endovascular aneurysm repair ( evar ) for abdominal aortic aneurysm ( aaa ) now becomes widely accepted as primary choice for aortic aneurysm repair .
main obstacles for this less invasive procedure lies in proximal hostile neck anatomy which leads to aneurismal exclusion failure by causing type - i endoleak ( 1 , 2 ) .
although distal iliac stenotic lesion causes access difficulty to deliver the system , smaller profile and lubricant sheath offers more chance to overcome this limitation ( 3 ) .
the other important iliac artery related issue is combined common iliac artery ( cia ) aneurysm which occurred up to 20% with aaa ( 4 ) . in such cases
, evar requires distal extension to external iliac artery with occlusion of hypogastric artery to prevent type ii endoleak via patent hypogastric artery .
predominantly this will cause buttock claudication and erectile dysfunction , but sometimes more serious consequences such as colon ischemia or spinal cord ischemia could happen ( 5,6,7,8 ) . to prevent this complication , surgical bypass to hypogastric artery via retroperitoneal approach has been performed ( 9 ) .
however this hybrid procedure sometimes offsets the benefit of less invasiveness of evar by causing complication such as retroperitoneal hematoma . the iliac branch device ( ibd ) ( cook inc .
, bloominton , in , usa ) introduced for pure endovascular approach . technical success and
however , in many countries including korea , the commercialized ibd is not available yet .
hence we report four cases using surgeon custom made ibd which could be used for substitute technique of endovascular salvage for hypogastric artery .
this is not an original concept , already many experiences have been reported in terms of branched stent graft ( 12 ) .
ibd is created making short cuff to tfle zenith iliac limb ( cook inc . ) . making branch portion
is done with partial proximal deployed state . for this , peel - away the system of limb needed to be removed , but to keep it in stable status , the main keeping wire should not be removed .
although the diameter of tfle limb is fixed as 12 mm , the length of limb used for ibd will be dependent on iliac artery anatomy .
this would be another benefit of custom - made devices compared to fixed length of factory ready - made devices .
sometimes second stent row is not fully expanded because of distal confined portion , we found that making a cuff was not hindered . to make an accurate hole for cuff , electric coagulator
. the hole should be made at the site of stent , not between stents .
flagstaff , az , usa ) graft for making cuff , but 8 mm graft also will work .
the length of cuff is decided between 15 mm to 20 mm based on working distance between cuff and hypogastric artery orifice .
the orientation of cuff can be decided in any direction using reference of knob at the handling portion .
the configuration of cuff should be downward shaped usually 45 degree . using 5 - 0 prolene , running suture as vascular anastomosis
the cuff located under the stent , we put three sutures including top to fix stent with cuff .
we put one gold marker at the outside of distal portion of cuff ( fig .
for the proximal marker of cuff , second stent will be used as the reference .
this whole " making device " procedure usually takes less than 10 min ( fig .
1e ) . in our first case , we made the device before operation to avoid unnecessary anesthetic time , but after that we did during the operation .
for the preload catheter , it could be decided by the configuration of aortic bifurcation ( fig .
for the sharp angle , cobra 2 or rim catheter will be proper other than we usually choose kmp catheter with terumo 035 inch 260 cm glide wire .
the first step is to insert a large diameter sheath enough to introduce cuffed ibd , into cia .
since the sheath size for 12 mm diameter zenith is 14 fr , we often choose 20 fr , 35 cm length sheath ( saint jude , inc .
even though 5fr angio catheter comes together for preload catheter , we found 20 fr sheath is enough size for ibd procedure .
after the tip of the sheath is located cia orifice level , the custom - made ibd needs to be loaded . this step would be the bustle up without experiences , because of back bleeding via sheath .
variable techniques in terms of reloading procedure can be used according to operator 's experiences .
this is two person 's work and both should be familiar with loading procedure to avoid inadvertent injury to stent of cuff component . since the hypogastric artery direction is always posterior , the cuff should be loaded with facing posterior , too . after introducing ibd at the level of cia proximal site , contralateral selection to make through - through guidewire
however if there is severe tortuosity in contralateral external iliac artery ( eia ) with sharp aortic bifurcation angle , this step would be very hard without snare .
we do not use a snare device for this step . instead of using preload catheter , we can do cross over guide wire first from any side of femoral artery and using this preplaced guidewire as through - through guidewire during ibd loading procedure . by avoiding snare procedure
this is another merit of custom - made ibd . after using this technique we could overcome any difficulties related to this step .
the proper diameter sheath to introduce bridging covered stent is inserted with holding through - through guidewire .
the tip should be placed beyond cuff to prevent inadvertent fall off during inserting covered stent , especially sharp aortic bifurcation angled anatomy . before this step
, proximal ibd portion needs to be deployed to cuff level . if there is limited working distance between cuff and hypogastric artery , bridging procedure would be failed or kinking could happen .
measuring the distance between cuff and hypogastric artery is important to decide proper covered stent .
if there is some aneurismal change with hypogastric artery , we prefer balloon expandable stent - graft , v12 ( atrium , inc . , hudson , nh , usa ) because diameter adjustment with bigger balloon is capable . after introducing covered stent to proper site ,
careful balloon for covered stent with proper diameter is important to prevent distal type i endoleak . after completing this procedure
the main body of zenith stent graft will be introduced via contralateral side and deployed as regular evar procedure . to bridge the gap between contralateral limb and proximal stent of ibd , also sizing catheter introduced after contralateral gate selection .
since only 22 mm length of stent in limb graft offers overlapping zone , operator should be careful during bridging procedure .
it should not cover the orifice of ibd internal opening which could lead to hypogastric artery occlusion .
for this step , proper oblique c - arm angle , with caudal - cranial view is recommended .
ibd is created making short cuff to tfle zenith iliac limb ( cook inc . ) . making branch portion
is done with partial proximal deployed state . for this , peel - away the system of limb needed to be removed , but to keep it in stable status , the main keeping wire should not be removed .
although the diameter of tfle limb is fixed as 12 mm , the length of limb used for ibd will be dependent on iliac artery anatomy .
this would be another benefit of custom - made devices compared to fixed length of factory ready - made devices .
sometimes second stent row is not fully expanded because of distal confined portion , we found that making a cuff was not hindered . to make an accurate hole for cuff , electric coagulator
. the hole should be made at the site of stent , not between stents .
flagstaff , az , usa ) graft for making cuff , but 8 mm graft also will work .
the length of cuff is decided between 15 mm to 20 mm based on working distance between cuff and hypogastric artery orifice .
the orientation of cuff can be decided in any direction using reference of knob at the handling portion .
the configuration of cuff should be downward shaped usually 45 degree . using 5 - 0 prolene , running suture as vascular anastomosis
the cuff located under the stent , we put three sutures including top to fix stent with cuff .
we put one gold marker at the outside of distal portion of cuff ( fig .
for the proximal marker of cuff , second stent will be used as the reference .
this whole " making device " procedure usually takes less than 10 min ( fig .
1e ) . in our first case , we made the device before operation to avoid unnecessary anesthetic time , but after that we did during the operation .
for the preload catheter , it could be decided by the configuration of aortic bifurcation ( fig .
for the sharp angle , cobra 2 or rim catheter will be proper other than we usually choose kmp catheter with terumo 035 inch 260 cm glide wire .
the first step is to insert a large diameter sheath enough to introduce cuffed ibd , into cia . since the sheath size for 12 mm diameter zenith is 14 fr , we often choose 20 fr , 35 cm length sheath ( saint jude , inc . , st .
even though 5fr angio catheter comes together for preload catheter , we found 20 fr sheath is enough size for ibd procedure .
after the tip of the sheath is located cia orifice level , the custom - made ibd needs to be loaded . this step would be the bustle up without experiences , because of back bleeding via sheath .
variable techniques in terms of reloading procedure can be used according to operator 's experiences .
this is two person 's work and both should be familiar with loading procedure to avoid inadvertent injury to stent of cuff component . since the hypogastric artery direction is always posterior , the cuff should be loaded with facing posterior , too . after introducing ibd at the level of cia proximal site , contralateral selection to make through - through guidewire
needs to be started . with proper shape of preload catheter , passing guidewire to opposite iliac artery
however if there is severe tortuosity in contralateral external iliac artery ( eia ) with sharp aortic bifurcation angle , this step would be very hard without snare .
we do not use a snare device for this step . instead of using preload catheter , we can do cross over guide wire first from any side of femoral artery and using this preplaced guidewire as through - through guidewire during ibd loading procedure . by avoiding snare procedure , it offers huge medical costs saving effect .
the proper diameter sheath to introduce bridging covered stent is inserted with holding through - through guidewire .
the tip should be placed beyond cuff to prevent inadvertent fall off during inserting covered stent , especially sharp aortic bifurcation angled anatomy . before this step , proximal ibd portion needs to be deployed to cuff level .
if there is limited working distance between cuff and hypogastric artery , bridging procedure would be failed or kinking could happen .
measuring the distance between cuff and hypogastric artery is important to decide proper covered stent . preplaced gold marker with stent row used as reference marker for this step . if there is some aneurismal change with hypogastric artery , we prefer balloon expandable stent - graft , v12 ( atrium , inc . , hudson , nh , usa ) because diameter adjustment with bigger balloon is capable . after introducing covered stent to proper site ,
careful balloon for covered stent with proper diameter is important to prevent distal type i endoleak . after completing this procedure , the rest of ibd part will be deployed without pressure to hypogastric artery
. the main body of zenith stent graft will be introduced via contralateral side and deployed as regular evar procedure . to bridge the gap between contralateral limb and proximal stent of ibd , also sizing catheter introduced after contralateral gate selection .
since only 22 mm length of stent in limb graft offers overlapping zone , operator should be careful during bridging procedure .
it should not cover the orifice of ibd internal opening which could lead to hypogastric artery occlusion .
for this step , proper oblique c - arm angle , with caudal - cranial view is recommended .
each step of procedure for ibd loading , hypogastric artery cannulation , bridging procedure with covered stent was done uneventfully .
all iliac artery aneurysm was excluded without type i endoleak which was confirmed in early post operative ct scans . the indication of ibd were bilateral ciaa combined with aaa in all patients ( table 1 ) . for the bridging procedure , v12 ( atrium , inc . )
was used for the other patient . in all three v12 using cases , flaring of distal v12 with bigger balloon to adjust aneurismal portion of hypogastric artery was achieved . in three patients ,
contralateral hypogastric artery was already occluded by disease progression and single hypogastric artery was saved by ibd . the 4th patient ( case 4 in table 1 )
3 ) . the acute angle over aorta and left cia hindered the advancing of limb stent graft which offered a bridge between contralateral limb and ibd . during the pushing up of the limb stent graft ,
since v12 was already deployed and fixed to hypogastric artery , the cuff portion of ibd could have been fallen off and lead to disconnection .
to overcome this situation we have used 24 french big sheath ( cook , inc . ) to offer paving .
the risk of hypogastric artery embolization during evar is well known but sometimes it is inevitable when aaa is combined with cia aneurysm . the most disastrous complication such as ischemic colon necrosis reported with bilateral embolization ( 13 ) .
however even with unilateral hypogastric embolization , up to 50% of patients suffer from buttock claudication ( 14 ) .
although this is not a critical complication and expected spontaneous improvement with time , many of these patients turn out to be in a disabled walking life style .
since the elective aneurysm repair is preventive surgery even without any symptom , postoperative life quality is severely affected . surgical bypass such as hypogastric artery transposition or
interposition graft could offer pelvic perfusion for such cases , but still need general anesthesia with increasing peri - operative risk to comorbid patients .
separate covered stent insert to hypogastric artery in parallel configuration with main stent graft to salvage hypogastric perfusion ( 15 ) .
also there is high risk for endoleak through the gap between parallel covered stents , especially hostile anatomy .
iliac branch device was designed to pursue more stable procedure which could offers natural anatomic configuration .
the clinical outcome of cook zenith ibd have showed prominent results with desirable longterm patency results ( 10 ) .
however , even with these highly acceptable results , the device availability in some countries are very limited . because of health costs and reimbursement issues , many countries including korea ,
this situation motivates vascular surgeons to customize conventional stent graft ( 16,17,18 ) . because the vascular surgeons are already getting used to manipulating graft , they have some privileges for customization such as suture cuff to iliac limb stent graft .
we used ptfe graft to favor ibd loading into big sheath by reducing profile . through our four cases of experiences
, we found that the loading procedure is the most demanding step because of back - bleeding .
the benefit of our procedural customization is revising the order of procedures and capable cross over guide wire without snare device .
if the angle of aortic bifurcation is sharp with tortuous iliac arterial anatomy , crossing guide wire is not easy .
snaring is not directly related with ibd , but it is an expensive complement and another burden of medical cost . even without snare ,
if the cross over guidewire is done at first and using this wire to insert preload catheter of ibd during loading procedure , hostile iliac anatomy could be surmounted .
the other benefit is choosing the most proper size of ibd graft in terms of length and diameter .
we chose the distal diameter 10 mm and the limb length 56 mm ( tfle-10 - 54 ) in three cases .
this aspect offers more flexibility in case of tortuous anatomy as in our fourth case ( fig .
the cia lumen should be enough to allow cuff with limb stent graft which is more than 20 mm .
if the lumen is smaller than this , the cuff could be compressed by arterial wall .
the length of cia is also an important factor for cross over introducing bridging covered stent .
based on configuration of limb stent graft and considering working distance for bridging , 50 mm length is the minimum requirement .
severe tortuosity of external iliac artery and acute angle between aorta and cia could act as an obstacle for ibd , but it is not absolute contraindication .
careful planning based on ct workstation is a prerequisite with hostile anatomy as in our case .
it is better to do ibd procedure in straight cia side , because tortuous iliac artery may cause displacement of preplaced ibd during introduction of other components during evar . in summary , we reported the first case of surgeon custom - made ibd in korea .
the procedure is feasible and useful to preserve pelvic perfusion especially in the situation of unavailability of device .
long - term follow - up is needed to evaluate stent graft patency and ibd - related complications .
 endovascular salvage of the hypogastric artery using iliac branch device ( ibd ) during endovascular aortic aneurysm repair ( evar ) , offers less invasive alternative solution to surgery to prevent pelvic ischemia . 
 we have performed the first korean surgeon custom - made ibd for this purpose to overcome the limitation of unavailability of the devices in korea . 
 four patients with abdominal aortic aneurysm with bilateral common iliac artery aneurysm ( ciaa ) were treated using custom - made ibds from october 2013 to december 2013 . 
 ibd was created in back table before evar operation using tfle zenith iliac limb stent graft ( cook inc . ) . 
 three v12 ( atrium , inc . ) one viabahn ( gore , inc . ) were used for bridging between ibd and target hypogastric artery . with this modification of ibd procedure , 
 exteriorize the guide wire without snare device is possible which offers another benefit in terms of reducing medical costs comparing to commercial ibd . 
 all operations were successful without any device related complications or postoperative endoleaks . during the mean follow up of 3 months , all ibd were patent without clinical complications . 
 surgeon custom made ibd is feasible and useful to preserve pelvic perfusion especially in the situation of limited commercial ibd availability in many countries . 
 long - term follow - up is needed to evaluate stent graft patency and ibd - related complications . 
INTRODUCTION
MATERIALS AND METHODS
Device customization
Deploy procedure (
RESULTS
DISCUSSION