Background

The Covered Endovascular Reconstruction of the Aortic Bifurcation approach serves as a sophisticated minimally invasive procedure that targets aortoiliac occlusive disease when the aortic bifurcation requires extensive treatment. This treatment emerged to provide minimally invasive care instead of traditional open surgical reconstruction such as aortobifemoral bypass (ABFB) but carries elevated medical risks and prolonged postoperative recovery.

Doctors previously used open surgical bypass treatment and endovascular stenting techniques for AIOD. The surgical approach achieves reliable long-term outcomes, yet it carries substantial dangerous risks soon after the operation especially for patients who face high medical risks. Traditional kissing stents (KS) utilize two balloon-expandable stents placed at the aortic bifurcation though they present significant hemodynamic drawbacks that include:

Arterial flow at the central aorta undergoes disturbances because of the loss of structural integrity to the lumen.

Increased risk of restenosis at the bifurcation

Higher rates of stent fracture

The CERAB device introduced solutions to these limitations through a distinctive conical flow design at the aortic bifurcation which enhanced laminar flow properties and resulted in longer-lasting treatment success.

Indications

Aortoiliac Occlusive Disease (AIOD) – TASC C and D Lesions

Trans-Atlantic Inter-Society Consensus (TASC) II C and D aortoiliac lesions include extensive cases of stenosis or occlusion of the distal aorta and both iliac arteries.

The medical condition affects patients who have extensive blockages or complex vascular structures which do not respond to basic balloon angioplasty methods and isolated stenting techniques.

Patients at High Surgical Risk for Open Aortobifemoral Bypass: CERAB provides a minimally invasive option to open aortobifemoral bypass therefore it serves patients with multiple health problems that make them unsuitable for standard open surgical procedures due to: Significant comorbidities (e.g., severe cardiac or pulmonary disease)

Elderly patients with increased surgical risk

Patients with prior abdominal surgeries (e.g., history of aortic aneurysm repair or previous aortobifemoral bypass failure)

Symptomatic Aortoiliac Occlusive Disease: Medical professionals should use CERAB as the treatment of choice for symptomatic AIOD patients whose symptoms cause severe deterioration in quality of life

Chronic limb-threatening ischemia

Ischemic ulceration or gangrene

Contraindications

Severe aortic calcification or hostile aortic anatomy preventing optimal stent graft placement

Severe iliac tortuosity or small iliac arteries making delivery of covered stents difficult

Patients with contraindications to anticoagulation or dual antiplatelet therapy

Outcomes

Equipment

Imaging & Guidance Equipment

Fluoroscopy with Digital Subtraction Angiography (DSA)

Angiographic catheters (e.g., Cobra, Multipurpose, Pigtail)

Iodinated contrast media (e.g., Visipaque, Omnipaque)

Vascular Access Equipment

Vascular sheaths (7F–12F)

Long sheaths (e.g., Flexor Ansel, Cook) for iliac artery access

Guidewires

0.035-inch stiff guidewires (e.g., Amplatz Super Stiff, Lunderquist)

Hydrophilic guidewires (e.g., Glidewire, Terumo)

Stent Grafts (Covered Stents)

Proximal aortic covered stent graft:

Atrium Advanta V12

iCAST (Getinge/Maquet)

BeGraft (Bentley)

Iliac covered stents (distal extensions):

Atrium Advanta V12

BeGraft Peripheral Stent

Gore Viabahn (self-expanding covered stent, if needed)

Bare-metal stents (if additional support is required)

Balloon Dilatation Devices

Pre-dilation balloons (e.g., Mustang, Dorado)

Post-dilation non-compliant high-pressure balloons (e.g., Atlas Gold, Armada)

Closure Devices

Perclose ProGlide (Abbott) or Angio-Seal for percutaneous access site closure

Medications & Anticoagulation

Heparin (IV bolus for anticoagulation during procedure)

Dual antiplatelet therapy (DAPT) post-procedure

Patient Preparation

The evaluation process includes clinical tests for aortoiliac occlusive disease symptoms together with laboratory assessments of renal function and coagulation profile and lipids. CT angiography (CTA) and MR angiography (MRA) imaging tests help examine lesion severity and vessel diameter measurement while determining the best access site for intervention. Prior to the procedure patients begin dual antiplatelet therapy with aspirin and clopidogrel which should be started between 3–5 days in advance while intraoperative anticoagulation with heparin protects against thrombus formation. Diabetic patients at risk for contrast-induced nephropathy (CIN) will receive normal saline intravenous hydration or bicarbonate infusion to prevent lactic acidosis and metformin medication must be stopped for 24–48 hours.

Medical staff ensures optimal blood pressure conditions alongside glucose targets prior to surgery to reduce risks that occur during the operation. Both femoral artery access points undergo shaving then disinfection in the groin region before the physician applies local anesthesia with sedation. During the procedure the patient receives continuous ECG and blood pressure and oxygen saturation monitoring through an arterial line and IV fluids stand ready for managing any potential hemodynamic instability. The patient receives information about possible complications such as bleeding, infection, restenosis and embolization. Additionally, the patient needs to follow the preoperative NPO instruction of nothing by mouth for at least six hours. Following the procedure patients need to stay in bed for 4–6 hours while being required to take antiplatelet drugs throughout their lifetime for maintaining stent patency.

Computer artwork of a stent being placed in a narrowed blood vessel

Patient position

The patient rests in supine position while lying on the angiography table. Bilateral femoral artery access requires a slight opening of the legs because it represents the standard approach for this procedural method. Fluoroscopic imaging will benefit from a radiolucent cushion placed under the patient’s lower back which helps both provide comfort and better position vessels. The arm position should either rest by the sides or remain secured on board-shaped accessories to maintain easy access for both intravenous lines and monitoring tools.

Technique

Step 1: Supine positioning of the patient reveals both femoral arteries for access when legs maintain a slight abducted position. The physician administers local anesthesia followed by conscious sedation for the procedure though complex situations might require general anesthesia. The procedure requires evaluation of both common femoral arteries under ultrasound guidance to establish 7F–12F vascular sheaths into position. The patient needs intravenous administration of heparin to keep activated clotting time (ACT) above 250 seconds which prevents thrombotic complications.

Step 2: Catheter-based angiography should be performed from the contralateral femoral artery to display the aortoiliac bifurcation and start the procedure. Deploy an Amplatz or Terumo brand hydrophilic guide wire with diameter of 0.035 inches through both iliac artery lesions.

Step 3: Stent Graft Placement (CERAB Configuration) requires a three-layered reconstruction that establishes a conical funnel design for ideal blood conduit. The covered aortic stent (for example BeGraft or Advanta V12) needs to be placed above the aortic bifurcation. When deploying the system proceed with care to produce a wide funnel opening for the iliac stents. The lower portion of the stent must extend above the origin points of both common iliac arteries.

Step 4: Medical personnel place two covered stents inside the aortic stent through the “Kissing Stents” technique (one stent per common iliac artery). Equal distribution of blood flow depends on symmetrical stent placement which will also stop possible circulation disruptions. The iliac stents should be placed over each other within the aortic stent structure to create a smooth transition from aortic flow to iliac artery flow.

Step 5: The procedure requires balloon post-dilation of aortic and iliac stents using a non-compliant high-pressure balloon which can be Atlas Gold or Armada. The practitioner needs to check that stents have reached their maximal size while maintaining proper contact with vessel walls. A completion angiography should be performed to obtain final assessments.

Step 6: The procedure requires sheath removal and achievement of hemostasis through vascular closure device instruments like Perclose ProGlide and Angio-Seal. Check for complications at the access site by monitoring for bleeding and the formation of hematomas and checking for distal embolism. Healthcare providers should utilize dual antiplatelet therapy therapy by combining aspirin with clopidogrel for a minimum period of 6–12 months to stop in-stent restenosis. The patient should rest in bed for 4–6 hours following the procedure while healthcare providers monitor for instability.

Approach considerations

The selection process needs to focus on symptomatic aortoiliac patients while determining existing medical conditions carefully. Detailed imaging of the anatomy must take place for doctors to choose proper landing areas and identify vessel dimensions. Careful analysis should be implemented for choosing the common femoral arteries while considering backup access routes when needed. The preoperative planning stage requires necessary decision making about optimal stent graft size and configuration selection for restoring laminar flow patterns between patients for treatment. The preventive measures for thrombotic risks include initiating anticoagulation therapy together with dual antiplatelet therapy. Hemodynamic monitoring and established post-operative protocols serve as essential tools for preventing and managing potential complications during and after the procedure. Patient results benefit from optimal care because of the essential need for regular assessments that measure both stent effectiveness and prompt problem identification through these scheduled appointments.

Laboratory tests

Complete Blood Count

Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT)

Basic metabolic panel

Liver function test

B-Type Natriuretic Peptide

D-dimer

Complications

Bleeding

Infection

Vascular injury

Stent migration

Stent thrombosis

Distal embolization

Acute limb ischemia

References

Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis – PubMed

The CERAB technique: tips, tricks and results – PubMed

References

Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis – PubMed

The CERAB technique: tips, tricks and results – PubMed