sheath placement is required through an open
arteriotomy, the best way to do it is as follows. Use
a sheath with a long dilator tip. Usually, it is best
to use a dilator that is actually intended for a lon-
ger sheath. e tip of the dilator should extend
beyond the tip of the sheath by 10–20 cm. In this
manner, the operator can control the artery with
one hand to prevent bleeding and can advance the
tip of the dilator through the arteriotomy and into
the artery by tactile sense with the other hand.
e operator is using the sense of resistance to the
advancement of the dilator tip to attempt to gain
a secure foothold within the artery. is provides
the least likelihood of injury. e dilator can only
be advanced 2–4 cm blindly in this manner. Aer
a few centimeters, it must have wire guidance.
e further inside the artery that the dilator tip is
advanced, the less reliable is the feedback felt by
the operator. With the dilator tip in place in the
artery, the dacron tape can be tightened around
the artery and dilator and the guidewire advanced
using uoroscopic guidance prior to advancing the
dilator any further. If the working room is very
short or the situation is unstable, the operator can
maintain hand control of the artery and the dila-
tor and have an assistant advance the wire under
uoroscopic guidance. Aer the wire is inside the
artery a sucient distance to act as a rail, the dila-
tor is advanced. e sheath can be advanced over
the dilator while holding the dilator still.
When a sheath is placed antegrade through an
open arteriotomy, only backbleeding is faced by
the operator, and not prograde ow as described
in the situation above. erefore, this maneuver
is performed more routinely. An example of this
would be to place a sheath antegrade into the SFA
through the open arteriotomy performed to facili-
tate a common femoral endarterectomy. Caution
A B C
Fig. 27.4 Puncture the artery or perform open arteriotomy. (A) This patient has a common femoral
artery lesion and a distal SFA lesion requiring treatment. (B) After the femoral endarterectomy and
patch angioplasty are performed, a micropuncture needle is placed in an antegrade direction in the
proximal SFA. The guidewire has been introduced. This will serve as the sheath access site in this par-
ticular case. There must be an acceptable length of healthier SFA with which to work. A purse-string
suture can be used for hemostasis at the conclusion of the distal intervention. (C) Another option is
to place the sheath through the open arteriotomy along the anterior surface of the artery. In this case
the tip of the sheath must be placed somewhat blindly, at least initially, in its first few centimeters
into the SFA. While this is being performed, there is no flow to the limb through the profunda femoris
artery or around the sheath into the SFA. Usually this would not matter, but if the lesion is complex or
the sheath requires a lengthy time frame to be in place, it may be suboptimal for the patient.
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386 Hybrid procedures
must still be exerted to avoid blind passage of the
wire and sheath. If the lesion is complex or the
proximal SFA is severely diseased, ensure that
the tip of the dilator is advanced into the correct
lumen.
Another technical point is that inow bal-
loon occlusion, when needed, can be performed
through an artery that has been surgically exposed
or percutaneously. Occasionally, inow occlusion
is required during a lower extremity revasculariza-
tion because the artery is so severely calcied that
it cannot be clamped or some unexpected bleed-
ing occurs (Fi gu r e 2 7. 5). e operator has a choice
based on the location at which control must be
A B
C
D
Fig. 27.5 Inflow occlusion balloons. (A) This figure demonstrates an inflow occlusion balloon at the aor-
tic level. This is a common maneuver when performing endovascular treatment of a ruptured aneurysm.
The occlusion balloon is typically quite compliant. It must be supported closely at its base by a large
sheath. It can be placed through a sheath that has been advanced either percutaneously or through
open exposure of the femoral artery. (B) An “embolectomy” type balloon has been placed to achieve
hemostasis. This is a fairly compliant and round-shaped balloon. It can be placed through a sheath or
directly into the artery without sheath support. It is inflated with a 3 mL or 5 mL syringe with a stopcock
to prevent deflation. (C) A standard angioplasty balloon has been inflated to perform inflow control for
the open femoral procedure. This balloon can be placed through a sheath or alone without a sheath.
The value of having a sheath is to perform interval arteriography, ensure hemostasis, and carry out any
other catheter-based treatments that are required. (D) In this case a stent has been placed in the inflow
iliac artery. After stent placement, to achieve hemostatic control, the balloon is inflated within the stent.
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Iliac stent and femoral endarterectomy 387
asserted. If control is required at the aortic level,
an aortic occlusion balloon should be used. ese
are compliant and can assume full prole at only a
few atmospheres of pressure. is type of balloon
usually requires a 10- or 12-Fr sheath, depending
on the manufacturer. is is a standard maneu-
ver for endovascular repair of a ruptured aneu-
rysm and is discussed in more detail in Chapter
28. Because of the large diameter of the aorta and
the dynamic forces working against the balloon at
this level, sheath support is usually required close
to the base of the balloon to prevent downward or
distal slippage. In the case of iliac artery inow
control for a lower extremity operation, the opera-
tor may choose an “embolectomy” type balloon or
a standard angioplasty balloon. e embolectomy
type balloon is typically quite compliant and can
self-adjust to a range of diameters. e downside
is that they are short and can move easily, usually
pushed distally by prograde ow, and this is sub-
optimal for hemostasis. e standard angioplasty
balloon comes in longer lengths and this is better
for hemostasis. If there is room to work, the best
hemostasis is with the longest balloon with the lon-
gest seal length of balloon to artery. e disadvan-
tage is that standard angioplasty balloons for large
arteries are not compliant enough to cover a range
of diameters. Correct sizing is essential to achieve
hemostasis. If inow balloon occlusion is required
during femoral endarterectomy or lower extrem-
ity bypass, and there is a stent placed as the inow
portion of the hybrid procedure, ination of the
balloon within the stent usually produces better
hemostasis than ination of the balloon within the
native artery, which has a more irregular surface.
ILIAC STENT AND FEMORAL
ENDARTERECTOMY
A common type of hybrid procedure is described
here. Hybrid procedures associated with aneurys-
mal disease are presented in Chapter 28. Femoral
endarterectomy combined with an inow iliac
stent is demonstrated in F i g ure 27. 6 .
When inow aortic or iliac stenting is being per-
formed with femoral endarterectomy, it is usually
best to perform a thorough exposure while dissect-
ing out the femoral artery. If the disease extends to
the femoral bifurcation or near to it, the proximal
SFA and proximal profunda femoris artery will
also require circumferential exposure for clamping.
Usually, a more distal exposure is required com-
pared with the impression acquired at rst glance.
Aer the artery is opened, it is not desirable to
spend additional time performing vessel exposure.
e proximal segment where the clamp will
be placed should be so to the touch and must be
assessed for clampability. is is consistent with the
concept of assessing the “working room”, as dem-
onstrated in F i g ure 27. 2 . It is usual for the proxi-
mal common femoral artery to be calcied and
diseased, even in the segment that is proximal to
the most diseased portion that must be treated by
endarterectomy. It is also not unusual for the dis-
tal external iliac artery to be diseased and there
may be concern about whether it can be clamped.
e calcic disease may be circumferential and
longitudinally continuous. is is the most dan-
gerous for clamping because the artery can dissect
and rupture. More commonly, the disease is on the
posterior wall of theartery. In this case, the opera-
tor places the clamp so that the anterior wall of
the artery is compressed toward the posterior wall
of the artery, a so-called “front-to-back” type of
clamping maneuver. Calcication can be assessed
prior to the procedure by CTA and also by plain
spot lms of the arteries, which can be performed
during arteriography.
e medial and lateral iliac circumex vessels
should be preserved, unless ligation is required to
mobilize the distal external iliac artery to bring
it slightly inferiorly out of the retroperitoneum.
If the distal external iliac artery requires clamp-
ing, the inguinal ligament can also be partially
mobilized. is is performed by opening the tissue
plane along the inferior aspect of the inguinal liga-
ment. By doing this, the inguinal ligament can be
retracted more proximally. Care must be taken to
avoid going too deep along this plane so that the
femoral nerve and lymphatic vessels are avoided.
Aer adequate exposure and administration of
anticoag ulation, a micropunctu re needle is inserted
at the location along the femoral artery where the
upper end of the arteriotomy is likely to be placed.
If the puncture site is too proximal, it can create a
situation where the arteriotomy and patch is longer
than needed. If the arteriotomy is too distal, the
advancing 0.018-inch micropuncture guidewire
may not pass through the common femoral artery
lesion. e best way to determine where to place
the needle is by palpation. Aer the 4-Fr micro-
puncture dilator is in place, a Glidewire
®
may
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388 Hybrid procedures
be advanced across the iliac lesion that requires
treatment. If visualization is needed, a retrograde
arteriogram can be obtained through the micro-
puncture dilator. If the lesion is complex, the wire
may not be expected to advance easily through
the lesion and sheath access should be established
prior to crossing. e sheath will require a rail to
be advanced and enough wire must be advanced
to support this. e larger the sheath, the longer
and stier the rail must be. Aer the guidewire is
in place, a 6-Fr, 30-cm length sheath with a radi-
opaque tip can be placed. is is adequate for
A
D E
B C
Fig. 27.6 Iliac stent and femoral endarterectomy. (A) An iliac artery stenosis and a common femoral
artery lesion require treatment. (B) The common femoral artery and its bifurcation are thoroughly
exposed. (C) A dacron tape has been looped around the artery proximal to the common femoral
artery lesion. A micropuncture needle has been introduced into the anterior wall of the artery near
the proximal portion of the common femoral artery lesion requiring treatment. (D) A sheath is placed
at the location of the puncture site in the common femoral artery. The guidewire has been advanced
across the iliac artery lesion. (E) An iliac artery stent has been placed. A Ramel tourniquet is tightened
around the sheath and the artery to maintain hemostasis. (Continued)
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Femoral endarterectomy plus distal intervention 389
most iliac reconstructions. If a much larger stent or
stent–gra is required, the sheath must be upsized.
Use an Amplatz Super Sti
®
wire to support the
sheath if a substantially larger sheath is required.
Usually, the sheath tip is advanced so that it is just
inferior to the lesion. Retrograde arteriography
will guide treatment of the lesion. If the lesion is
an occlusion or a critical stenosis, a retrograde
arteriogram will not be adequate and a catheter
must be advanced to the position proximal to the
lesion to obtain adequate arteriograms. During
this time the sheath is secured by a dacron tape
looped around the artery and tightened with a
Ramel tourniquet at the location of its insertion
into the common femoral artery. e common
femoral artery distal to the sheath insertion site
may also require clamping. is can be done selec-
tively, based on the adequacy of the hemostasis.
Aer the inow lesion is treated, and an arterio-
gram has conrmed that this is the case, the wire
is removed. e femoral artery clamp is placed in
position, and the operator places a nger over the
arteriotomy site. e assistant removes the sheath.
As the sheath tip slides out of the arteriotomy the
clamp is placed. e arteriotomy site is then used
as the proximal part of the longitudinal arterial
incision, through which the femoral endarterec-
tomy will be performed.
FEMORAL ENDARTERECTOMY
PLUS DISTAL INTERVENTION
If the plan is to perform a more distal endovascular
reconstruction with the femoral endarterectomy,
the sequence of events is as follows. e femoral
artery is exposed as described above. e common
femoral artery is clamped as well as the artery dis-
tal to the lesion. Aer the femoral endarterectomy
is performed, the clamps are removed and the ow
is restored to the limb. If there is acceptably non-
diseased or less diseased artery at the proximal SFA
and there is “working room” proximal to the lesion
intended for treatment, the additional infraingui-
nal endovascular reconstruction can then be per-
formed through a puncture site in the proximal
SFA. A micropuncture is used in antegrade fashion.
A guidewire is advanced and a sheath placed over
it. e sheath tape is advanced close to the lesion.
e intervention is performed through the sheath,
usually in a hemostatic manner. A Ramel tourni-
quet and a dacron tape can be placed at the site of
the arteriotomy, if needed, while ow is maintained
through the femoral endarterectomy site and the
profunda femoris artery. A purse-string suture is
placed at the site of the access. In this way, hemosta-
sis is usually maintained fairly well while the proce-
dure is being performed.
GF
Fig. 27.6 (Continued) Iliac stent and femoral endarterectomy. (F) The wire and sheath have been
removed and the common femoral, superficial femoral, and profunda femoris arteries have been
clamped. Potts scissors are introduced through the very small arteriotomy site where the sheath had
initially been placed. The scissors are used to open the arteriotomy. (G) The endarterectomy is then
performed through the open common femoral artery.
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391
28
Technical aspects of treating
aortic aneurysms
INTRODUCTION
e aim of this chapter is to highlight techni-
cal aspects of endovascular treatment of aortic
aneurysm disease. Numerous device-specic
aspects will not be covered, as they are typically
taught with training for the specic device itself.
Nevertheless, there are many aspects of aneurys-
mal disease management that are common in the
placement of the endovascular aneurysm devices.
IMAGING
It is standard to obtain a CT angiogram of the area
to be repaired. is will permit evaluation of the
diameter, presence of calcium, presence of throm-
bus and tortuosity, and presence of access artery
disease. If upper extremity access is considered for
abdominal aortic or thoracic aneurysm repair, a
CT angiogram of the thoracic aorta should also be
obtained. If the primary pathology is in the tho-
racic aorta, such as dissection, aneurysm intra-
mural hematoma, or penetrating ulcer, CTA of the
thoracic aorta should be performed. In addition,
because the access vessels will include the abdomi-
nal aorta and iliac arteries, CTA of the abdomen
and pelvis should also be performed. When CTA
of the pelvis is performed it should include images
through the common femoral artery bifurcation.
ere are multiple imaging-related issues. e CT
angiogram can be used to make a complete plan
for access and endogra placement, including gra
sizing, and to assess whether any special devices or
maneuvers may be required. Ultrasound also plays
a role. If axillary or brachial access is anticipated,
consider ultrasound evaluation preoperatively
and prior to nalizing the plan. If brachial access
is considered, this is outside the zone included
in the CT angiogram. Ultrasound can be used to
assess the diameter and adequacy for use as an
access site. If the intended sheath size approaches
half the diameter of the artery, consider open
exposure of the brachial artery for access. If the
intended sheath size approaches the full diameter
of the brachial artery, any plan to use the brachial
artery for access probably should be modied and
the access site moved proximally to the axillary
artery. Evaluation of the axillary artery, its depth,
and whether there is any disease can be accom-
plished with ultrasound. Duplex with velocity of
the subclavian and axillary arteries should be con-
sidered in patients that have evidence of occlusive
disease present on the preoperative CT angiogram.
Depending on the procedure being performed, the
operator may elect to access the contralateral side
or proceed with a plan to treat the access artery
during the procedure. In patients with aneurys-
mal disease, it is usually worthwhile to evaluate
the diameter of the common femoral artery as
well, since these patients are prone to aneurysm
formation in this location. is may inuence the
plan with respect to which femoral artery to use
for the largest sheath. Access site placement along
the femoral artery may also be inuenced by the
location of the enlargement or occlusive disease of
the common femoral artery as identied by pre-
operative imaging. Iliac arteries that are small (for
the intended sheath), have signicant occlusive
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392 Technical aspects of treating aortic aneurysms
disease, are calcied, or tortuous can be identied
preoperatively and a plan made for the procedure.
Preoperative imaging using CTA and duplex can
assist the operator in selecting the access sites, pre-
paring the plan for access, and deciding whether
percutaneous access is appropriate.
OPEN ACCESS OR PERCUTANEOUS
ACCESS OF FEMORAL ARTERIES
Percutaneous access can be obtained in most
patients who require treatment for aneurysmal dis-
ease. Evaluation with CTA and/or ultrasound helps
to identify any potential obstacles and pick the
best sites. e exact plan and contingencies should
be decided prior to the procedure. Percutaneous
access tends to be a little faster, keeps the patient
in the hospital for shorter lengths of stay, and has
the same or lower rates of complications than open
access. In most practices, percutaneous access is
the rst choice and open exposure for access is a
default approach.
Typically, when open femoral access is
obtained, it is because there is extensive com-
mon femoral disease that requires open repair
or because some other adjunctive procedure is
required. Indications for open access through the
femoral artery include: common femoral artery
occlusion; critical stenosis of the common femo-
ral artery; and severe calcication. One might
also consider open exposure in the situation of
supercial femoral artery (SFA) occlusion and
coincidental profunda femoris artery stenosis. In
this case, the majority of the perfusion to the limb
depends on a diseased profunda femoris artery
that should probably be xed.
The common femoral artery exposure in these
cases is usually extensive in order to prepare for
any other required procedures, such as femoral
endarterectomy. The femoral bifurcation should
be exposed so that the SFA and profunda femoris
artery can be clamped separately, if needed. If
open exposure is anticipated, consider perform-
ing the surgical dissection and then puncturing
the surface of the artery proximal to the disease
and proceeding with the endovascular portion
of the operation. This offers better hemosta-
sis and less clamp time. After the endovascu-
lar procedure is performed, the artery can be
clamped proximally and distally and the repair
performed.
PERCUTANEOUS LARGE BORE
ACCESS USING THE PRE-CLOSE
TECHNIQUE
On the day of the procedure, the skin of the femo-
ral areas is extensively prepared. Ultrasound is
used to identify the best place along the length
of the artery to perform the percutaneous access.
e inguinal ligament may be marked along its
course for anatomic denition from pubic tubercle
to anterior-superior iliac spine. If there is exten-
sive common femoral disease, and the decision is
to proceed with percutaneous access, it is usually
best to enter the artery with the needle proximal
to the common femoral artery disease. Ultrasound
is used to avoid calcic areas of the artery wall.
A short skin incision is made, usually just large
enough to accommodate the intended sheath
(Figure 28.1). A Kelly clamp can be used to dilate
the tissues a little along the intended pathway of
the needle. is is performed under ultrasound.
A micropuncture needle is then inserted under
ultrasound guidance and the micropuncture
sheath placed. A Bentson guidewire is advanced
through the aneurysm and into the aorta proximal
to the abdominal aortic aneurysm. Dilators are
used and an 8-Fr sheath is placed. e operator has
the option of giving heparin immediately or wait-
ing until the pre-close has been performed. e
8-Fr sheath creates space large enough for inser-
tion of the Perclose ProGlide™ suture-mediated
closure system. e sheath is removed and pressure
is held manually at the access site. e ProGlide™
is advanced over the guidewire. When the guide-
wire port is visible at skin level, the wire is removed
and the ProGlide™ advanced into the artery
until backbleeding occurs from the side port. e
ProGlide™ is then tilted approximately 30° from
the midline so that the sutures will be placed on
the anterior oblique surface of the artery. e
plunger of the ProGlide™ delivery is used to place
sutures in the artery wall. Aer suture placement,
the ProGlide™ delivery is withdrawn. When it has
been withdrawn to the extent that the guidewire
port is visible at the skin level, the Bentson guide-
wire is replaced through the side of the ProGlide™
delivery catheter and advanced again into the
artery. In between each exchange, pressure is held
manually to prevent bleeding. As the access site
entry into the artery is gradually enlarged, more
aggressive manual pressure is required to achieve
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Percutaneous large bore access using the pre-close technique 393
A B
C D
E F
G H
Fig. 28.1 Percutaneous large bore access with pre-close technique. (A) A small skin incision is placed
at the groin. Under ultrasound guidance, a micropuncture needle is placed in the anterior wall of the
common femoral artery and an 8-Fr sheath placed. The sheath is approximately the same caliber as the
closure device. (B) A Perclose ProGlide™ closure device is advanced over the guidewire. When the side
hole guidewire port of the closure device is reached, the wire is removed. (C) After guidewire removal the
Perclose ProGlide™ catheter is advanced until backbleeding is visible from the side port at the hub. This
indicates that the footplates are inside the artery. (D) After side port backbleeding is identified, the latch
on the side of the catheter is flipped upward to deploy the footplate inside the artery. (E)Depressing the
plunger at the top of the hub deploys the sutures into the anterior wall of the artery. (F)By releasing the
latch and returning it to its initial position, the footplates are retracted and recede back into the catheter.
(G) As the catheter is being removed, the guidewire port becomes visible on the side of the catheter. The
guidewire is reinserted through the guidewire port and advanced into the aorta to provide access avail-
ability for the next Perclose ProGlide™ closure device to be placed. (H) For large bore access closure, two
closure devices are typically placed. They are angulated 30° from the midline and sutures are deployed.
The artery is closed with two sutures in the anterior surface of the artery.
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