Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making

Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making LianHui Yu, Shih-Tsung Cheng, Ye Li, Jer-Shen Chen, AI-HSIEN LI, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7587341/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To describe emergency direct transabdominal aortic access as a bailout strategy for thoracic endovascular aortic repair (TEVAR) when bilateral iliac artery spasm precludes device delivery and contextualize this approach among contemporary access techniques. Case Report: A 58-year-old woman with a thoracic aortic pseudoaneurysm underwent planned TEVAR. Bilateral femoral cut-downs failed due to severe iliac artery spasm with > 50% luminal narrowing and contrast extravasation despite vasodilators and ballooning. After recognition of definitive access failure, emergency conversion to direct transabdominal aortic access was performed via midline laparotomy. A 21-French sheath was inserted under direct vision, enabling successful stent graft deployment. Postoperative recovery was uneventful, and one-month CTA confirmed complete pseudoaneurysm exclusion. Conclusion Iliac artery spasm is a dynamic and under-recognized cause of TEVAR access failure. Emergency direct transabdominal aortic puncture offers a rapid and definitive bailout solution, underscoring the importance of surgical preparedness and multidisciplinary coordination in complex endovascular therapy. TEVAR access failure iliac artery spasm direct aortic puncture bailout strategy emergency conversion Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Learning Points Iliac artery spasm, although rare, can decisively prevent femoral TEVAR device delivery. Emergency direct transabdominal aortic access is safe and definitive when pharmacological and endovascular measures fail. Preprocedural planning should include a hierarchy of bailout strategies with immediate surgical expertise available. Multidisciplinary coordination is critical for timely recognition of access failure and safe emergency conversion. Introduction Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for many thoracic aortic pathologies, with reduced morbidity compared to open repair [ 1 , 2 ]. However, procedural success depends on securing large-bore vascular access. Access complications occur in up to 15% of TEVAR cases [ 3 , 4 ], while stenosis, tortuosity, and calcification are common obstacles. Dynamic complications such as severe iliac artery spasm are rarely reported but can be equally prohibitive [ 5 – 7 ]. Several alternative access strategies exist, including iliac conduits, endoconduits, transcarotid, transsubclavian, and direct aortic approaches [ 8 – 10 ]. Most reports describe these in elective or preplanned settings. In contrast, emergency application of direct aortic puncture for acute access failure has received little attention. We report a case of emergency direct transabdominal aortic puncture after failed bilateral femoral access due to iliac spasm, highlighting the decision-making, technical considerations, and enduring role of open surgical expertise in endovascular therapy. Case Report A 58-year-old woman with hypertension, chronic smoking, and lumbar tuberculosis presented with intermittent hemoptysis for one month. CTA revealed a 1.3–1.4 cm saccular pseudoaneurysm with a 0.9 cm neck at the arch-descending aorta junction. Preoperative imaging revealed a right iliac diameter of 7.0 mm (Fig. 1 ). TEVAR was planned to use a TAG thoracic endoprosthesis (34 mm × 15 cm; W. L. Gore & Associates, Flagstaff, AZ, USA). Timeline of access attempts: T = 0–15 min left femoral cut down. Immediate severe spasm (> 50% narrowing) after guidewire passage. T = 75 min: Right femoral access attempted, same spasm response (Fig. 2 ). T = 125–140 min: maximal pharmacological therapy (intra-arterial nitroglycerin, verapamil) and balloon dilatation attempted; contrast extravasation indicated vascular injury [ 5 , 11 ]. T = 250 min: Access failure recognized; decision for emergency conversion T = 360 min: Midline laparotomy performed Emergency direct aortic access: The infrarenal aorta was exposed, clamped proximally and distally. An 18-gauge puncture using the Seldinger technique was performed, advancing a stiff guidewire to the arch. A 21-French sheath was inserted and secured using purse-string sutures (Fig. 3 ). The endograft was deployed from the left subclavian origin to zone three, achieving complete exclusion (Fig. 4 ). The puncture site was primarily repaired. Outcomes Operative time, 180 min; blood loss, 300 mL. The patient was extubated within 6 h and discharged on postoperative day seven. One-month CTA confirmed complete exclusion, with no endoleaks (Fig. 5 ). Discussion Dynamic spasm represents a unique access obstacle that differs fundamentally from fixed anatomical challenges. Unlike stenosis or calcification, iliac spasm may occur suddenly, is invisible on preoperative imaging, and may not respond to vasodilators [ 5 , 11 ]. Forcing devices through spastic vessels risks dissection or rupture, necessitating a prompt transition to alternative strategies [ 6 ]. Most studies have described elective aortic conduits or planned alternative access [ 12 – 14 ]. In emergencies, speed and simplicity are paramount. Our direct puncture technique avoids graft anastomosis, minimizes operative time, and provides immediate hemostatic control, making it particularly suitable for emergency bailout situations. Compared with other alternatives, each approach has distinct advantages and limitations (Table 1 ). Iliac conduits and endoconduits are effective for treating fixed diseases but may be unsuitable for spasms with existing vascular injuries [ 8 , 9 ]. Supra-aortic access (carotid and subclavian) carries an inherent stroke risk and may not be feasible in urgent scenarios [ 7 , 10 ]. Direct aortic puncture provides the most definitive, rapid, and large-caliber access route [ 12 – 14 ]. Technical success depends on several key factors: (1) the early detection of access failure to avert catastrophic vessel injury [ 6 ], (2) having pre-arranged surgical backup for timely conversion, (3) ensuring adequate vascular control with clamps to minimize bleeding risk [ 11 ], and (4) securing closure with purse-string sutures [ 9 ]. Future developments, including lower-profile devices, simulation-based planning [ 15 ], and improved spasm management protocols may reduce the need for surgical bailouts. Nevertheless, surgical readiness remains critical in managing these complex scenarios. Table 1 Comparison of Bailout Strategies in TEVAR Approach Advantages Limitations Best Use Case Iliac conduit Secure, controlled Incision morbidity, longer time Severe fixed stenosis Endoconduit Minimally invasive Risk of rupture/device failure Calcified iliac segments Transcarotid/subclavian Avoids laparotomy Stroke risk, smaller caliber Arch pathology Direct abdominal aorta (this case) Large, straight, definitive Laparotomy morbidity Urgent bailout, spasm/failed iliac Conclusion Severe iliac spasm is a rare, but decisive barrier to TEVAR device delivery. When endovascular and pharmacological measures fail, emergency direct transabdominal aortic access provides a rapid and definitive bailout solution. This case underscores the importance of multidisciplinary readiness, surgical expertise, and structured bailout algorithms in ensuring procedural success in complex endovascular therapy. Declarations Conflicts of interest: The authors declare no competing interests. Ethical approval: All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent: Written informed consent was obtained from the patient for the publication of this case report and all accompanying images. Funding: The authors declare that no funds, grants, or other support was received for the preparation of this manuscript. Authors' contributions: LHY, STC, AHL, and JSC analyzed and interpreted the patient data. AHL, YL, FL, and HQL collaborated in clinical decisions and reporting plans and were all contributors in writing the manuscript. All authors have read and approved the final manuscript. Acknowledgements: We acknowledge Jun Xu, and HePin Liu, who contributed to this article and provided professional services in terms of clinical decision-making. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP (1994) Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 331(26):1729–1734 Patel R, Sweeting MJ, Powell JT, Greenhalgh RM (2016) Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1). Lancet 388(10058):2366–2374 Chen SW, Lee KB, Napolitano MA et al (2023) Complications and Management of TEVAR. AORTA J 11(2):49–65 Awiwi MO, Kandemirli VB, Kokash D, Hossain F, Gjoni M, Odisio E et al (2024) Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7587341","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":517198741,"identity":"43d50df0-5f82-4e5b-a478-86eefb8a2ad8","order_by":0,"name":"LianHui Yu","email":"","orcid":"","institution":"Heilongjiang Far East Cardiocerebrovascular Hospital","correspondingAuthor":false,"prefix":"","firstName":"LianHui","middleName":"","lastName":"Yu","suffix":""},{"id":517198742,"identity":"44eac18f-c815-4597-a20c-b55e1857d185","order_by":1,"name":"Shih-Tsung Cheng","email":"","orcid":"","institution":"Everan Hospital, 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08:05:18","extension":"png","order_by":33,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26375,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFig5B600.png","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/decfb3f4da01f0525ecb6cca.png"},{"id":92575457,"identity":"27d73456-0238-43a7-a178-c47fd8bc5490","added_by":"auto","created_at":"2025-10-01 08:21:18","extension":"png","order_by":34,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":248644,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinerenamed9baac.png","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/24fe807d37be76abc5e68ee7.png"},{"id":92572771,"identity":"1c0c1a36-7a15-4211-aaaa-7da9a3249fc4","added_by":"auto","created_at":"2025-10-01 08:05:18","extension":"xml","order_by":35,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45007,"visible":true,"origin":"","legend":"","description":"","filename":"CIRED25003270structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/c34c1babf2f32da53c6da011.xml"},{"id":92575458,"identity":"5f37230a-b2b5-4621-b215-641eacd91afc","added_by":"auto","created_at":"2025-10-01 08:21:18","extension":"html","order_by":36,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52944,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/e76d5182d89e8c29cc83eef0.html"},{"id":92572742,"identity":"9175f6e3-d4f9-4c44-851a-42c93e599dcd","added_by":"auto","created_at":"2025-10-01 08:05:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":910236,"visible":true,"origin":"","legend":"\u003cp\u003ePre-operative CTA (\"volume-rendered 3D reconstruction\" and \"sagittal oblique MIP). Coronal 3D reconstruction and Sagittal view showing the pseudoaneurysm at the aortic arch-descending aorta junction.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/7b282e75b20c71dfe9d9ad0e.jpg"},{"id":92574708,"identity":"5d56c754-b3e6-4179-93d2-895e89bb1592","added_by":"auto","created_at":"2025-10-01 08:13:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1274960,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-procedural angiography demonstrating access failure. (A) Initial aortography confirming the pseudoaneurysm (arrow) in Zone 3. (B) Attempted sheath insertion via the left femoral artery resulting in severe iliac spasm and suspicious contrast extravasation. (C) Attempted bare passage of the stent-graft device via the right femoral artery, also thwarted by spasm.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/f8e72fb4a83e87a549df4ece.jpg"},{"id":92575455,"identity":"2e54cfbf-2078-4db3-a279-6c5abe635159","added_by":"auto","created_at":"2025-10-01 08:21:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1928280,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images:(A) Mini-laparotomy with direct aortic puncture and sheath insertion. (B) Fluoroscopy showing the guidewire navigated from the aortic sheath to the aortic arch.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/b215744e638866694ddb50c9.jpg"},{"id":92572744,"identity":"0522a194-96bd-4089-991a-0f8506cdf6f3","added_by":"auto","created_at":"2025-10-01 08:05:18","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":932161,"visible":true,"origin":"","legend":"\u003cp\u003eCompletion angiography. (A) Successful deployment of the stent graft. (B) Final angiogram confirming complete obliteration of the pseudoaneurysm with no endoleak.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/78510cd7057cd4adeb66a467.jpg"},{"id":92572747,"identity":"208e7802-0900-4bd3-ae94-f2d55070d877","added_by":"auto","created_at":"2025-10-01 08:05:18","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":718678,"visible":true,"origin":"","legend":"\u003cp\u003eOne-month follow-up CTA (A) and curved planar reformation (B) showing complete obliteration of the pseudoaneurysm and a stable stent graft position with patent stent graft and no endoleak.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/45a3d4e386da4c246730afb2.jpg"},{"id":93066069,"identity":"3ab7ba8a-6832-4e40-bb91-d84ac19b502e","added_by":"auto","created_at":"2025-10-08 16:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6225886,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7587341/v1/c3466323-f4e4-4cbf-b7e2-bbde63081bff.pdf"}],"financialInterests":"","formattedTitle":"Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making","fulltext":[{"header":"Learning Points","content":"\u003cul\u003e\n \u003cli\u003eIliac artery spasm, although rare, can decisively prevent femoral TEVAR device delivery.\u003c/li\u003e\n \u003cli\u003eEmergency direct transabdominal aortic access is safe and definitive when pharmacological and endovascular measures fail.\u003c/li\u003e\n \u003cli\u003ePreprocedural planning should include a hierarchy of bailout strategies with immediate surgical expertise available.\u003c/li\u003e\n \u003cli\u003eMultidisciplinary coordination is critical for timely recognition of access failure and safe emergency conversion.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eThoracic endovascular aortic repair (TEVAR) is the preferred treatment for many thoracic aortic pathologies, with reduced morbidity compared to open repair [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, procedural success depends on securing large-bore vascular access. Access complications occur in up to 15% of TEVAR cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], while stenosis, tortuosity, and calcification are common obstacles. Dynamic complications such as severe iliac artery spasm are rarely reported but can be equally prohibitive [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral alternative access strategies exist, including iliac conduits, endoconduits, transcarotid, transsubclavian, and direct aortic approaches [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Most reports describe these in elective or preplanned settings. In contrast, emergency application of direct aortic puncture for acute access failure has received little attention.\u003c/p\u003e\u003cp\u003eWe report a case of emergency direct transabdominal aortic puncture after failed bilateral femoral access due to iliac spasm, highlighting the decision-making, technical considerations, and enduring role of open surgical expertise in endovascular therapy.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 58-year-old woman with hypertension, chronic smoking, and lumbar tuberculosis presented with intermittent hemoptysis for one month. CTA revealed a 1.3\u0026ndash;1.4 cm saccular pseudoaneurysm with a 0.9 cm neck at the arch-descending aorta junction. Preoperative imaging revealed a right iliac diameter of 7.0 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTEVAR was planned to use a TAG thoracic endoprosthesis (34 mm \u0026times; 15 cm; W. L. Gore \u0026amp; Associates, Flagstaff, AZ, USA).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTimeline of access attempts:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eT\u0026thinsp;=\u0026thinsp;0\u0026ndash;15 min left femoral cut down. Immediate severe spasm (\u0026gt;\u0026thinsp;50% narrowing) after guidewire passage.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eT\u0026thinsp;=\u0026thinsp;75 min: Right femoral access attempted, same spasm response (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eT\u0026thinsp;=\u0026thinsp;125\u0026ndash;140 min: maximal pharmacological therapy (intra-arterial nitroglycerin, verapamil) and balloon dilatation attempted; contrast extravasation indicated vascular injury [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eT\u0026thinsp;=\u0026thinsp;250 min: Access failure recognized; decision for emergency conversion\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eT\u0026thinsp;=\u0026thinsp;360 min: Midline laparotomy performed\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEmergency direct aortic access:\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe infrarenal aorta was exposed, clamped proximally and distally.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAn 18-gauge puncture using the Seldinger technique was performed, advancing a stiff guidewire to the arch.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA 21-French sheath was inserted and secured using purse-string sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe endograft was deployed from the left subclavian origin to zone three, achieving complete exclusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe puncture site was primarily repaired.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003cp\u003eOperative time, 180 min; blood loss, 300 mL. The patient was extubated within 6 h and discharged on postoperative day seven. One-month CTA confirmed complete exclusion, with no endoleaks (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDynamic spasm represents a unique access obstacle that differs fundamentally from fixed anatomical challenges. Unlike stenosis or calcification, iliac spasm may occur suddenly, is invisible on preoperative imaging, and may not respond to vasodilators [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Forcing devices through spastic vessels risks dissection or rupture, necessitating a prompt transition to alternative strategies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMost studies have described elective aortic conduits or planned alternative access [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In emergencies, speed and simplicity are paramount. Our direct puncture technique avoids graft anastomosis, minimizes operative time, and provides immediate hemostatic control, making it particularly suitable for emergency bailout situations.\u003c/p\u003e\u003cp\u003eCompared with other alternatives, each approach has distinct advantages and limitations (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Iliac conduits and endoconduits are effective for treating fixed diseases but may be unsuitable for spasms with existing vascular injuries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Supra-aortic access (carotid and subclavian) carries an inherent stroke risk and may not be feasible in urgent scenarios [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Direct aortic puncture provides the most definitive, rapid, and large-caliber access route [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTechnical success depends on several key factors: (1) the early detection of access failure to avert catastrophic vessel injury [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], (2) having pre-arranged surgical backup for timely conversion, (3) ensuring adequate vascular control with clamps to minimize bleeding risk [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and (4) securing closure with purse-string sutures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFuture developments, including lower-profile devices, simulation-based planning [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and improved spasm management protocols may reduce the need for surgical bailouts. Nevertheless, surgical readiness remains critical in managing these complex scenarios.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Bailout Strategies in TEVAR\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApproach\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdvantages\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBest Use Case\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIliac conduit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecure, controlled\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncision morbidity, longer time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSevere fixed stenosis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndoconduit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimally invasive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRisk of rupture/device failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCalcified iliac segments\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTranscarotid/subclavian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvoids laparotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStroke risk, smaller caliber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eArch pathology\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect abdominal aorta (this case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLarge, straight, definitive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaparotomy morbidity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUrgent bailout, spasm/failed iliac\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSevere iliac spasm is a rare, but decisive barrier to TEVAR device delivery. When endovascular and pharmacological measures fail, emergency direct transabdominal aortic access provides a rapid and definitive bailout solution. This case underscores the importance of multidisciplinary readiness, surgical expertise, and structured bailout algorithms in ensuring procedural success in complex endovascular therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003cp\u003eAll procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from the patient for the publication of this case report and all accompanying images.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support was received for the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthors' contributions:\u003c/h2\u003e\u003cp\u003eLHY, STC, AHL, and JSC analyzed and interpreted the patient data. AHL, YL, FL, and HQL collaborated in clinical decisions and reporting plans and were all contributors in writing the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003e We acknowledge Jun Xu, and HePin Liu, who contributed to this article and provided professional services in terms of clinical decision-making.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP (1994) Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 331(26):1729\u0026ndash;1734\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel R, Sweeting MJ, Powell JT, Greenhalgh RM (2016) Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1). Lancet 388(10058):2366\u0026ndash;2374\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen SW, Lee KB, Napolitano MA et al (2023) Complications and Management of TEVAR. AORTA J 11(2):49\u0026ndash;65\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAwiwi MO, Kandemirli VB, Kokash D, Hossain F, Gjoni M, Odisio E et al (2024) Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review. Curr Probl Diagn Radiol 53(5):648\u0026ndash;661\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFranken E, Sequeira F, Girod D, Smith J, Hurwitz R, Smith W (1982) Femoral artery spasm in children: catheter size is the principal cause. Am J Roentgenol 138(2):295\u0026ndash;298\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh V, Macon CJ, Shaw ES, Londo\u0026ntilde;o JC, Martinez CA (2013 Sept) Transcatheter Aortic Valve Replacement: Techniques, Complications, and Bailout Strategies. Postgrad Med 1(5):31\u0026ndash;42\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuyton RA, Babaliaros V, Lerakis S, Thourani VH, Block PC (2013) Carotid artery access for transcatheter aortic valve replacement. Cathet Cardio Intervent 82(4):n. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/a\u003c/span\u003e\u003cspan address=\"http:///a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWada T, Kadohama T, Takagi D et al (2021) Direct abdominal aortic access in severe calcification. Ann Vasc Surg. ;73:509.e21-509.e24\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIrvine JN, Lapar DJ, Mahapatra S, Ailawadi G, Dimarco JP (2011) Treatment of a malpositioned transcutaneous ventricular pacing lead in the left ventricle via direct aortic puncture. Europace 13(8):1207\u0026ndash;1208\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltaha MA, Bailey S, Mafeld S, Jaberi A, Tan KT (2024) Axillary compared to brachial access for endovascular procedures. Vascular. Aug 30\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacdonald S, Byrne D, Rogers P, Moss JG, Edwards RD (2001) Common iliac artery access during endovascular thoracic aortic repair via transabdominal wall tunnel. J Endovasc Ther 8(2):135\u0026ndash;138\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTabata K, Ono S, Shimozawa M et al (2025) Abdominal Aortic Access for TEVAR. Cureus 17(1):e77887\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltoijry A (2024) Thoracic endovascular repair of descending thoracic aorta aneurysm using thoracic stent graft in a challenging complex patient: An innovative access technique during an emergency using a mini-thoracotomy approach. Vascular 33(1):127\u0026ndash;131\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGallagher C, Tsikouris J, Roonsritong C, Meyerrose G, Shanklin C, Halldorsson A (2006) Bilateral External Iliac Artery Catheter-Induced Vasospasm During Angiography. Angiology 57(1):115\u0026ndash;118\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorzs\u0026aacute;k S, Szentiv\u0026aacute;nyi A, S\u0026uuml;vegh A, Fontanini DM, Vecsey-Nagy M, Banga P et al (2022) Complex Aortic Interventions Can Be Safely Introduced to the Clinical Practice by Physicians Skilled in Basic Endovascular Techniques. Life. June 16;12(6):902\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"TEVAR, access failure, iliac artery spasm, direct aortic puncture, bailout strategy, emergency conversion","lastPublishedDoi":"10.21203/rs.3.rs-7587341/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7587341/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo describe emergency direct transabdominal aortic access as a bailout strategy for thoracic endovascular aortic repair (TEVAR) when bilateral iliac artery spasm precludes device delivery and contextualize this approach among contemporary access techniques.\u003c/p\u003e\u003ch2\u003eCase Report:\u003c/h2\u003e\u003cp\u003eA 58-year-old woman with a thoracic aortic pseudoaneurysm underwent planned TEVAR. Bilateral femoral cut-downs failed due to severe iliac artery spasm with \u0026gt;\u0026thinsp;50% luminal narrowing and contrast extravasation despite vasodilators and ballooning. After recognition of definitive access failure, emergency conversion to direct transabdominal aortic access was performed via midline laparotomy. A 21-French sheath was inserted under direct vision, enabling successful stent graft deployment. Postoperative recovery was uneventful, and one-month CTA confirmed complete pseudoaneurysm exclusion.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIliac artery spasm is a dynamic and under-recognized cause of TEVAR access failure. Emergency direct transabdominal aortic puncture offers a rapid and definitive bailout solution, underscoring the importance of surgical preparedness and multidisciplinary coordination in complex endovascular therapy.\u003c/p\u003e","manuscriptTitle":"Emergency Direct Transabdominal Aortic Access for TEVAR Following Spasm-Induced Iliac Access Failure: Technical Considerations and Clinical Decision-Making","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 08:05:13","doi":"10.21203/rs.3.rs-7587341/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64d6537a-a7d2-4ba7-97ae-d72a53251a10","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T16:46:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-01 08:05:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7587341","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7587341","identity":"rs-7587341","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}