Balloon Occlusion of the Contralateral Iliac Artery to Assist Recanalization of the Ipsilateral Iliac Artery in Total Aortoiliac Occlusion: A Technical Note

Endovascular recanalization of chronic total aortoiliac occlusion is technically challenging. Inability to reenter the true aortic lumen, following retrograde iliac recanalization, is one of the most common causes of failure. We describe a case of a total aortoiliac occlusion where balloon occlusion of the right common iliac artery, following its recanalization from a brachial approach, was used to facilitate antegrade recanalization of the occluded contralateral left common iliac artery. 1. Introduction Chronic obstruction of the aortic bifurcation, involving to a varying degree and extent both the infrarenal aortic and common iliac arteries (CIAs), can result in a triad of symptoms consisting of intermittent claudication, absent or diminished peripheral pulses, and impotence. Classically described in males, the anatomic pattern of obstruction is equally common in males and females [1]. The onset is mainly between 40 and 60 years of age, and the disease can lead to severe impairment of walking capacity, rest pain, and wheelchair dependence [1, 2]. Aortobifemoral bypass has been considered the gold standard for treating chronic aortoiliac occlusions [3], but results of endovascular recanalization of the iliac arteries now approach those of aortobifemoral bypass with reduced morbidity and mortality and shorter hospitalization [4]. The Trans-Atlantic Inter-Society Consensus for the management of Peripheral Arterial Disease (TASC II) document classifies total aortoiliac occlusion as type D, with surgery as the treatment of choice [3]. Nowadays, endovascular therapy is increasingly performed in patients with extensive aortoiliac disease, including total aortoiliac occlusion [1]. We describe a technique that might facilitate the recanalization of chronic total iliac occlusion, during endovascular recanalization of a total aortoiliac occlusion. 2. Case Description The patient was a 53-year old female with multiple cardiovascular factors, including hypertension, hypercholesterolemia, diabetes mellitus, coronary artery disease, and history of heavy smoking (60 pack-years; quit 3 years ago), who presented with bilateral lower extremity intermittent claudication, right worse than left, forcing her to stop after 3 minutes of walking. On physical examination, her bilateral femoral, popliteal, dorsalis pedis and posterior tibialis pulses were not palpable. At rest, her ankle-brachial index (ABI) measured 0.57 on the right and 0.58 on the left. She underwent a computed tomographic angiography (CTA) that showed complete occlusion of the distal abdominal aorta,