Endovascular Aortic Aneurysm Repair in Patients with Aortoiliac Occlusive Disease

Although endovascular aortic aneurysm repair (EVAR) has become an attrac-tive, minimally invasive option for patients with abdominal aortic aneurysms (AAA), significant challenges in arterial access exist in patients with concomitant aortoiliac occlusive disease (AIOD), particularly for more advanced TASC C and D lesions. Under these circumstances, endograft delivery is possible but requires extensive preoperative planning and intraoperative techniques including but not limited to surgical conduit creation, plain balloon angioplasty, endoconduit placement, and subintimal recanalization. Newer generation aortic endografts have also shown promise in accommodating compromised access vessels. Concomitant AIOD and compromised access vessels complicate EVAR and increase operative time and complexity. Therefore, extreme caution, meticulous preoperative planning, familiarity and facility with the various surgical and endovascular options needed to circumvent these obstacles are essential for safe and effective delivery of EVAR in this high-risk subset of patients. The purpose of this chapter is to present standard approaches for access in patients undergoing EVAR; discuss how advanced AIOD precludes routine access; and present various methods to overcome difficult access in patients undergoing EVAR.