Endovascular aneurysm repair (EVAR) is the primary treatment modality for abdominal aortic aneurysms; however, a suitable anatomy is a prerequisite for optimal outcomes. Proximal neck anatomic configuration, including length followed by size and angulation, is the main morphometric characteristic that determines EVAR suitability. Iliac landing zone and access vessels’ adequacy should also be considered [1]. Another characteristic that may affect EVAR feasibility but has received less attention is the presence of a narrow aortic bifurcation (NAB). Data on EVAR outcomes in patients with NAB are scarce and heterogeneous. Overall, EVAR in patients with NAB has been reported to present outcomes similar to those in patients with a standard aortic bifurcation at the expense of considerably more iliac limb stentings and overall adjunctive manipulations during the primary procedure [2,3]. Regarding the definition of NAB, most relevant studies have used a threshold of <20 mm, although <18 mm and <16 mm thresholds have also been used [3]. We report a patient with a very tight 10-mm aortic bifurcation who was successfully treated with an ALTO (Endologix Inc.) endograft (Fig. 1, 2). In this case, simultaneous deployment of the iliac limbs was performed, in contrast to the standard technique in which the contralateral limb is deployed first. Specifically, the contralateral limb was placed in its indented location but was not deployed until the ipsilateral limb was advanced to allow simultaneous deployment by the two operators. Aggressive kissing ballooning was then performed, resulting in successful expansion to an additional 10 mm diameter for each limb (Fig. 3). During the 1-year follow-up, both limbs remained patent with no signs of stenosis (Fig. 4, 5). An alternative approach for treating this patient would be using a unibody AFX2 system, which has been reported as suitable for NAB patients [4]. Nevertheless, this was not feasible because the neck length was only 11 mm, which is adequate for the ALTO but not the AFX2 system [5]. Written patient consent was obtained for this report.

Figure 1. (A) Coronal and axial views of the narrow aortic bifurcation were shown in this picture. Dotted green and blue lines represent the coordinator axes of the computed tomography (CT) scans. (B) Three-dimensional reconstruction of the preoperative CT scan, in which the narrow aortic bifurcation is apparent (white arrow). Remarkably, no specific threshold for the diameter of aortic bifurcation is reported in the instructions for use of the ALTO device (Endologix Inc.).

Figure 2. Morphometric characteristics of the abdominal aortic aneurysm were presented in a preoperative plan. This was an off-label case for the ALTO device (Endologix Inc.) owing to the significant neck calcification and conical configuration, whereas a juxtarenal angulation of 49.8° was also noted. Narrow access is observed on both sides. The sizes and lengths of the main body (20×80 mm), right (14×10×140 mm), and left (14×10×160 mm) iliac limbs were also presented.

Figure 3. Simultaneous deployment of the limbs and aggressive kissing ballooning (Mustang percutaneous transluminal angioplasty balloon, 10×60 mm, 8 atm; Boston Scientific) were performed to facilitate expansion of the limbs. Additional deployment of kissing balloon expandable stents within the stent grafts was considered; however, this was not required because of the adequate iliac limb expansion after angiography.

Figure 4. Three-dimensional reconstruction of the postoperative computed tomography scan.

Figure 5. Coronal and axial views of the 1-year postoperative computed tomography scan indicated the satisfactory expansion and good patency of the limbs at the level of aortic bifurcation.