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Off-Label Use of Reversed Zenith Limb Extension Stent-Grafts to Treat Different Types of Aortoiliac Aneurysmal Disease

The management of iliac artery aneurysms (IAA) often presents formidable challenges. The high operative mortality rates and substantial morbidity associated with open surgical repair of IAAs prompted the development of alternative, less invasive endovascular techniques for their repair. The potential applicability of currently available endovascular devices is often limited to on-label use as specified by the Instructions for Use. However, the practitioner is placed in an awkward position when the individual patient being treated would best be served by an endovascular approach, yet current commercially available endovascular devices appropriate to the patient’s situation and anatomy are not available unless they are modified before implantation. A great deal of creativity is therefore required to modify existing endovascular devices and techniques in an off-label manner in order to accommodate them to a multitude of challenging clinical scenarios. Among these novel techniques, we described in 2009 the off-label use of a commercially available flared limb extension stent-graft to treat IAAs after pre-deploying, reversing, and re-sheathing the device to form a tapered endograft, although the concept itself had been successfully used prior to our publication, but with a different graft and applied to a different arterial segment. Others have subsequently expanded the use of this concept and methodology. We now read with significant interest the article in this issue of JEVT by Dr. Peppelenbosch and colleagues from Maastricht, The Netherlands, who for the first time report intermediate and long-term follow-up of a series of patients treated for aortoiliac aneurysmal disease with reversed endograft limbs. Despite the thorough description of their technique and experience, a few additional comments are appropriate. The relative ease of the endograft reversal process described by the authors stands somewhat in contrast to our personal experience. In our hands, the procedure proved to be a bit tedious, and the extent of manipulation required to re-accommodate the stent-graft inside the delivery system is worrisome. We found simply pushing the graft back into the sheath to be inefficient, so we devised several aids to help reaccommodate the stent-graft within its original sheath. The stent-graft is first deployed on a separate Mayo table (Figure) before remounting it in reversed fashion into its original sheath, allowing retrograde delivery of the wider end of the stent into the common iliac artery and the tapered end into a distal position either in the distal common iliac artery or the proximal external iliac artery. For re-sheathing, we suggest the use of silk ties for the initial segment, where there is external fabric and metallic stents on the inside. Once that segment has been introduced, vessel loops can be used to crimp the remainder of