How Safe is Bilateral Internal Iliac Artery Embolization Prior to EVAR?

Novel Strategies for the Hostile Iliac Artery during Endovascular Aortic Aneurysm Repair

Successful endovascular aneurysm repair can be achieved with favorable aortic and iliac arterial anatomies. However, patients with challenging iliac anatomy, such as stenotic, calcified, tortuous arteries, or concomitant iliac artery aneurysms, are commonly encountered. Such a hostile iliac anatomy increases the risk of intraprocedural complications and worsens long-term outcomes. This review addresses various technical options for treating patients with a hostile iliac anatomy, including innovative endovascular solutions, physician-modified endografts, and hybrid procedures. These considerations demonstrate the wide scope of therapies that may be offered to patients with an unfavorable iliac anatomy.

Effectiveness of the Rotarex Excisional Atherectomy System in Both Subacute and Chronic Aortoiliac Endograft Thrombosis: An Innovative Option for the Modern Endovascular Surgeon Toolkit

PURPOSE

To report a successful revascularization case using the Rotarex™S atherothrombectomy system in a recent iliac limb thrombosis, and chronic hypogastric stent obstruction after previous aortoiliac aneurysm endovascular repair (EVAR).

CASE REPORT

A 72-year-old patient was treated for recent right iliac limb thrombosis and left iliac branch chronic hypogastric stent occlusion, 5 years after EVAR. A total endovascular approach, using both upper extremity and femoral vascular access, was settled with 2 Rotarex™S (6Fr and 10Fr) devices. The Rotarex™S catheters removed most of the intraluminal material, allowing additional endografts and bare metal stents to be deployed to support a new healthy lumen surface.

CONCLUSION

The total endovascular approach provided by the Rotarex™S device appears to be safe and effective in treating aortoiliac endografts occlusions, both in subacute and chronic phases. Larger studies could highlight differences and eventual advantages compared with more traditional solutions.

Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis

BACKGROUND

Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA.

METHODS

Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate.

RESULTS

There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703).

CONCLUSIONS

The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

Failure to Preserve the Internal Iliac Artery During Abdominal Aortic Aneurysm Repair is Associated with Mortality and Ischemic Complications

OBJECTIVE

Open or endovascular repair of abdominal aortic aneurysms may involve the sacrifice of the internal iliac artery. The effect of internal iliac artery exclusion on ischemic complications and overall mortality was investigated.

METHODS

Data of 326 patients who underwent elective open surgical or endovascular treatment for a non-ruptured abdominal aortic aneurysm between January 2010 and December 2019 in a tertiary hospital were retrospectively reviewed. Ischemic complications included buttock claudication and spinal ischemia, including paraparesis, ischemic colitis, lower limb paresthesia, and skin necrosis. Their duration and mortality during this period were investigated.

RESULTS

Nearly 50% of patients (148; 45.4%) underwent endovascular aortic repair and 178 (54.6%) underwent open surgery. The median patient age was 78.00 years (range: 31-94 years). The median follow-up period was 1,140 days (range: 0-4,757 days). A total of 50 patients (15.3%) died during follow-up. Bilateral internal iliac arteries were preserved in 187 patients (57.4%); a single internal iliac artery was preserved in 86 patients (26.4%), and no internal iliac artery was preserved in 53 patients (16.3%). Ischemic complications occurred in 57 patients (17.5%). According to the multivariable analysis, failure to preserve bilateral internal iliac arteries (hazard ratio: 8.65, 95% confidence interval: 4.31-17.36, p<0.01), management of the internal iliac artery (hazard ratio: 3.05, 95% confidence interval: 2.17-4.28, p<0.01), and hyperlipidemia (hazard ratio: 2.09, 95% confidence interval: 1.04-4.17, p=0.04) affected ischemic complications. Further, according to the univariable analysis, patients experienced more ischemic complications when a single (hazard ratio: 6.97; 95% confidence interval: 3.74-13.02; p<0.01) or none of the internal iliac arteries were preserved (hazard ratio: 8.88; 95% confidence interval: 4.12-19.16; p<0.01) than when both internal iliac arteries were preserved. Moreover, according to the multivariable analysis, stage 5 chronic kidney disease (hazard ratio: 2.7, 95% confidence interval: 1.09-6.14, p=0.03), age > 75 years (hazard ratio: 2.48, 95% confidence interval: 1.12-5.49, p=0.03), cerebrovascular accident (hazard ratio: 1.95, 95% confidence interval: 1.00-3.78, p=0.05), and failure to preserve bilateral internal iliac arteries (hazard ratio: 1.91, 95% confidence interval: 1.02-3.46, p=0.04) were associated with higher mortality rates following abdominal aortic aneurysm repair.

CONCLUSIONS

Internal iliac artery exclusion is a risk factor for ischemic complications and overall mortality. Regarding abdominal aortic aneurysm repair, preservation of the internal iliac artery as much as possible is recommended.

Management of Postoperative Complications Following Endovascular Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) is a minimally invasive therapeutic approach to manage abdominal aortic pathologies (eg, aneurysm and dissection). EVAR was first introduced in 1991. In 1994, endovascular technique was also applied for thoracic aorta, thoracic endovascular aortic repair (TEVAR). In recent decades, EVAR has become an acceptable first-line treatment with 50% utilization rate across most practices, especially in high-risk patients. The safety profile of EVAR is comparable to the open approach, with superiority in terms of perioperative mortality and morbidity. This article summarizes the most common complications following EVAR/TEVAR and the most current treatment modalities across practices.

Outcomes of Hypogastric Coverage and Occlusion during Endovascular Treatment of Aortoiliac Occlusive Disease

BACKGROUND

The risk of hypogastric occlusion (HO) following bare-metal stent (BMS) coverage of the hypogastric origin during endovascular treatment of aortoiliac occlusive disease (AIOD) is unclear. This study sought to determine the rate and clinical significance of HO following BMS coverage during iliac stenting for complex AIOD.

METHODS

Consecutive patients undergoing elective iliac stenting for AIOD from 2010-2018 at Cleveland Clinic were reviewed. Patients with BMS coverage of a patent hypogastric origin were included. Rate of HO were determined by review of intraoperative angiography and follow up imaging. Predictors of HO were identified by univariable and multivariable logistic regression. Outcomes were compared between those who did and did not develop HO.

RESULTS

There were 251 patients (338 limbs) with BMS coverage of the hypogastric origin during treatment of AIOD. Lesion severity was classified as TASC C/D in 249/338 (73.7%) of cases. Bilateral hypogastric coverage occurred in 93/251 (37.1%) patients. Hypogastric patency was 78.1% at 24-months following coverage. Recanalization of an ipsilateral external iliac artery (EIA) occlusion was predictive of HO (HR 3.12, 95% CI: 1.33, 7.34; P= 0.009). Increased luminal diameter of the hypogastric origin protected against HO (HR 0.64; 95% CI: 0.47, 0.88; P= 0.006). Perioperative outcomes were no different between patients with and without HO. There were no cases of gluteal necrosis, spinal cord ischemia, or pelvic organ ischemia. Four-year mortality and limb salvage were not affected by HO. HO was associated with decreased primary patency of ipsilateral iliac stents and increased risk of ipsilateral reintervention (HR 5.49; 95% CI: 1.82, 16.58; P= 0.002).

CONCLUSIONS

HO is relatively infrequent following BMS coverage during treatment of AIOD. Luminal diameter of the hypogastric origin and ipsilateral EIA occlusion are associated with occlusion. HO is well tolerated in AIOD, though it is potentially associated with increased risk iliac stent occlusion and reintervention.

Spinal Cord Ischemia Following Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm

Spinal cord injury (SCI) following endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA) is a rare but serious complication. Case 1 presented with ruptured AAA and shock and underwent emergency EVAR. The patient developed incomplete paraplegia 2 days following EVAR. Case 2, diagnosed with impending rupture of AAA with extremely shaggy aorta, was treated with emergency EVAR. The patient was diagnosed with complete paraplegia soon after EVAR. Case 3 underwent elective EVAR and developed delayed paraplegia 2 weeks later. In EVAR, the etiology of SCI leading to paraplegia is often multifactorial. Surgeons must consider the possibility of SCI-induced paraplegia.

Internal iliac artery preservation outcomes of endovascular aortic repair for common iliac aneurysm: iliac branch device versus crossover chimney technique

OBJECTIVES

To compare the outcomes of using iliac branch devices (IBD) and the crossover chimney (COCh) technique for preserving the internal iliac artery (IIA) during endovascular aortic repair in patients with common iliac aneurysm (CIA).

METHODS

From February 2010 to July 2016, we recruited 61 consecutive and elective patients. Thirty of them received the IBD, and the remaining 31 received the COCh. Their medical chart was reviewed retrospectively, and computed tomographic angiography was performed at 3, 6, and 12 months postoperatively and then yearly as a follow-up.

RESULTS

The median follow-up time was 19.72 ± 5.45 months. The technical success rate reached 100% in both groups. The 12-month and 24-month primary IIA patency rates between IBD and COCh group were 90.00% versus 93.54% (p = 0.67) and 83.33% versus 93.54% (p = 0.25). The numbers of stents were 1.00 ± 0.00 and 1.93 ± 0.24 in the IBD and COCh group (p < 0.001). No significant difference was observed for the incidence of type 1a (IBD/COCh = 3.33%/6.45%, p > 0.99) and type 2 endoleak (IBD/COCh = 13.33%/12.90%, p > 0.99) between two groups. Neither type 1b or type 3 endoleak nor delayed aortic rupture appeared in our series. The postoperative complication rates did not exhibit significant differences either. Free from reintervention was also similar in both groups (IBD/COCh = 22.50 ± 4.62/23.00 ± 3.87 months, p = 0.64).

CONCLUSIONS

The IBD and COCh techniques exhibited similar success rates and IIA patency rates at the 24-month follow-up. Both these techniques are feasible for the preservation of IIA in patients with CIA.

Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair

BACKGROUND

Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea.

METHODS

We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale.

RESULTS

The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis.

CONCLUSIONS

Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

Is endovascular treatment of aorto-iliac aneurysms with simultaneous unilateral revascularization of internal iliac artery by branched iliac stentgraft sufficient?

AIMS

The coverage / occlusion of internal iliac artery (IIA) during endovascular treatment of aorto-iliac aneurysms (AIA) can be associated with risk of ischemic complications. To reduce these complications, unilateral or bilateral iliac branch device implantation (IBDI) has been reported. This study aims at evaluating the efficacy of simultaneous unilateral IBDI in the treatment of AIAs and comparing our results with literature.

MATERIALS AND METHODS

From March 2010 to December 2019, 27 patients (25 men, 2 women, range 54-84 years) were treated for aorto-iliac/isolated common iliac aneurysms with simultaneous unilateral revascularization of IIA and surgical / endovascular occlusion of contralateral IIA. 27 iliac-branched devices were implanted in 27 patients. The results including ischemic complications were evaluated and compared with literature.

RESULTS

The technical success was 100% with no perioperative mortality and morbidity of 3.7%. Primary internal iliac branch patency at a median follow-up of 52 months (range 1-118 months) was 96.42%. Secondary endoleak was observed in 6 patients (Type 1a [1], Type 1b [1], Type II [4]) and inflammatory complication in 1 patient. The incidence of buttock claudication one year after the procedure was 11.1%. Except for buttock claudication no other ischemic complications occurred.

CONCLUSION

Unilateral flow preservation in the IIA territory using IBDI is associated with a lesser, but a certain risk of ischemic complications. Bilateral IBDI with bilateral flow preservation of IIAs increases the complexity, procedure -/ fluoroscopy times, contrast agent volume and cost, however, may further reduce these ischemic complications.

[Embolization of the internal iliac artery during endovascular repair of abdominal aortic aneurysms]

An abdominal aortic aneurysm is one of frequently encountered cardiovascular diseases, which is often accompanied by an aneurysm of the common and/or internal iliac arteries. Recent trends are towards increased use of endovascular methods of treatment, associated with a certain risk for the development of type IIa endoleaks. This raises the question as to the necessity of embolization of the internal iliac artery while covering it with a stent graft. Our study included a total of 20 patients operated on for abdominal aortic aneurysms combined with aneurysms of the common and/or internal iliac arteries. In order to evaluate the obtained outcomes, the patients were divided into 4 groups depending on the intervention performed. The scope of the performed operations varied from endoprosthetic repair of an abdominal aortic aneurysm with coverage of one internal iliac artery without embolization to endoprosthetic repair of an abdominal aortic aneurysm with coverage of both internal iliac arteries with embolization. In the latter event, two-stage interventions were performed. The duration of follow up amounted to more than 3 years. We assessed the short- and long-term outcomes, with zero lethality and the absence of either specific or non-specific complications observed. Embolization increases the duration of the operation and X-ray exposure, as well as the amount of the contrast medium, thus casting doubt upon the necessity of carrying it out, since the immediate and remote results do not differ as compared with mere coverage of the internal iliac artery.

A Comparative Study of the Efficacy by using Different Stent Grafts in Bell-Bottom Technique for the Treatment of Abdominal Aortic Aneurysm Concomitant with Iliac Artery Aneurysm

BACKGROUND

Bell-bottom technique (BBT) is one method to preserve the internal iliac artery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) that extends to iliac artery. The data on the efficacy of this technique are still limited. We sought to evaluate the midterm efficacy of BBT by using different stent grafts in the treatment of AAA combined with iliac artery aneurysm (IAA).

METHODS

From January 2011 to December 2016, AAA patients with IAA using BBT to preserve the internal iliac artery were retrospectively analyzed in our institution. Patients were followed up at 3, 6, and then every 12 months after surgery. The outcomes among 3 types of stent grafts (Zenith, Excluder, and Endurant) were compared. BBT-related end points including type Ib endoleak, IAA sac expansion, distal neck expansion, and rupture during follow-up were compared. Other events including perioperative death, any other types of endoleak, and corresponding management were also documented.

RESULTS

A total of 125 patients with 141 IAAs were identified. Ninety-eight patients (78.4%) with 113 lesions (80.4%) received a median follow-up time of 38 months. The incidence of type Ib endoleak was 22.9%, 8.3%, 11.9%, and 14.2% (P = 0.19) in Zenith, Excluder, Endurant group, and total patients, respectively. The incidence of IAA sac enlargement was 17.1%, 5.6%, 7.1%, and 9.7% (P = 0.20). The incidence of IAA rupture was 8.6%, 0.0%, 0.0%, and 2.7% (P = 0.03). The incidence of IAA neck enlargement was 34.3%, 13.9%, 16.7%, and 21.2% (P = 0.07). Totally, 14 cases (10.7%) received further treatment for BBT-related issues.

CONCLUSIONS

Although BBT remains a safe and effective treatment option to preserve internal iliac artery during standard EVAR with acceptable complication rates in Asians, different IAA rupture rates were found among 3 different stent grafts. Our data for the first time revealed that the type of stent grafts has influence on the final clinical outcome. Based on that, iliac extension should be selected appropriately while treating AAA-IAA.

Endovascular Treatment of Concurrent Bilateral Common and Internal Iliac Artery Aneurysms with Preserved Pelvic Circulation: Bilateral Iliac Branch Devices with Opposing Single Division Internal Iliac Artery Sparing

An 83-year-old man with bilateral common iliac artery aneurysms (right, 3.0 cm; left, 2.7 cm), bilateral internal iliac artery aneurysms (right, 3.4 cm; left, 2.6 cm), and an abdominal aortic aneurysm (3.8 cm) was treated with an aortobi-iliac stent graft and bilateral iliac branch devices. The internal iliac components were extended into opposing posterior (left) and anterior (right) divisions of the internal iliac artery using stent grafts. Computed tomography angiography demonstrated that all aneurysms decreased or were stable in size with patent stent grafts at 1 month. The patient was asymptomatic without complications of pelvic ischemia at the last clinical follow-up at 6 months.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Novel Application of Branched Endograft for Preservation of Pelvic Circulation

BACKGROUND

Endovascular repair of a proximal anastomotic pseudoaneurysm (APSA) of an end-to-side aortobifemoral bypass (ABF) can lead to pelvic ischemia. We present a novel application of branched aortic endograft to repair such pseudoaneurysm while preserving flow into the ABF and native aortoiliac system.

METHODS

A 71-year-old male with history of aortoiliac occlusive disease resulting in lifestyle limiting claudication was treated with an aortobifemoral bypass in 1999. The patient developed an 8.8 cm pseudoaneurysm at the aortic anastomosis. CTA demonstrated patent right common and internal iliac arteries with an occluded right external iliac artery and occluded left common and external iliac arteries.

RESULTS

A 24 × 80 mm endograft with an 8 × 15 mm posterior branch based on the Cook Zenith device (Bloomington, IN) was delivered via a right femoral artery exposure. The preloaded wire of the main body was snared via left brachial access. A 10F sheath was advanced into the side branch of the graft to deliver a 10 × 10-mm Bard Fluency (Covington, Georgia) stent graft into the right common iliac artery. The branch was reinforced proximally with an 8 × 17 mm Boston Scientific Express (Marlborough, MA) stent. The patient was discharged after 5 days. At 1 month, CTA demonstrated patent ABF, patent branch graft into the pelvis, and exclusion of the pseudoaneurysm.

CONCLUSIONS

Branch grafts can provide minimally invasive revision of a failing ABF, in this case an APSA, while preserving pelvic circulation and lower extremity perfusion.

Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome

OBJECTIVE

Occlusion of the internal iliac artery (IIA) may be necessary prior to endovascular aneurysm repair (EVAR) to prevent endoleak Type II. We compared efficacy and clinical outcome after proximal occlusion of an unaffected IIA (ProxEmbx) using an Amplatzer vascular plug (AVP) I vs distal occlusion of aneurysmatic IIA with coils and plugs (DistEmbx).

METHODS

Between 2009 and 2012, 22 patients underwent EVAR. In 9 patients with unaffected IIA, occlusion was performed by a single AVP. In 13 patients with aneurysmatic IIA, more distal embolization (DistEmbX) was conducted by using several coils and additional AVPs. Retrospectively, technical success, clinical outcome and complications were evaluated.

RESULTS

Embolization of the IIA was successful in all patients. Three patients with more DistEmbX of aneurysmatic IIAs suffered from new onset of sexual dysfunction after occlusion without statistically significant difference (p > 0.05). Transient buttock claudication was observed in three patients in each group. Bowel ischaemia did not occur. The procedure time (p = 0.013) and fluoroscopy time (p = 0.038) was significantly lower in the ProxEmbx group than in the DistEmbx group.

CONCLUSION

Proximal occlusion of an unaffected IIA and more distal occlusion of an aneurysmatic IIA prior to EVAR had the same technical and clinical outcome. However, proximal plug embolization of an unaffected IIA prior to EVAR was associated with shorter procedure and fluoroscopy time in comparison with more DistEmbX of aneurysmatic IIAs. Advances in knowledge: Proximal embolization of unaffected IIA and DistEmbX of aneurysmatic IIA before EVAR are both effective in preventing Type II endoleaks and have the same technical and clinical outcome.

Outcomes of Extended Endovascular Aortic Repair for Aorto-Iliac Aneurysm with Internal Iliac Artery Occlusion

Objective: Patients of aorto-iliac aneurysms who undergo endovascular aortic repair (EVAR) require internal iliac artery (IIA) occlusion with coil embolization and its coverage with the stent graft to prevent type II endoleak after extending the endograft into the external iliac artery. However, it has become well recognized that IIA occlusion cause buttock claudication and other various sequelae due to pelvic ischemia. We retrospectively analyzed IIA occlusion outcomes.

Methods: From October 2008 to February 2015, 71 patients with aorto-iliac aneurysms underwent IIA occlusion prior to EVAR. The relationship between pelvic circulation and symptom of pelvic ischemia was studied.

Results: Buttock claudication occurred in 17 patients (22.9%) of all. Eight patients (14.8%) in unilateral IIA occlusion group (54 patients) and nine patients (52.9%) in bilateral IIA group (17 patients) had sequelae of claudication. The sacrifice of the communication of superior gluteal artery (SGA) and inferior gluteal artery (IGA) led to buttock claudication in 18 (64.3%) of 28 limbs. Instead, only 4 of 60 limbs had buttock claudication, when we preserved the communication between SGA and IGA. In all patients, staged treatment of aorto-iliac aneurysms with IIA occlusion and EVAR were done successfully without pelvic ischemic complications except for buttock claudication, and postoperative CT scanning showed no endoleakage.

Conclusion: IIA occlusion prior to EVAR is recognized as a safe and reasonable strategy. It is emphasized that preservation of the communication of SGA and IGA is important to prevent buttock claudication. (This is a translation of Jpn J Vasc Surg 2016; 25: 240–245.)

Staged Endovascular Repair of Isolated Bilateral Internal Iliac Artery Aneurysms: A Case Report

This report aims to present an unusual case with isolated bilaterally located internal iliac artery aneurysms (IIAAs) that were incidentally detected. Owing to the high surgical risk of the patient and anatomical location of the aneurysms, an endovascular management was preferred. Initially, the patient underwent a percutaneous embolization of the right-sided aneurysm with coiling. A stent-graft deployment covering the orifice of the left-sided internal iliac artery and occluding the ipsilateral aneurysm followed 1 month later. The patient remains asymptomatic after 6 months. Endovascular management has been associated with lower morbidity and hospital stay compared with open repair for IIAAs, although both techniques show satisfying early and mid-term results. Especially for bilaterally located aneurysms, a staged strategy decreases the risk for ischemic complications. Finally, endovascular methods should be preferred when there are no compression symptoms or in cases of higher surgical risk.

Embolization or Simple Coverage to Exclude the Internal Iliac Artery During Endovascular Repair of Aortoiliac Aneurysms? Systematic Review and Meta-analysis of Comparative Studies

Purpose: To compare results of simple coverage vs preemptive embolization to exclude the internal iliac artery (IIA) during endovascular repair of aortoiliac aneurysms. Methods: A systematic review of the literature was conducted by searching MEDLINE, CENTRAL, and OpenGray databases until March 2016. Primary outcome measures were safety and efficacy of the 2 strategies. Safety was determined by 30-day mortality and the minor and major complication rates. Efficacy was determined by absence of endoleak from the target IIA. Secondary outcomes of any endoleak, reintervention, operative time, fluoroscopy time, blood loss, contrast volume, and length of hospitalization were also examined. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI). Forest plots and inconsistency ( I2) statistics were used to evaluate the heterogeneity of the included studies. Results: Eight observational studies were included in the analysis. Overall, 284 and 255 subjects underwent IIA coverage or embolization, respectively. IIA coverage resulted in a significantly lower major complication rate (6% vs 29%; OR 2.97, 95% CI 1.46 to 6.04, p=0.003; I2=0%) and shorter hospitalization (MD 0.48 days, 95% CI 0.08 to 0.89, p=0.02; I2=0%), while differences in all other outcomes were not statistically significant. Conclusion: In the presence of limited data, available evidence suggests that simple coverage of the IIA may result in significantly fewer major complications compared to preemptive embolization; at the same time, the rates of endoleaks and/or reinterventions are similar between groups.

Patency of the Internal Iliac Artery after Placement of Common and External Iliac Artery Stents

BACKGROUND

Treatment of severe aortoiliac occlusive disease (AIOD) frequently requires long-segment stenting of the common and external iliac arteries (CIA and EIA, respectively). This study aims to analyze the patency of the internal iliac artery (IIA) after placement of a CIA and EIA stents across the orifice.

METHODS

A retrospective analysis of all patients who underwent de novo ipsilateral stent placement in the CIA and EIA between 2006 and 2013 was performed. Kaplan-Meier analysis was used to analyze patency of the IIA, and Cox proportional hazard models were used to identify characteristics associated with occlusion.

RESULTS

We identified 77 patients and 93 limbs where ipsilateral CIA and EIA stents were placed. Preintervention angiographic review found 52 cases of a patent ipsilateral IIA where stents were placed across the origin of the IIA in 31 cases and staggered across the orifice in 20 limbs. Kaplan-Meier analysis demonstrated a 37% patency in limbs where the stent covered the IIA orifice compared to 78% patency in uncovered arteries (P = 0.04). New-onset buttock claudication developed in 4 patients, 2 with patent IIAs and 2 with occluded. New-onset impotence also developed in 3 patients with occluded IIA and 5 patients with patent IIAs.

CONCLUSIONS

Placement of stents across the origin of the IIA may not result in immediate occlusion, but long-term patency of covered IIAs is decreased compared to uncovered IIAs. This study is limited by a small sample size, but when treating AIOD, coverage of the internal iliac origin should be avoided to maintain patency of the pelvic circulation.

Clinical and Functional Impact of Hypogastric Artery Exclusion During EVAR

PURPOSE

Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center.

METHODS

We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction.

RESULTS

From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05).

CONCLUSIONS

Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.

Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms

AIM

The aim was to conduct a systematic review of the literature investigating outcomes after interruption or preservation of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR).

METHODS

A systematic review was undertaken using the MEDLINE and EMBASE databases to identify studies reporting IIA management during EVAR. The search identified 57 articles: 30 reported on IIA interruption (1468 patients) and 27 on IIA preservation (816 patients).

RESULTS

The pooled 30 day buttock claudication (BC) rate was 29.2% (95% CI 24.2-34.7). Patients undergoing bilateral IIA interruption had a higher incidence of BC than patients with unilateral IIA interruption (36.5% vs. 27.2%, OR 1.7, 95% CI 1.11-2.6, p = .01). During a median follow up of 17 months, the pooled rate of persistent BC was 20.5% (95% CI 15.7-26.2). Of the patients, 93.9% underwent an endovascular revascularization procedure for IIA preservation. Most patients (87.6%) had an iliac branched device, and technical success was 96.2%. Within 30 days of EVAR, 4.3% of internal iliac branches occluded. During a median follow up of 15 months, the pooled occlusion rate at the site of IIA revascularization was 8.8% (95% CI 6.8-11.3). In patients treated with an iliac-branched device, 5.2% of internal iliac branches and 1.7% of external iliac arteries occluded. The pooled BC rate on the side of the IIA revascularization during follow up was 4.1% (95% CI 2.9-5.9). Pooled rates of late device related endoleak type I or III and secondary procedures on the side of the previous IIA revascularization were 4.6% (95% CI 3.2-6.5) and 7.8% (95% CI 5.7-10.7) respectively.

CONCLUSION

Unilateral or bilateral IIA occlusion during EVAR seems to carry a substantial risk of significant ischemic complications in nearly one quarter of patients. Bilateral IIA occlusion was related to a significantly higher rate of BC. IIA preservation techniques represent a significant improvement in the treatment of aorto-iliac aneurysms and have been associated with high technical success and low morbidity.

Risk Factor Analysis for Buttock Claudication after Internal Iliac Artery Embolization with Endovascular Aortic Aneurysm Repair

Purpose:

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) involving the common iliac artery requires extension of the stent-graft limb into the external iliac artery. For this procedure, internal iliac artery (IIA) embolization is performed to prevent type II endoleak. In this study, we investigated the frequency and risk factor of buttock claudication (BC) in patients having interventional embolization of the IIA.

Materials and Methods:

From January 2010 to December 2013, a total of 110 patients with AAA were treated with EVAR in our institution. This study included 27 patients (24.5%) who had undergone unilateral IIA coil embolization with EVAR. We examined hospital charts retrospectively and interviewed by telephone for the occurrence of BC.

Results:

Mean age of total patients was 71.9±7.0 years and 88.9% were males. During a mean follow-up of 8.65±9.04 months, the incidence of BC was 40.7% (11 of 27 patients). In 8 patients with claudication, the symptoms had resolved within 1 month of IIA embolization, but the symptoms persisted for more than 6 months in the remaining 3 patients. In univariate and multivariate analysis, risk factors such as age, sex, comorbidity, patency of collateral arteries, and anatomical characteristics of AAA were not significantly related with BC.

Conclusion:

In this study, BC was a frequent complication of IIA embolization during EVAR and there was no associated risk factor. Certain principles such as checking preoperative angiogram, proximal and unilateral IIA embolization may have contributed to reducing the incidence of BC.

How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review

PURPOSE

Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications.

METHODS

We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia.

RESULTS

Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive.

CONCLUSIONS

We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

Endovascular Treatment of Isolated Bilateral Common Iliac Artery Aneurysms Using Iliac Branched Stent Graft

Endovascular treatment of isolated bilateral common iliac artery aneurysm (CIAA) requires salvage of at least one internal iliac artery to prevent complications such as ischemic buttock claudication. We treated a case of bilateral CIAAs using an internal iliac branched stent graft. We report a case of a 58-year-old man who presented with bilateral CIAAs. The left internal iliac artery was occluded with coil embolization. The right internal iliac artery was saved by using a branched stent graft. The aneurysms were excluded with conventional endovascular aneurysm repair. Completion angiography showed technical success. Follow up computed tomography angiogram at three months showed complete exclusion of bilateral CIAAs, no endoleaks, and patent right internal iliac artery. There was no pelvic ischemic complication. We treated successfully a case of isolated bilateral CIAAs using an iliac branched stent graft.

8-Year Long-Term Outcome Comparison: Two Ways to Exclude the Internal Iliac Artery during Endovascular Aorta Repair (EVAR) Surgery

Purpose

To evaluate the 8-year long-term outcome after internal iliac artery (IIA) coverage with or without embolization in EVAR.

Patients and Methods

From January 2006 to December 2013, abdominal aortic aneurysm (AAA) subjects that underwent EVAR and IIA exclusion were recruited and analyzed retrospectively. All the subjects were divided into group A or B based on the presence or absence of intraoperative IIA embolization before coverage (group A: without embolization; group B: with embolization). The 30-day mortality, stent patency, and the incidences of endoleaks and ischemia of the buttocks and lower limbs were compared. The follow-up period was 96 months.

Result

There were 137 subjects (A: 74 vs. B: 63), 124 male (91.1%) and 13 female (9.5%), with a mean age of 71.6 years. There were no significant differences in the early outcomes of intraoperative blood loss (87.23±14.07 ml; A: 86.53±9.57 ml vs. B: 88.06±18.04 ml, p = .545) and surgery time (87.13±9.25 min; A: 85.99±7.07 min vs. B: 88.48±11.19 min, p = .130). However, there were significant differences in contrast consumption (65.18±9.85 ml; A: 61.89±7.95 ml vs. B: 69.05±10.50 ml, p<.001) and intraoperative X-ray time (5.9±0.86 min; A: 5.63±0.49 min vs. B: 6.22±1.07 min, P<.001). The 30-day mortality was approximately 0.73%. In the follow-up analysis, no significant differences were identified in the incidence of endoleak (22 subjects; type I: A: 2 vs. B: 2, p = 1.000; type II: A: 8 vs. B: 4, p = .666; type III: A: 4 vs. B: 3, p = 1.000), occlusion (5 subjects; 4.35%; A: 1 vs. B: 4, p = .180), or ischemia (9 subjects; 7.83%; A: 3 vs. B: 6, p = .301). In the analysis of group B, although there were no significant differences between subjects with unilateral and bilateral IIA embolization, but longer hospital stays were required (P<.001), and a more severe complication (skin and gluteus necrosis) occurred in 1 subject with bilateral IIA embolization.

Conclusion

IIA could be excluded during EVAR. IIA coverage without embolization had a good surgical and prognostic outcome, and this procedure was not different significantly from coverage with embolization in terms of endoleaks, patency and ischemia.

Iliac anatomy and the incidence of adjunctive maneuvers during endovascular abdominal aortic aneurysm repair

Purpose

Challenging iliac anatomy remains an important issue during endovascular aneurysm repair (EVAR), and it is known that the length of the common iliac artery (CIA) is shorter in Asians than in Western groups. We analyzed both the iliac anatomy and the incidence of adjunctive maneuvers to overcome iliac artery-related difficulties during EVAR.

Methods

Seventy-four EVARs were performed for abdominal aortic aneurysm between January 2010 and March 2013. Patient demographic data, iliac anatomical characteristics (presence of iliac artery aneurysm, iliac artery diameter and length, and iliac tortuosity), and adjunctive iliac artery maneuvers were reviewed retrospectively.

Results

Mean CIA length was 52.8 mm (range, 6.6-98.0 mm) on the right and 56.3 mm (range, 0-94.8 mm) on the left. CIA length was ≥20 mm, except in one patient with bilateral short CIAs. Forty patients (54%) had a CIA aneurysm, and 18 had aneurysms on both sides. Iliac adjunctive procedures were performed in 38 patients (51%) as follows: 23 internal iliac artery (IIA) embolizations or ligations, seven IIA revascularizations, 16 external iliac artery (EIA) balloon angioplasties or stenting, one EIA patch angioplasty, one EIA interposition, two femoral endarterectomies with patch angioplasty, and nine femoro-femoral bypasses after EVAR with an aorto-uni-iliac device. Technical success for the adjunctive iliac procedures was achieved in all patients.

Conclusion

Short CIA length was uncommon. Although many patients had access-related difficulties, most were overcome by an endovascular or hybrid technique. Liberal use of iliac adjunctive procedures can facilitate EVAR.

Endovascular repair with contralateral external-to-internal iliac artery bypass grafting: a case series

BACKGROUND

To report a technique of keeping unilateral blood flow in the internal iliac artery in cases of an abdominal aortic aneurysm in achieving successful Endovascular abdominal aortic aneurysm repair using an external-to-internal artery bypass.

CASE PRESENTATION

6 japanese patients with infra-renal abdominal aortic aneurysms were treated using the retroperitoneal approach via a left (right) paramedian incision followed by an external-to-internal artery bypass. Endovascular abdominal aortic aneurysm repair was conducted on mean postoperative day 29 ± 18 and was performed because the contralateral internal iliac artery, which was not involved in the external-to-internal artery bypass, was treated with a coil embolization. No complications developed during the postoperative follow-up period (17 ± 1.5 months). In all 6 patients, patent grafts were evident on computed tomography angiography scans even after 1-3 months.

CONCLUSIONS

Endovascular abdominal aortic aneurysm repair with unilateral internal iliac artery embolization and contralateral external-to-internal artery bypass is feasible with a relatively low risk. It is a safe procedure and reduces the incidence of postoperative complications.

Crossover chimney technique to preserve the internal iliac artery during endovascular repair of iliac or aortoiliac aneurysms: midterm results

PURPOSE

To report our midterm results of the crossover chimney technique to preserve the internal iliac artery (IIA) in patients with aortoiliac aneurysms (AIA) and isolated common iliac artery aneurysms (CIAA).

METHODS

Between May 2012 and January 2014, 14 consecutive patients (mean age 77.3 years; all men) with 17 AIA, isolated CIAAs, or abdominal aortic aneurysms with short CIAs underwent elective endovascular aneurysm repair (EVAR) with the crossover chimney technique to preserve the IIA. Follow-up assessment, including computed tomographic angiography or duplex ultrasound, was performed at 1, 6, and 12 months and annually thereafter.

RESULTS

Technical success, defined as successful preservation of IIA without intraoperative type I or III endoleak, was 100%. Over a mean 14.3 months (range 6-21), primary patency was 92.8%. There was no early or late procedure-related mortality. Among the 17 iliac aneurysms excluded, the sac diameter significantly (at least 5 mm) decreased in 3, decreased <5 mm in 10, and did not change in 4.

CONCLUSION

The crossover chimney technique is a simple and safe alternative for IIA endovascular revascularization with high technical success and acceptable midterm patency.

Complex common and internal iliac or aortoiliac aneurysms and current approach: individualised open-endovascular or combined procedures

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates.

Preservation of pelvic circulation in one-stage endovascular repair of bilateral hypogastric artery aneurysms

Bilateral hypogastric artery aneurysms (HAAs) are relatively rare conditions that pose increased management difficulties. We report a case of one-stage endovascular repair of bilateral HAAs preserving pelvic circulation. A 67-year-old asymptomatic man with bilateral HAAs (4-cm right and 3.9-cm left) was successfully treated with an endovascular approach. The aneurysmal sac of the right hypogastric artery (HA) was embolized first and 2 covered stent grafts were deployed into the HA. Coil embolization of the left HAA was then performed followed by deployment of a covered stent graft to the common and external iliac arteries. Final angiography revealed complete exclusion of the aneurysms without endoleaks and with preservation of the pelvic flow. At the 18-month follow-up, the patient remained asymptomatic with good patency of the stent grafts. This case demonstrates an alternative endovascular approach for the treatment of bilateral HAAs that minimizes the risk of ischemic complications by preserving pelvic circulation.