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

Purpose: 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.
Case Report: 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.
Conclusion: Careful communication, wire marking, and attention to intraoperative flow can minimize risks of complication, but knowledge of bail out techniques remains imperative.
Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.