Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications

Preserved Pelvic Circulation After Stent-Graft Treatment of Complex Aortoiliac Artery Aneurysms:A New Approach

PURPOSE

To describe an endovascular technique that allows stent-graft treatment of aortoiliac aneurysmal disease affecting both common iliac arteries (CIA), with maintenance of pelvic circulation on one side.

TECHNIQUE

For patients with aortoiliac aneurysms, both common femoral arteries (CFA) were surgically exposed. One internal iliac artery (IIA) was initially embolized with coils. A bifurcated stent-graft main body was deployed with the proximal end just below the renal arteries. On the ipsilateral side, the stent-graft limb was extended 3 cm beyond the orifice of the embolized IIA into the external iliac artery (EIA) using stent-graft limb extenders. On the contralateral side, the stent-graft limb was deployed so that the distal end was 10 to 15 mm proximal to the patent IIA orifice. Via a left brachial artery access, the IIA was catheterized, and stent-grafts were deployed from the distal end of the contralateral AAA stent-graft limb into the IIA. A femorofemoral crossover graft provided circulation to the leg ipsilateral to the IIA stent-graft, and the EIA on the same side was ligated. The technique can also be modified to treat isolated bilateral CIA aneurysms.

CONCLUSIONS

By extending the distal aspect of the stent-graft into an IIA, bilateral CIA aneurysms can be excluded while preserving pelvic circulation on one side.

Endovascular Aortic Aneurysm Repair with the Zenith Endograft in Patients with Ectatic Iliac Arteries

Endovascular aortic aneurysm repair (EVAR) in patients with ectatic iliac arteries is feasible; however, most studies have reported experience from single institutions where distal flare techniques with endograft components were used on an "off-label basis." The Zenith endovascular graft allows adequate seal in ectatic common iliac arteries (CIAs) with diameters up to 20 mm. To determine whether large or ectatic CIAs are a risk factor for early and late endograft failure, we analyzed data from the Zenith U.S. multicenter trial. Among 352 patients receiving the endograft in the Zenith u.s. clinical study, 156 patients (44%) had at least one ectatic iliac artery (maximum diameter between 14 and 20 mm), whereas 22 (6.3%) had bilateral CIAs of normal diameter (< 14 mm). Variables analyzed included those defined by the reporting standards for EVAR (SVS/AAVS) as well as iliac-related outcome and indications for secondary iliac interventions. Univariate (Kaplan-Meier [KM] receiver operating characteristics curve, and Cox regression analyses were used to determine the association between CIA diameter and iliac-related complications. The median follow-up period was 24 months. Technical success was similar (>99%) for patients with ectatic and normal CIAs. Only one late type I distal endoleak was reported and was attributed to failure of distal iliac seal in a patient with ectatic CIAs. Freedom from iliac-related secondary intervention (IRSI) was not significantly different between the groups (KM, log-rank test, p = 0.98) with rates at 1, 12, and 24 months of 98%, 97%, and 95% for patients with ectatic CIAs, and 100%, 95%, and 95% for patients with normal iliac arteries, respectively. Moreover, Cox regression analysis revealed that the maximum CIA diameter was not a significant predictor of freedom from IRSI (hazard ratio, 0.98; 95% confidence interval, 0.7-1.4; p = 0.98). In patients with large CIAs, indications for IRSI included distal type I endoleak (1, 0.6%), type III endoleak (1, 0.6%), graft limb occlusion (4, 2.6%), and device stenosis (1, 0.6%). The only IRSI in a patient with normal CIAs was performed for device stenosis (4.6%). In conclusion, the Zenith endograft is effective for EVAR in patients with ectatic CIAs. Moreover, the presence of large CIAs was not associated with an increased risk of adverse iliac-related outcome or subsequent IRSI. Long-term surveillance, however, is mandatory, as IRSIs may be necessary.

Internal Iliac Artery Coil Embolization in the Prevention of Potential Type 2 Endoleak after Endovascular Repair of Abdominal Aortoiliac and Iliac Artery Aneurysms: Effect of Total Occlusion versus Residual Flow

PURPOSE

To evaluate whether the presence of type 2 endoleak after internal iliac artery (IIA) coil embolization in patients with residual antegrade flow through the coils is more frequent than in patients who presented with total occlusion of the IIA after embolization.

MATERIALS AND METHODS

Records were reviewed of 45 patients who underwent unilateral (n = 37) or bilateral (n = 8) IIA coil embolization between 1998 and 2004 for endovascular repair of aortoiliac aneurysms (n = 32), iliac artery aneurysms (n = 12), pseudoaneurysm (n = 1), or distal type 1 endoleak after placement of an aortoiliac stent-graft (n = 8). A total of 53 IIAs were embolized by means of coils and/or microcoils. Computed tomography (CT) was used for follow-up in 40 patients, angiography was used in three, and color Doppler ultrasonography was used in three.

RESULTS

At the end of the embolization procedure, 23 IIAs were occluded and 30 IIAs demonstrated residual antegrade flow through the coils. Control CT demonstrated two type 2 endoleaks after endovascular stent-graft placement resulting from retrograde blood flow into the left IIA main branch via a patent iliolumbar artery. One of these two patients showed residual antegrade flow through the coils at the end of the IIA embolization procedure, and the other patient underwent complete coil embolization of the ostia of the anterior and posterior division but not of the main trunk of an aneurysmal IIA.

CONCLUSION

IIA coil embolization with residual antegrade flow through the coils causes no greater incidence of type 2 endoleak after aortoiliac or iliac stent-graft placement. However, care must be taken in case of a proximal postostial origin of the iliolumbar artery on the IIA, which may cause type 2 endoleak if not embolized.

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair

PURPOSE

Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption.

METHODS

From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg).

RESULTS

There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits.

CONCLUSIONS

Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Overt ischemic colitis after endovascular repair of aortoiliac aneurysms

OBJECTIVE

Controversy exists as to the cause of ischemic colitis complicating endovascular aneurysm repair. Occlusion of the hypogastric arteries (HAs) during endovascular repair of aortoiliac aneurysms (AIAs) results in a significant incidence of buttock claudication, and has been suggested as a causative factor in the development of postprocedural colonic ischemia, in addition to factors such as systemic hypotension, embolization of atheromatous debris, and interruption of inferior mesenteric artery inflow. To analyze the relationship between perioperative HA occlusion and postoperative ischemic colitis, we reviewed our experience over 2 years with Food and Drug Administration-approved endovascular graft devices for treatment of AIAs.

METHODS

Elective repair of AIAs with bifurcated endovascular grafts was performed in 233 patients over a 2-year period. These included 184 AneuRx grafts, 17 Ancure grafts, and 32 Excluder grafts. During the experience, 44 patients (18.9%) underwent unilateral perioperative HA occlusion (28 right, 16 left) during the course of endovascular AIA repair, and 1 patient (0.4%) underwent bilateral HA occlusion.

RESULTS

In 4 patients (1.7%) signs and symptoms of ischemic colitis developed 2.0 +/- 1.4 days postoperatively. In all patients the diagnosis was confirmed at sigmoidoscopy, and initial treatment included bowel rest, hydration, and intravenous antibiotic agents. Three patients with bilateral patent HAs required colonic resection 14.7 +/- 9.7 days after the initial diagnosis, and 2 of these 3 patients died in the postoperative period. Pathologic findings confirmed the presence of atheroemboli in the colonic vasculature in all 3 patients who underwent colonic resection. The fourth patient had undergone multiple manipulations of the left HA in an unsuccessful attempt to preserve patency of this vessel during AIA repair. This patient recovered completely with nonoperative management. Perioperative unilateral HA occlusion was not associated with a significantly higher incidence of postoperative ischemic colitis.

CONCLUSION

Perioperative HA occlusion during aortoiliac open or endovascular surgery may contribute to development of the rare but potentially lethal complication of ischemic colitis. However, our extensive experience suggests that embolization of atheromatous debris to the HA tissue beds during endovascular manipulations, rather than proximal HA occlusion, is the primary cause of clinically significant ischemic colitis after endovascular aneurysm repair.

Transcatheter Embolization of Hypogastric Artery Aneurysms: Lessons Learned

Transcatheter embolization of hypogastric artery aneurysms has become an attractive therapeutic alternative for many patients with this difficult lesion. Because of the increasing use of stent grafting for treatment of abdominal aortic aneurysms, transcatheter embolization of normal-caliber hypogastric arteries has become an almost routine procedure, usually accomplished with little morbidity. Applying this treatment to aneurysmal hypogastric arteries, however, involves greater technical complexity and a significantly higher risk of ischemic complications. We present three cases to illustrate the technical challenges of hypogastric aneurysm embolization, the potentially devastating ischemic complications, and the clinical situations that may predispose to poor outcomes.

Feasibility of open simple prostatectomy with early vascular control

OBJECTIVE

To determine the feasibility of open simple prostatectomy with early vascular control in the treatment of benign prostate hyperplasia (BPH), and thus reduce blood loss.

PATIENTS AND METHODS

Thirty-seven patients were reviewed from 1991 to 2002; 34 had a Millin's and three a Freyer's prostatectomy performed by one surgeon, with early vascular control.

RESULTS

The mean operative duration was 1.3 h and the mean blood loss 841 mL, with a mean decrease in haemoglobin level of 22 g/L. Six (16%) of the patients received a blood transfusion. The mean weight of the prostate removed was 97.8 g; the duration of catheterization and the hospital stay after surgery were 6.21 and 11.7 days, respectively. There was one (3%) death and one case of pulmonary embolism. Three patients (8%) developed stress incontinence. Two failed to void after surgery and one developed acute retention 3 years later. Five patients developed recurrent obstructive symptoms.

CONCLUSION

Open simple prostatectomy with early vascular control reduces the amount of blood loss, rendering it a safe option for treating BPH.

Hypogastric artery bypass to preserve pelvic circulation: improved outcome after endovascular abdominal aortic aneurysm repair

OBJECTIVE

This study was carried out to compare the functional outcomes after hypogastric artery bypass and coil embolization for management of common iliac artery aneurysms in the endovascular repair of aortoiliac aneurysms (EVAR).

METHODS

Between 1996 and 2002, 265 patients underwent elective or emergent EVAR. Data were retrospectively reviewed for 21 (8%) patients with iliac artery aneurysms 25 mm or larger that involved the iliac bifurcation. Patients underwent hypogastric artery bypass (n = 9) or coil embolization (n = 12). Interviews about past and current levels of activity were conducted. A disability score (DS) was quantitatively graded on a discrete scale ranging from 0 to 10, corresponding to "virtually bed-bound" to exercise tolerance "greater than a mile." Worsening or improvement of symptoms was expressed as a difference in DS between two time points (-, worsening; +, improvement).

RESULTS

There was no difference in age (72.6 +/- 7.3 years vs 73.1 +/- 6.4 years), sex (male-female ratio, 8:1 vs 11:1), abdominal aortic aneurysm size (60.1 +/- 5.9 mm vs 59.3 +/- 7.0 mm), or number of preoperative comorbid conditions (1.9 +/- 0.8 vs 2.1 +/- 0.8) between hypogastric bypass and coil embolization groups, respectively. Mean follow-up was shorter after hypogastric bypass (14.8 vs 20.5 months; P <.05). There was no difference in the mean overall baseline DS between the bypass and the embolization groups (8.0 vs 7.8). Six (50%) of the 12 patients with coil embolization reported symptoms of buttock claudication ipsilateral to the occluded hypogastric artery. No symptoms of buttock claudication were reported after hypogastric bypass (P <.05). There was a decrease in the DS after both procedures; however, coil embolization was associated with a significantly worse DS compared with hypogastric artery bypass (4.5 vs 7.3; P <.001). In 4 (67%) of 6 patients with claudication after coil embolization symptoms improved, with a DS of 5.4 at last follow-up. This was significantly worse than in patients undergoing hypogastric artery bypass, with a DS of 7.8 at last follow-up (P <.001). There was no difference between the groups in duration of procedure, blood loss, length of hospital stay, morbidity, or mortality (0%).

CONCLUSIONS

Hypogastric artery bypass to preserve pelvic circulation is safe, and significantly decreases the risk for buttock claudication. Preservation of pelvic circulation results in significant improvement in the ambulatory status of patients with common iliac artery aneurysms, compared with coil embolization.

Coil embolization of iliac artery aneurysms developing after abdominal aortic aneurysm repair with a conventional bifurcated graft

PURPOSE

To evaluate the efficacy of embolizing iliac artery aneurysms (IAAs) developing after abdominal aortic aneurysm (AAA) repair.

METHODS

The records of 6 patients (5 men; mean age 79 years, range 61-87) with unilateral (n=3) or bilateral (n=3) IAAs that had developed after AAA repair were reviewed. In all patients, the limbs of the bifurcated graft were anastomosed end-to-end or end-to-side with the external iliac arteries during AAA repair. Before embolization, superior mesenteric artery (SMA) arteriography was done in all patients to evaluate collateral pathways to the inferior mesenteric artery (IMA).

RESULTS

The unilateral IAAs were treated by proximal and distal embolization. In 2 patients with bilateral IAAs, SMA angiography showed sufficient collateral flow to the IMA, so the aneurysms were treated by proximal embolization and packing. In the other bilateral IAA case, the left 6-cm IAA was treated by proximal and distal embolization, while the contralateral 3-cm IAA was not embolized because angiography demonstrated inadequate collateral flow to the IMA, indicating a possible risk of colon ischemia if both IAAs were embolized. Immediate postprocedural angiography in all patients showed complete exclusion of the IAAs. Mild buttock claudication occurred in 1 patient. There were no episodes of rupture over a mean 46-month follow-up.

CONCLUSIONS

Embolization is a safe and effective alternative to open surgery for the treatment of IAAs that develop after AAA repair. However, before embolization, angiographic evaluation of collateral pathways to the IMA is essential to reduce the risk of colon ischemia.

Transvaginal sonographic appearance of thrombosed uterine arteries after uterine artery embolization: the "white snake" sign

PURPOSE

The aim of this prospective study was to describe the appearance of thrombosed uterine arteries on transvaginal sonography performed after uterine artery embolization (UAE) and to assess the prognostic value of the "white snake" sign with regard to symptomatic outcome at 12 months.

METHODS

Patients who underwent UAE from January 1, 1999, to July 31, 2000, for the treatment of symptomatic leiomyomas were included in the study. Transvaginal sonography was performed before and at 3, 6, and 12 months after UAE. Patients graded the severity of their symptoms on a scale from 1 to 5, with 1 being the least and 5 the most severe, before and at 12 months after the procedure. The Wilcoxon rank-sum test was used to determine correlations between severity of symptoms and presence of the white snake sign; a p value of less than 0.05 was considered significant.

RESULTS

During the study period, UAE was performed in 19 patients with a mean age of 41 years (range, 32-48 years). UAE was technically successful in all patients. Eighteen patients (95%) reported symptomatic improvement at 12 months: 8 patients (42%) by 4 severity-scale points, 5(26%) by 3 points, and 5 (26%) by 2 points. The 1 patient who did not experience improvement had undergone a hysterectomy at 4 months after the UAE. At the 3-month follow-up, transvaginal sonography demonstrated a tortuous echogenic structure in the adnexa (the white snake sign) in all patients; the finding was still apparent in 10 patients at 6 months but in only 2 patients at 12 months. A direct correlation was found between persistence of the white snake sign and the degree of symptomatic improvement at 6 months (p=0.04) but not at 12 months (p=0.08).

CONCLUSIONS

After UAE, a thrombosed uterine artery appears on transvaginal sonography as an echogenic tortuous structure in the adnexa. Persistence of this white snake sign at 6 months after UAE may suggest a more favorable symptomatic outcome.

Distal internal iliac artery embolization: a procedure to avoid

OBJECTIVES

Internal iliac artery (IIA) coil embolization as an adjunct to endovascular stent grafting (ESG) is common practice for treating abdominal aortic aneurysm (AAA) in patients with a substantially enlarged common iliac artery requiring extension of the stent-graft limb into the external iliac artery. The literature describing pelvic ischemia in association with IIA coil embolization contains conflicting reports of symptom severity. We studied IIA occlusion outcome as a function of coil placement in the IIA.

METHODS

From August 1997 to March 2002, 20 patients with AAA underwent ESG with unilateral IIA coil embolization. Coils were placed proximal to the first branch of the IIA in 8 patients and distal to the first branch in 12 patients. Symptoms of pelvic ischemia and mid-term outcome were studied.

RESULTS

Patients included 18 men and 2 women with mean age of 70(1/2) years (range, 53-86 years). Mean diameter of AAA was 54.4 mm (range, 38-80 mm), and of common iliac artery was 24.2 mm (range, 15-48 mm). Ten patients (50%) had new onset of symptoms of pelvic ischemia after endograft procedures: 1 of 8 patients (13%) with proximal IIA embolization had buttock claudication, and 9 of 12 patients (75%) with distal IIA embolization had pelvic ischemic symptoms, including buttock claudication in 8 and impotence in 1 (P =.02, Fisher exact test). No colonic ischemia occurred in this series. At 12-month follow-up, 4 patients with distal IIA embolization were symptom-free. At further follow-up to 24 months, 4 patients remained significantly limited with symptoms of claudication.

CONCLUSIONS

A significantly higher incidence of symptoms of pelvic ischemia occurred with more distal placement of coils for IIA embolization. Failure to control for extent of coil placement may account for the apparently conflicting results in published studies. IIA coil embolization should be performed as proximal as possible to prevent interference with pelvic collateral circulation.

Retrograde endovascular hypogastric artery preservation (REHAP) and aortouniiliac (AUI) endografting in the management of complex aortoiliac aneurysms

The preservation of internal iliac artery (IIA) flow during endovascular repair of abdominal aortic aneurysms (er-AAA) remains a controversial area. Ectasia and aneurysmal disease of the iliac arteries represent a formidable challenge to the endovascular surgeon, particularly when aortic neck length and diameter are suitable for er-AAA. We describe a procedure to maintain arterial perfusion to the pelvis during er-AAA called retrograde endovascular hypogastric artery preservation (REHAP). This technique is particularly useful in the presence of common iliac artery (CIA) and internal iliac artery (IIA) aneurysms when pelvic perfusion to one IIA needs to be maintained. A Wallgraft is first placed from the IIA to the ipsilateral EIA followed by er-AAA using an aortouniiliac graft (AUI) and a femorofemoral bypass graft (BPG). This procedure represents one alternative to maintaining pelvic perfusion using standard endovascular and surgical techniques.

Urological manifestations of vascular disease

We have detailed several of the urological manifestations of vascular disease. With the aging of the North American population, urologists will encounter the urological complications of vascular disease with ever-increasing frequency.

Internal iliac artery embolization with bilateral occlusion before endovascular aortoiliac aneurysm repair-clinical outcome of simultaneous and sequential intervention

PURPOSE

To retrospectively evaluate the clinical outcome of patients after simultaneous or sequential internal iliac artery (IIA) embolization for bilateral IIA occlusion.

MATERIALS AND METHODS

Sixteen patients (65-88 y; mean, 75.6 y; two women), 11 with aortobiiliac aneurysms, three with bilateral common iliac artery (CIA)/IIA aneurysms, and two with unilateral CIA/IIA aneurysms, underwent IIA occlusion before endovascular aortoiliac repair. Eight patients underwent simultaneous bilateral IIA embolization before endovascular aortic repair (EVAR). Eight patients had sequential bilateral IIA occlusion. The outcome was assessed by clinical follow-up.

RESULTS

There were no severe ischemic complications such as buttock necrosis or acute bowel, bladder, or spinal cord ischemia. Early ischemic complications occurred in 25% (buttock/thigh claudication, n = 3, 18.8%; and sexual dysfunction, n = 1, 6.2%) and had an onset not later than 6 months after intervention: buttock claudication resolved (n = 2) or persisted after aggravation by inferior mesenteric artery embolization for type II endoleak (n = 1). Impotence in a fourth patient persisted. The ischemic complication rate after 6 months was 30% (three of 10) because of a fifth patient who developed ischemic colitis with aggravation of ischemic heart disease after 15 months. The mean follow-up duration was 19.7 months. Patients with simultaneous embolization had a lower complication rate than those with sequential embolization (one of eight [12.5%] vs four of eight [50%], respectively).

CONCLUSIONS

IIA embolization for bilateral IIA occlusion can be performed with a complication rate comparable with results of previous studies of unilateral IIA embolization. Chronic buttock claudication may be aggravated by embolization of aortic side branches. Late complications can have an insidious course and be initiated by low-output cardiac failure. Bilateral IIA occlusion is recommended only in patients who are considered unfit for aortic surgery.

The first 150 endovascular AAA repairs at a single institution: how steep is the learning curve?

PURPOSE

To determine whether increasing experience with endovascular abdominal aortic aneurysm (AAA) repair in a single institution will result in improved outcome.

METHODS

A retrospective review was undertaken of 150 consecutive cases of endovascular AAA repairs performed using the AneuRx device between October 1996 and April 2000 in a university-based medical center. The population was divided into early and late groups of 75 patients each. Endpoints included technical success; complications; early (< or =30-day) morbidity, mortality and rupture; endoleak at discharge and at 1 month; early secondary intervention; proximal neck and iliac tortuosity; extender cuff placement; femoral reconstructions beyond primary repair; total fluoroscopy time; and contrast load.

RESULTS

Baseline patient and aneurysm characteristics were similar between the 2 groups. Technical success was 98.7%; 2 cases were converted intraprocedurally owing to difficult iliac access (early group) and a severely angulated proximal neck (late group). There was a tendency toward more frequent use of intraoperative proximal extender cuffs in the early group (12% versus 4% in the late group, p=0.13). Femoral reconstructions were more frequent in the early group (36% versus 19%, p<0.025). While total contrast volume was similar (111 +/- 56 versus 105 +/- 45 mL, p=NS), total fluoroscopy time was significantly reduced (p<0.05) between the early and late groups.

CONCLUSION

With attention to detail and careful patient selection, successful endovascular AAA repair can be achieved with very few conversions and low perioperative mortality even during the center's early experience. Evidence indicates, however, that a learning curve definitely exists, as shown by fewer access site problems, more accurate device deployments, and decreased fluoroscopy times as proficiency is attained.

A technique for combined hypogastric artery bypass and endovascular repair of complex aortoiliac aneurysms

Endovascular repair of complex aortoiliac aneurysms may necessitate distal fixation of the endograft to the external iliac artery and percutaneous embolization of the hypogastric artery for prevention of a retrograde endoleak. However, acute interruption of hypogastric perfusion can result in symptoms of pelvic ischemia. We describe a technique in which a prosthetic graft is used as an external iliac artery conduit to facilitate the passage of the endograft delivery catheter/sheath and after completion of the endovascular portion of the procedure, a surgical bypass is completed with anastomosis of the graft to the hypogastric artery.

Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow

OBJECTIVE

Dilated common iliac arteries that complicate aortic aneurysm stent grafting usually have been managed with endograft extension across the iliac artery bifurcation with internal iliac artery (IIA) occlusion. We studied 25 patients with significant common iliac artery (CIA) dilation treated with two methods: endograft extension across the iliac bifurcation or a new approach with a flared cuff within the CIA that preserves the IIA.

METHODS

Of 86 patients with abdominal aortic aneurysm (AAA) who underwent bifurcated endovascular stent grafting (ESG), 25 (29.1%) had at least one dilated CIA. Two treatment groups had different methods of management of iliac artery dilation. Group 1 underwent ESG with straight extension across the iliac bifurcation and IIA coil embolization before the ESG procedure (n = 2) or simultaneously with ESG (n = 8). Group 2 underwent ESG with flared distal cuff (AneuRx, Medtronic AVE, Santa Rosa, Calif) contained within the CIA, the so-called "bell-bottom" procedure, thus preserving the IIA (n = 15). Iliac artery dimensions, operating room time, fluoroscopy time, and postoperative complications were prospectively gathered.

RESULTS

Two women and 23 men had mean diameters of AAA of 56.6 mm (range, 38 to 98 mm) and of CIA of 21.4 mm (range, 15 to 48 mm). The diameters of CIA treated with device extension into external iliac artery after IIA coil embolization in group 1 and with the bell-bottom procedure in group 2 were not different (mean CIA diameter, 19.9 mm; range, 15 to 26 mm; and mean, 19.1 mm; range, 15 to 24 mm; respectively). However, significantly lower operating room and catheter procedure times were found in group 2 compared with group 1 (137 versus 192 minutes; 58 versus 106 minutes; P =.02 and.02, respectively). No periprocedural type I endoleaks were found in either group. Nine patients in group 2 also had a second contralateral CIA aneurysm, and five patients (mean CIA diameter, 33.0 mm; range, 22 to 48 mm) underwent treatment with extension across the iliac artery bifurcation and IIA occlusion. Use of the bell-bottom procedure on the other side allowed preservation of one IIA. Four cases (mean diameter, 19.3 mm) also underwent contralateral bell-bottom procedure. Two of these group 2 patients had complications, with severe buttock claudication in one and distal embolism necessitating limb salvage bypass after preoperative coil embolization of the IIA in another.

CONCLUSION

Significant CIA ectasia or small aneurysm is often associated with AAA. In such cases, the bell-bottom procedure that preserves IIA circulation is a new alternative to the common practice of placement of endograft extensions across the iliac artery bifurcation in patients with at least one CIA diameter of less than 26 mm. Additional benefits include reduced total procedure time. Early technical success appears to justify continued use. However, long-term evaluation is necessary to determine durability because the risk of rupture as the result of potential expansion of the excluded iliac artery or late failure is unknown.

Use of aortic cuffs to exclude iliac artery aneurysms during AneuRx stent-graft placement: initial experience

PURPOSE

As many as 39% of patients who undergo aortic endografting for abdominal aortic aneurysm disease will have ectasia of the iliac arteries that will require intervention. Coil embolization of the internal iliac artery and extension of the graft to the external iliac artery is one solution to this problem. However, 19%-41% of these patients experience buttock claudication, which may be permanent, after unilateral embolization. The authors examined an alternative: the use of larger-sized aortic cuffs to seal the iliac limb. Outcomes and short-term results are presented in this article.

MATERIALS AND METHODS

From October 1999 to August 2000, 144 AneuRx stent-grafts were placed at the authors' institution. Among the population receiving stent-grafts, 14 patients had 15 aortic cuffs placed across the distal iliac graft limbs to seal them and preserve flow to the internal iliac artery. One patient had bilateral cuffs placed. Five patients had embolization of the contralateral internal iliac artery because of bilateral disease. Patients were followed with computed tomography (CT) at 1, 6, and 12 months to evaluate for endoleaks.

RESULTS

One- and 6-month endoleak rates, determined from only those patients with follow-up CT, were 0% and 10%, respectively. One type II endoleak was first discovered 9 months after graft placement. It sealed spontaneously at 15-month follow-up. One patient among the five who had internal iliac artery embolization had claudication. Mean CT follow-up was 7.8 months (range, 1-15). One patient declined CT but was alive and well 11 months after endografting. One patient moved across the country and declined follow-up.

CONCLUSION

Placement of aortic cuffs in dilated iliac arteries can preserve flow to the ipsilateral internal iliac artery and provide an adequate seal. Additionally, the option of later treatment is maintained. Patients with bilateral iliac ectasia can undergo stent-graft placement without bilateral internal iliac artery embolization. Longer-term follow-up in larger numbers of patients will be important to determine the ultimate durability of this technique.

Postoperative management: buttock claudication and limb thrombosis

As a result of endovascular repair of abdominal aortic aneurysms and the necessary associated adjunctive procedures, postoperative buttock claudication and limb thrombosis are complications that every physician who implants stent-grafts should be able to recognize and treat. Whereas the presenting complaints of these complications can be quite obvious, the treatment of them may be not so simple. Studies have shown that 28% of patients who underwent embolization of one or both hypogastric arteries develop buttock claudication. Yet 78% of these affected patients spontaneously resolve their symptoms. Strategies to both minimize and successfully treat this complication are obviously of the utmost importance. Likewise, limb thrombosis can be easy to recognize, but treatment strategies and methods to limit this complication can be quite complex and remain somewhat controversial. One center was able to reduce their limb thrombosis rate from 17% to 0% through the use of intravascular ultrasound and aggressive adjunctive stenting. The purpose of this article is to first review the data concerning these complications and then to discuss treatment strategies that are designed to minimize and treat the actual complication.

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms

PURPOSE

Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally.

METHODS

A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm.

RESULTS

Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months).

CONCLUSIONS

IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.

Sloughing of the scrotal skin and impotence subsequent to bilateral hypogastric artery embolization for endovascular aortoiliac aneurysm repair

Sloughing of the scrotal skin is an extremely rare event due to pelvic ischemia. We report herein one case of scrotal skin sloughing and impotence after bilateral hypogastric artery embolization for endoluminal aortoiliac aneurysm repair. Postoperative penile plethysmography demonstrated a 75% reduction in the penile brachial index, suggesting that pelvic ischemia is the main culprit for this complication. The devastating morbidity in our patient underscores the importance of maintaining pelvic collateral circulation when planning for endovascular aortoiliac aneurysm repair.

Clinical implications of internal iliac artery embolization in endovascular repair of aortoiliac aneurysms

To overcome constraints imposed by iliac artery anatomy, the anatomic inclusion criteria for endovascular aortic aneurysm repair can be extended by means of intentional coil occlusion of one or both internal iliac arteries and extension of the distal limb of the graft into an external iliac artery. We reviewed our experience with this intervention to determine the safety and efficacy of this approach to aneurysm repair. Over a 30-month period, 84 patients underwent endovascular abdominal aortic aneurysm repair; 23 underwent intentional unilateral (22) or bilateral (1) internal iliac artery occlusion. Morbidity, mortality, and long-term clinical outcomes were evaluated in these 23 patients. Patients were specifically questioned about exercise-induced buttock and extremity symptoms. Our results showed that intentional internal iliac artery embolization to allow endovascular repair of abdominal aortic aneurysms is accompanied by significant morbidity and should be approached with caution.

Internal iliac artery embolization before endovascular repair of abdominal aortic aneurysms: frequency, efficacy, and clinical results

OBJECTIVE

The aim of our study was to assess the frequency, efficacy, and incidence of adverse effects of internal iliac artery embolization.

MATERIALS AND METHODS

Of 343 patients examined for stent-graft repair, 147 were suitable for endovascular treatment. Fifty-five patients underwent preprocedural embolization of the internal iliac artery either unilaterally (46 patients) or bilaterally (nine patients). Successful embolization was assessed angiographically and with helical CT follow-up examinations. Colonic ischemia was ruled out clinically or colonoscopically. Buttock claudication, and sexual dysfunction in men, were evaluated through a questionnaire.

RESULTS

Embolization of the internal iliac artery increased by 16% the percentage of patients for whom endovascular repair was suitable. After successful embolization in all patients, routine CT follow-up examinations after a mean time of 16.7 months showed no evidence of endoleaks related to retrograde perfusion via embolized internal iliac arteries. Nevertheless, in all patients who had undergone embolization, a primary endoleak was detected in 43.4% at the first postoperative CT examination. None of our patients had evidence of colonic ischemia. Clinical follow-up data of 46 patients were available. Of these patients, mild to severe new onset buttock claudication was found in 13 (36.1%) of 36 patients with unilateral, and in eight (80%) of 10 patients with bilateral, internal iliac artery embolization (p = 0.03). Five (25%) of 20 men had an erectile dysfunction after the procedure.

CONCLUSION

Embolization of the internal iliac artery is a safe and efficient procedure that increases the applicability for endovascular repair of aortoiliac aneurysms. However, buttock claudication and erectile dysfunction are a drawback in a substantial number of patients.

Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm

The authors report a rare neurologic complication after the implantation of a bifurcated stent-graft for abdominal aortic aneurysm. The stent-graft was extended to both external iliac arteries after embolization of both internal iliac arteries. The patient subsequently had weakness and numbness of both lower limbs with bowel and bladder incontinence. He probably had ischemic injury to the nerve roots or the lumbosacral plexus, which was related to extensive occlusion of their supplying arteries. The mechanism of spinal cord and neurologic ischemia after aortic stent-graft implantation is discussed.

Hypogastric artery embolization in endovascular abdominal aortic aneurysm repair

PURPOSE

Iliac artery anatomy is a central factor in endoluminal abdominal aortic aneurysm therapy. It serves as the conduit for graft deployment and as the region of distal graft seal. Thirty-eight percent of iliac vessels in our patients require special treatment because of aneurysms, tortuosity, or small size. Bilateral hypogastric artery exclusion has been avoided because of concerns of colorectal ischemia, hip/buttock claudication, and impotence. We suggest that elective, staged, bilateral hypogastric embolization can be performed safely with reasonably low morbidity and can expand the anatomic boundaries for stent-graft abdominal aortic aneurysm repair.

METHODS

This study was performed as a retrospective chart review of patients requiring hypogastric artery embolization for endovascular repair of abdominal aortic aneurysms between June 1998 and June 2000. Patients with otherwise appropriate anatomy and common iliac artery aneurysms were informed of the option for stent-graft repair with internal iliac artery embolization with its risks of impotence, hip/buttock claudication, and bowel ischemia. Patients underwent unilateral or staged bilateral coil embolizations of their proximal hypogastric arteries with an approximate 1-week interval between procedures. Hospital and office records were reviewed; phone interviews were performed. Follow-up ranged from 1 to 12 months.

RESULTS

During a 24-month period, 65 patients underwent endovascular abdominal aortic aneurysm repair; 18 patients (28%) required hypogastric artery embolization. Seven (39%) of these patients underwent bilateral embolization. There were no episodes of clinically evident bowel ischemia. Lactate levels were normal in all measured patients. Postoperative fevers (> 101.0 degrees F) were documented in 10 (56%) of 18 patients. The average white blood cell count was 12.8 x 10(9)/L (range, 8.5-22.9). There were no positive blood culture results. The return to the full preoperative diet occurred in 1 to 3 days. Hip/buttock claudication occurred in approximately 50% of patients with persistent but improved symptoms at 6 months. Eighty-seven percent of patients had preoperative erectile dysfunction. Only two patients noted worsening of erectile function postoperatively.

CONCLUSIONS

Preliminary results indicate that bilateral hypogastric artery embolization can be performed, when necessary, with reasonable morbidity in patients undergoing stent-graft abdominal aortic aneurysm repair.

Balloon embolization of the internal iliac artery before aneurysm endograft deployment

Six patients, ranging from 69 to 81 years of age, underwent iliac artery embolization with use of Detachable Silicon Balloons (DSB) 11-14 days before stent-graft repair of aneurysms. Balloons of 8.8-mm, 9.4-mm, and 9.9-mm sizes were used with 20-30 g of release force. Deployment difficulty was experienced in three cases. Five of six cases were successful, with the iliac artery remaining occluded at the time of endografting; one case required subsequent coil replacement. The average operative time for balloon embolization (75 min +/- 28) was shorter than that in 18 cases of coil embolization performed within the same time period (111 min +/- 105), but the difference was not significant (P = .21). Postoperatively, one patient (17%) reported buttock claudication after the procedure. Use of the DSB represents an alternative to use of coils for embolization of large and tortuous iliac arteries.

Outcome after unilateral hypogastric artery occlusion during endovascular aneurysm repair

PURPOSE

The purpose of this study was to determine the long-term functional outcome after unilateral hypogastric artery occlusion during endovascular stent graft repair of aortoiliac aneurysms.

METHODS

During a 41-month period, 157 consecutive patients underwent elective endovascular stent graft repair of aortoiliac aneurysms with the Medtronic AneuRx device. Postoperative computed tomography scans were compared with preoperative scans to identify new hypogastric artery occlusions. Twenty-three (15%) patients had unilateral hypogastric occlusion, and there were no cases of bilateral occlusions. Telephone interviews about past and current levels of activity and symptoms were conducted, and pertinent medical records were reviewed. All 23 (100%) patients were available for the telephone interview. A disability score (DS) was quantitatively graded on a discrete scale ranging from 0 to 10 corresponding to "virtually bed-bound" to "greater-than-a-mile" exercise tolerance. Worsening or improvement of symptoms was expressed as a difference in DS between two time points (-, worsening/+, improving).

RESULTS

Among the 23 patients, two groups were identified: 10 patients (43%) had planned and 13 patients (57%) had unplanned or inadvertent occlusions. The patients in the two groups did not differ significantly in the mean age (73.4 vs 73.7 years), sex (male:female, 9:1 vs 10:3), and duration of follow-up (15.6 vs 14.4 months). Nine (39%) of the 23 patients, five patients in the planned and four patients in the unplanned group, reported significant symptoms of hip and buttock claudication ipsilateral to their occluded hypogastric arteries. The mean decrement from baseline of these nine patients in their DS postoperatively was -3.3. The symptoms were universally noted on postoperative day 1. Although most patients improved (89%), one (11%) never got better. Among those whose symptoms improved, the mean time to improvement was 15 weeks, but with a plateau thereafter resulting in a net decrement of DS of -2.3 from baseline. Finally, when questioned whether they would undergo the procedure again, all 23 patients unanimously answered, "Yes."

CONCLUSIONS

A significant number (39%) of patients who sustain hypogastric artery occlusion after endovascular aneurysm repair have symptoms. Although most patients with symptoms have some improvement, none return to their baseline level of activity. Despite this, all patients in retrospect would again choose endovascular repair over conventional open repair.

"Accordion" deformity of a tortuous external iliac artery after stent-graft placement

PURPOSE

To identify a complication of endograft deployment in aneurysmal iliac arteries.

CASE REPORT

A 71-year-old man was referred for endovascular treatment of a 60-mm-diameter right common iliac artery aneurysm; however, deployment of a homemade covered stent (Palmaz-Schatz and polytetrafluoroethylene) induced shortening of the tortuous external iliac artery, causing an "accordion" deformity. The anomaly proved difficult to treat with serial Wallstent deployment, because the convolution tightened and migrated caudally with each stent deployed, threatening outflow. Finally, after 3 Wallstents were implanted, the contour of the external iliac artery was straight, and flow was unimpeded. However, 3 weeks later, the external iliac artery had recoiled to its original redundant appearance, but flow remained satisfactory. The aneurysm remains excluded, with satisfactory distal flow after 24 months.

CONCLUSIONS

Implanting endografts in redundant, tortuous arterial segments may prove problematic, since induced straightening by the device precipitates kinking in the redundant system. Although treatment may be required in some situations, the vessels may return to a noncompressed state by removing the delivery system and guidewire.