title: Endovascular aneurysm repair in emergent ruptured abdominal aortic aneurysm with a 'real' hostile neck and severely tortuous iliac artery of an elderly patient.
abstract: BACKGROUND
  Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.
  
  
  METHODS
  A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.
  
  
  CONCLUSIONS
  Endovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.
authors.forename: Nan
authors.initials: N
authors.lastname: Wu
authors.forename: Changwei
authors.initials: C
authors.lastname: Liu
authors.forename: Qining
authors.initials: Q
authors.lastname: Fu
authors.forename: Rong
authors.initials: R
authors.lastname: Zeng
authors.forename: Yu
authors.initials: Y
authors.lastname: Chen
authors.forename: Genhuan
authors.initials: G
authors.lastname: Yang
authors.affiliation: Department of vascular surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No, 1 Shuaifuyuan, Beijing 100730, P,R, China. dr.liubao@gmail.com.
authors.forename: Bao
authors.initials: B
authors.lastname: Liu
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D007083:Iliac Artery / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery; D014057:Tomography, X-Ray Computed