Anatomic Suitability of Aortoiliac Aneurysms for Next Generation Branched Systems

Dilated Internal Iliac Artery Confers a Higher Risk of Endoleak in Iliac Branch Devices in a Single Centre Retrospective Experience

OBJECTIVE

Iliac branch devices (IBDs) have shown good results but there is little evidence for the risk of internal iliac artery (IIA) endoleak, so there are no clear recommendations on the maximum diameter it should be. Based on limited evidence, it was hypothesised that an IIA of ≥ 11 mm in diameter presents an increased risk of type Ic endoleak.

METHODS

This was a single centre, retrospective case control study. Patients undergoing an IBD with the main trunk of the IIA as the target vessel, between 2015 and 2021, were identified. Two groups were created: those with a main trunk diameter of < 11 mm; and those with a diameter of ≥ 11 mm. Technical success, freedom from type Ic endoleak, and re-intervention rates were compared. A receiver operating characteristic (ROC) curve was performed to show a cutoff IIA diameter value for risk of type Ic endoleak. Multivariate analysis was performed to assess the risk of type Ic endoleak and the presence of calcification, stenosis, and landing zone length in the IIA.

RESULTS

There were 182 IBDs identified. The dilated IIA group (54 IBDs) had significantly lower technical success (91% vs. 98.4%; p = .002), lower freedom from type Ic endoleak (77% vs. 97.1% at 24 months; p = .001), and lower freedom from re-interventions (70% vs. 92.4% at 24 months; p = .002). The ROC curve showed that 10.5 mm was the cutoff diameter for type Ic endoleak. Moderate or severe calcification as well as landing zone length < 5 mm also correlated with type Ic endoleak.

CONCLUSION

IBDs have a statistically significantly higher rate of technical failure, lower freedom from type Ic endoleak, and lower freedom from re-intervention when the IIA is ≥ 11 mm in diameter.

Endovascular repair of bilateral isolated common iliac artery aneurysms with unsuitable anatomy utilizing an aortic bifurcated unibody endograft and modified sandwich technique to preserve pelvic blood flow: a case series

Bilateral isolated common iliac artery aneurysms (CIAAs) are rare, and endovascular repair of CIAAs has emerged as an alternative to traditional open surgical repair. The primary goal of therapy is to exclude the aneurysm sac while maintaining perfusion of at least one internal iliac artery (IIA) to prevent pelvic ischemia. Although the iliac branch device (IBD) has improved the feasibility of preserving the IIA, its applicability is limited to a specific subset of aneurysm anatomy. We present a case series of three patients with bilateral isolated CIAAs in whom preoperative CT scans revealed an absence of a landing zone, the diameter of proximal CIA diameter was less than 13.0 mm, and normal diameter of the nonaneurysmal infrarenal aorta, making it challenging to use an IBD alone or a standard bifurcated aortic endograft to provide a proximal landing zone for iliac artery stenting. To overcome the small diameter of the infrarenal aorta, we implanted an aortic bifurcated unibody endograft. Then, we utilized a balloon-expandable covered stent-graft with overdilation as a modified sandwich technique to create an "eye of the tiger" configuration to prevent gutter leakage. The final angiography performed during the procedure revealed successful exclusion of the aneurysms, with blood flow to the right IIA and no type III endoleak. During the postoperative follow-up period, no patients exhibited symptoms associated with pelvic ischemia. There were no endoleaks or sac expansions on the two-year follow-up CT scans, and all external and internal iliac graft limbs were patent. This study demonstrated that a combination of an aortic bifurcated unibody endograft and a modified sandwich technique can effectively treat bilateral isolated CIAAs with certain anatomical constraints.

Outcomes of "Anterior Versus Posterior Divisional Branches of the Hypogastric Artery as Distal Landing Zone for Iliac Branch Devices": The International Multicentric R3OYAL Registry

OBJECTIVE

The aim of this multicentric registry was to assess the outcomes of "anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL)."

METHODS

The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability.

RESULTS

A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P = .18). Occurrence of any adverse event was noted in 14% of patients in both groups (P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001).

CONCLUSIONS

The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA.

CLINICAL IMPACT

The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.

Hybrid Pelvic Revascularization in Complex Aortoiliac Aneurysm Repair

Revascularization of complex pelvic vascular anatomy presents an ongoing clinical challenge when treating aortoiliac disease. As vascular surgeons continue to intervene upon increasingly complex aortoiliac pathology, the role of pelvic revascularization is important for the preservation of pelvic organ function and prevention of devastating spinal cord ischemia. In this study we describe the indications, techniques, and clinical outcomes of a novel hybrid pelvic revascularization repair that focuses on optimizing revascularization while limiting pelvic surgical dissection during the management of complex aortic pathology in patients physiologically or anatomically unsuitable for traditional pelvic revascularization techniques.

Technical Feasibility and Safety of a Snare-Less, EVAR-First Technique for Iliac Branch Endoprosthesis

OBJECTIVE

The purpose of this study was to evaluate the technical feasibility, safety, and early outcomes of a snare-less, endovascular abdominal aortic aneurysm repair (EVAR)-first technique (SET) for iliac branch endoprosthesis (IBE) placement.

METHODS

We retrospectively reviewed all patients who received IBEs between July 2018 and March 2022. Patients were divided into 2 categories based on method of IBE deployment: SET or Standard. Primary endpoints were technical success, major adverse events, mortality, reintervention, internal iliac artery (IIA) patency, and freedom from IIA branch instability. Technical success was defined by successful deployment of both the EVAR and the IBE with maintained patency of the IIA and no stent graft migration.

RESULTS

There were 20 patients (90% male, median age 72 [65.4-74.5] years) who underwent IBE placement. Among these, 5 (33.3%) underwent SET to treat 5 common iliac artery (CIA)/IIA aneurysms, while the remaining 15 (66.7%) underwent standard IBE deployment with through-and-through femoral access (n=13) or trans-brachial access (n=2) to treat 19 CIA/IIA aneurysms. Overall median renal to iliac bifurcation length was 169 (152-177) mm, with 9 patients falling short of the minimum of 165 mm for on-label IBE placement. Median contrast used was 148 (120-201) mL, fluoroscopy time 42.8 (35.0-49.8) minutes, estimated blood loss 200 (100-275) mL, and procedure time 192 (167-246) minutes, with no significant differences between the 2 groups. Technical success was achieved in 100% of cases. At 30 days, there were no mortalities or major adverse events in either group; there were 100% IIA patency, no IIA instability, and no reinterventions in both groups. Median follow-up in the SET group was 5.7 (5.5-6.2) months, with 1 death at 6 months and 1 type 1B endoleak at 6 months requiring reintervention. Median follow-up for the Standard group was 1.6 (0.8-2.1) years with 2 non-aneurysm-related deaths and no reinterventions at 1 year.

CONCLUSIONS

SET for IBE is a safe and effective approach that decreases technical complexity and mitigates anatomic barriers to IBE placement.

CLINICAL IMPACT

SET for IBE is a safe and effective approach to IBE placement that decreases technical complexity. A critical component to this technique is a large bore sheath with a stiff steerable tip. Importantly, this approach also mitigates anatomic barriers to IBE placement, expanding applicability of IBE technology to patients who may be otherwise ineligible.

Novel Surgeon-Modified Fenestrated Iliac Stent Graft

PURPOSE

We describe the feasibility and early results of a novel endovascular approach with a surgeon-modified fenestrated iliac stent graft to preserve pelvic perfusion in patients with iliac aneurysms not suitable for iliac branch devices (IBDs).

TECHNIQUE

Seven high-risk patients, median age 76 years (range 63-83), with a complex aortoiliac anatomy with contraindications for commercially available IBDs were treated with a novel surgeon-modified fenestrated iliac stent graft between August 2020 and November 2021. The modified device was built using an iliac limb stent graft (Endurant II Stent Graft; Medtronic), which was partially deployed, surgically fenestrated with a scalpel, reinforced, re-sheathed, and inserted via femoral access. The internal iliac artery was cannulated and bridged with a covered stent. Technical success rate was 100%. After a median follow-up period of 10 months, there was 1 type II endoleak and no migrations, stent fractures, or loss of device integrity. One iliac limb occlusion occurred after 7 months, which needed a secondary endovascular intervention, restoring patency.

CONCLUSION

Surgeon-modified fenestrated iliac stent graft is feasible and might be used as an alternative in patients with a complex iliac anatomy not suitable to commercially available IBDs. Long-term follow-up is needed to evaluate stent graft patency and potential complications.

CLINICAL IMPACT

Surgeon modified fenetrated iliac stent grafts might be a promising alternative to iliac branch devices, extending endovascular solutions to a broader patient population with complex aorto-iliac anatomies preserving antegrade internal iliac artery perfusion. It is possible to treat small iliac bifurcations and large angulations of the iliac bifurcation safely and there is no need for a contralateral or upper-extremity access.

Midterm Results of a Surgeon-Modified Device to Preserve the Flow of the Internal Iliac Artery During Endovascular Repair of Aneurysm: Single-Center Experiences

BACKGROUND

During endovascular aneurysm repair (EVAR), commercial iliac branch devices (IBDs) have become an inescapable alternative for preserving antegrade internal iliac artery (IIA) blood flow. Due to the different morphological features of aneurysms, commercial IBDs may not be suitable for all patients. Reported experience with the implantation of the new surgeon-modified IBD (sm IBD) is limited. This investigation describes the indications, efficacy, and safety of the sm IBD.

METHODS

Data from consecutive elective implantations of IBDs in patients between March 2011 and May 2021 in a single center were incorporated. The sm IBDs were indicated in patients with common iliac artery aneurysms (CIAAs) and with a challenging anatomy and in those patients with or without abdominal aortic aneurysm (AAA).

RESULTS

Fifteen patients (15 male, mean age 67.6 ± 7.9 years) were included. Fifteen sm IBDs were implanted in 1 procedure (100%). Fourteen (93.3%) patients had simultaneous endovascular aneurysm repair (EVAR) and 1 (6.7%) patient previously had a bilateral CIAAs repair by EVAR. The mean common iliac artery (CIA) diameter was 36.6 ± 12.5 mm. Technical success was obtained in all patients (100%). The median operation time was 189.7 ± 78.6 min, with a median fluoroscopy time of 45.3 ± 15.9 min. Axillary artery access was used in 11 (73.3%) procedures. The mean total hospital stay was 5.6 ± 2.8 days, and the postoperative follow-up was 35.4 months (range 2-120). The estimated IIA bridge stent patency at 1 year after operation was 100% and 85.7% ± 13.2% 5 years postoperatively. One (6.7%) IIA branch was occluded, and this patient remained asymptomatic. One patient (6.7%) needed reintervention, and another (6.7%) patient had type II leakage, which is currently under close surveillance.

CONCLUSIONS

Using an IBD to maintain the pelvic blood flow is an effective and feasible intravascular technique, especially for patients with an abnormal iliac artery anatomy. This novel technique has similar midterm procedural success rate compared to the use of commercial IBDs. Therefore, these devices are more suitable for patients with certain anatomic challenges and can be used as an alternative treatment.

Internal iliac artery preservation during endovascular aortic repair using in situ laser fenestration

OBJECTIVE

The purpose of the present study was to evaluate the technical and short-term clinical outcomes of internal iliac artery (IIA) reconstruction during endovascular aortic repair (EVAR) with in situ laser-assisted fenestration in cases of abdominal aortic aneurysm (AAA) in which the iliac artery is unfit for an internal branched device (IBD).

METHODS

In the present single-institution retrospective study, we analyzed patients with AAAs who had undergone EVAR with in situ laser-assisted fenestration for IIA reconstruction between January 2018 and April 2021. The study included patients with iliac artery anatomy unfit for the use of commercial IBDs. The primary safety end point was freedom from major adverse events and unplanned reinterventions within 30 days. The primary efficacy end point was freedom from IIA restenosis, reintervention, and symptoms due to pelvic ischemia at 1 year after the procedure.

RESULTS

A total of 20 patients requiring IIA reconstruction but with anatomy unfit for IBD placement were treated with in situ laser-assisted fenestration during EVAR for aortoiliac aneurysms during the study period. The mean age of our patients was 72 years, and 90% were men. The technical success rate was 100%. No patient had died within 30 days after the procedure. A suspicious IIA perforation had occurred in one patient, which was treated with an additional covered stent, for a primary safety end point of 95.0%. After a mean follow-up of 11 months, all except for one of the reconstructed IIAs were patent. Three patients reported symptoms of buttock claudication on the IIA occluded side at their 3-month follow-up after the procedure. However, these symptoms had subsided in two of these patients at 6 months. Type II endoleaks without sac expansion had occurred in two patients owing to retrograde blood flow from the inferior mesenteric artery and lumbar artery. Both patients were kept under close surveillance. The rate of freedom from major adverse events and unplanned reinterventions within 30 days (primary efficacy end point) was 86.3% at 1 year after procedure.

CONCLUSIONS

In situ laser-assisted fenestration was found to be a safe and effective alternative method for IIA reconstruction during EVAR for aortoiliac aneurysms in patients with anatomy unfit for IBD.

External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm

OBJECTIVE

Aneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE).

METHODS

Using the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb <20 mm; group 2, BBT with either a unilateral or bilateral limb >20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak.

RESULTS

The records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was -7.2 mm, -6.1 mm, -4.6 mm, and -6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group.

CONCLUSIONS

The present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

Successful endovascular repair of iliac artery aneurysms with unsuitable anatomy by combining unibody bifurcated endograft and iliac branch systems to preserve hypogastric artery blood flow: a report of two cases

Background

To overcome the anatomical limitation of a narrow aorta and short length from the renal artery to the terminal aorta, unibody endograft AFX2 and iliac branch endoprosthesis (IBE) can be combined.

Case presentation

Case 1: The first patient was an 89-year-old woman who had a right saccular common iliac artery (CIA) aneurysm (38 mm); the abdominal aorta was not aneurysmal (diameter, 19 mm). The right CIA’s origin was 10 mm in diameter. A bifurcated AFX2 was placed in an ordinary manner. Then, IBE was inserted in the right leg of the AFX2. Case 2: The second patient was an 87-year-old man diagnosed with an abdominal aortic aneurysm (55 mm), right dissecting CIA aneurysm (20 mm), and right hypogastric artery aneurysm (22 mm) extending to the bifurcation of the superior and inferior gluteal arteries. The length between the renal artery and terminal aorta was 107 mm. The beginning of the right CIA was segmentally stenotic (13 mm). A bifurcated AFX2 was placed in the infrarenal aorta; IBE was advanced to the origin of the right limb of the AFX2. To control the type 1b endoleak, the right superior gluteal artery was embolized with coils and internal iliac components were deployed toward the inferior gluteal artery. Satisfactory results were obtained in both cases.

Conclusion

The AFX2 main body and IBE could be combined to preserve hypogastric blood flow and overcome anatomical limitations.

In-vitro and In-silico Haemodynamic Analyses of a Novel Embedded Iliac Branch Device

Background

Iliac branch devices (IBDs) are valid tools for internal iliac artery preservation during endovascular abdominal aortic aneurysm and iliac aneurysm repair. The purpose of this study was to evaluate the effectiveness of a novel IBD with an embedded branch configuration.

Method

A typical iliac artery model was reconstructed, and two models were manufactured using three-dimensional printing technology. The novel IBD was deployed into one iliac artery model by an experienced vascular surgeon. A mock circulation loop (MCL) and a computational fluid dynamics (CFD) simulation were used to investigate the haemodynamic parameters of the iliac models without (Model A) and with (Model B) the IBD. A morphological analysis was conducted using computed tomography angiography and medical endoscopy. The flow distribution rate (FDR) and energy loss (EL) were used to quantify IBD performance.

Results

The FDR of the right internal iliac artery in the MCL of Model A and Model B was 18.88 ± 0.12% and 16.26 ± 0.09%, respectively (P = 0.0013). The FDR of the right internal iliac artery in the CFD simulation of Model A and Model B was 17.52 and 14.49%, respectively. The EL of Model A was greater than Model B in both the MCL and the CFD simulation. Compared with Model A, Model B had a larger region (8.46 vs. 3.64%) with a relative residence time of >20 Pa⁻¹ at peak systole. Meanwhile, the area where the oscillatory flow index was >0.4 was significantly smaller in Model B than in Model A (0.46 vs. 0.043%). The region with an average wall shear stress of >4 Pa was greater in Model B than in Model A (0 vs. 0.22%).

Conclusion

The MCL and CFD simulation showed that the novel IBD had little impact on the FDR and EL of the iliac artery models. However, the IBD might be an effective tool for the treatment of abdominal aortic/iliac aneurysms that extend into branches. Further investigations are warranted to confirm whether this IBD could be useful in the clinic.

A Multicenter Assessment of Anatomic Suitability for Iliac Branched Devices in Eastern Asian Patients With Unilateral and Bilateral Aortoiliac Aneurysms

Objective: This study aims to assess the suitability of four types of commercial iliac branch device systems to treat Eastern Asian abdominal aortic aneurysm (AAA) patients with bilateral or unilateral common iliac artery aneurysms (CIAAs).

Methods: Patients with a coexisting AAA and a unilateral or bilateral CIAAs who underwent endovascular aneurysm repair (EVAR) at two tertiary centers in China from 2015 to 2017 were reviewed. Morphology of lesions was measured and the anatomic suitability for Cook iliac branch device (IBD), Gore iliac branch endoprosthesis (IBE), Lifetech iliac branch stent graft (IBSG), and Jotec IBD was evaluated according to the latest instructions for use.

Results: Seventy-six patients with AAA were enrolled, including 35 bilateral CIAAs, 41 unilateral CIAAs. A hundred and eleven lesions were investigated aggregately: 16.2, 28.8, 21.6, and 19.8% met the criteria for Cook IBD, Gore IBE, Lifetech IBSG, and Jotec IBD, respectively. A total of 34 (44.7%) patients could be treated for at least one lateral lesion. The diameter of the internal iliac artery (IIA) was the most common restriction for IBD application. Additionally, the IIA diameter of lesions in the bilateral group was significantly larger compared with the unilateral group (P < 0.001). Based on the anatomical characteristics alone, it is likely that IBDs will be more suitable for unilateral lesions than bilateral ones (P < 0.05). However, there was no difference between the suitability for patients with unilateral or bilateral CIAAs (P > 0.05).

Conclusions: Less than half of Eastern Asian patients with aortoiliac aneurysms were eligible for IBD application. This was primarily due to the IIA diameter failing to meet the criteria. And thus, the suitability of lesions in bilateral group was significantly lower than that in the unilateral group. Aiming to expand the indications and optimize the design of the iliac branch devices, IIA diameter and the anatomical characteristics of the bilateral lesions should be considered deliberately.

Application of a Novel Common-Iliac-Artery Skirt Technology (CST) in Treating Challenge Aorto-Iliac or Isolated Iliac Artery Aneurysms

Purpose: To report a novel common-iliac-artery skirt technology (CST) in treating challenge iliac artery aneurysms. Methods: When required healthy landing zone of common iliac artery (CIA) is not available, CST is a strategy to exclude the internal iliac artery (IIA) and prevent IIA reflux without need of embolization. Patients who received endovascular aneurysm repair (EVAR) in our center from 2014 to 2020 were retrospectively screened, and patients treated with CST or with IIA embolization (IIAE) were enrolled. Results: After retrospective screen of 524 EVAR patients, 39 CST patients, 26 IIAE patients, and 7 CST + IIAE patients were enrolled in this study. CST group suggested to have more aged, hyperlipemia, and smoking patients than IIAE group. Two groups had comparable maximal diameter of abdominal aorta (AA), CIA, EIA, but larger diameter of IIA (CST 19.82 ± 2.281 vs. IIAE 27.82 ± 3.401, p = 0.048), and CIA bifurcation (CST 25.01 ± 1.316 vs. IIAE 29.76 ± 2.775, p = 0.087) was found in IIAE group. Anatomy of 79.5% of CST patients and 92.3% of IIAE patients (p = 0.293) was not suitable for potential use of iliac branch device. CST group had significant shorter surgery time (CST 97.42 ± 3.891 vs. IIAE 141.0 ± 8.010, p < 0.001), shorter hospital stay (CST 15.35 ± 0.873 vs. IIAE 19.32 ± 1.067, p = 0.009), lower in-hospital [CST 0% (0/39) vs. IIAE 11.5% (3/26), p = 0.059] and 1-year follow-up stent related MAEs [CST 6.7% (2/30) vs. IIAE 28.6% (6/21), p = 0.052], but comparable mortality and stent related MAEs for all-cohort follow-up analysis comparing to IIAE group. In our study, a lower in-hospital buttock claudication (BC) rate for CST (CST 20.5% vs. IIAE 46.2%, p = 0.053) and a comparable erectile dysfunction (ED) rate (CST 10.3% vs. IIAE 23.1%, p = 0.352) were found between CST and IIAE groups. After 1 year, both groups had about one third relief of BC symptoms [CST 33.3% (4/12) vs. IIAE 30.7% (4/13), p = 1.000]. Subgroup analysis of 14 patents concomitant with IIA aneurysm in CST group and the 7 CST + IIAE patients were carried out, and no difference was found in mortality, stent MAEs, sac dilation, or reintervention rate. Last, illustration of seven typical CST cases was presented. Conclusion: In selected cases, the CST is a safe, feasible-and-effective choose in treating challenge iliac artery aneurysms and preventing IIA endoleak.

Alternative Endograft Aortoiliac Reconstruction for Iliac Branch Endoprostheses

BACKGROUND

Endovascular treatment of complex common iliac artery (CIA) and internal iliac artery (IIA) aneurysms using iliac branch endoprostheses (IBE) has proven safe and effective. Instructions for use (IFU) require deployment of current IBE technology with the corresponding manufacturer's modular bifurcated aortic endograft. Concomitant aortoiliac occlusive disease, inadequate renal artery-iliac bifurcation length, and unfavorable aortic anatomy preclude on-label IBE deployment. This study aimed to evaluate the technical feasibility and safety of Alternative Endograft Aortoiliac Reconstruction (AEGAR) for branched endovascular treatment of complex iliac artery aneurysms.

METHODS

In 7 consecutive patients with CIA or IIA aneurysms, computed tomography angiography (CTA) and center-line reconstruction revealed aortoiliac anatomy incompatible with the current IBE IFU due to inadequate proximal CIA landing zone (n = 7), inadequate renal artery to iliac bifurcation length (n = 2), compromised aortic anatomy (n = 3), or short infrarenal neck <15 mm (n = 1), either alone or in combination. To overcome these restrictions and facilitate IBE deployment, aortoiliac reconstruction was performed using the Endologix AFX, Endologix Ovation limbs or the Medtronic Endurant II platforms (AEGAR technique). All internal iliac artery reconstructions and external iliac artery extensions were performed using the Gore VBX or Viabahn stent grafts. Technical success was defined as successful delivery of all endograft components without migration or endoleak.

RESULTS

The mean patient age was 69 years (range 52-82 years; 6 male). Four patients had bilateral CIA aneurysms and 3 patients had unilateral CIA aneurysms (mean diameter 4.3cm; range 2.2-7 cm). There were 13 IIA VBX stent grafts used for a total of 9 IIAs treated with IBE (bilateral IBE = 2 patients). The mean fluoroscopy time was 38.8 min (range 21.3-64.3 min) and the mean contrast volume was 168.5 mL (range 122-226 mL). Technical success was achieved in all patients and there were no perioperative complications. Mean hospital-stay was 2.2 days (range 1-3 days). Follow-up ranged from 82-957 days (mean = 487 days). At last follow-up, all patients were alive without cardiovascular morbidity; and CTA revealed stable or decreased aneurysm size, patent endografts, and no evidence of endoleak or migration.

CONCLUSIONS

The AEGAR technique can be used to safely and effectively overcome certain aortoiliac anatomic constraints that preclude use of current IBE technology. We encourage broader use of these alternative endografts in pertinent anatomic configurations.

Results of the Galician registry in the treatment of complex aortoiliac aneurysms with GORE® EXCLUDER® Iliac Branch Endoprosthesis (GALIBER)

OBJECTIVE

The objective of this study is to report the medium-term results of GORE^® EXCLUDER^® Iliac Branch Endoprosthesis (IBE, W. L. Gore & Associates, Flagstaff, Ariz) for the treatment of aortoiliac aneurysms by using the GALIBER registry.

METHODS

Patients with aortoiliac or isolated common iliac/hypogastric aneurysms treated with Iliac Branch Endoprosthesis device between January 2014 and May 2019 were prospectively collected from 5 centers. Demographic, clinical, and radiologic data were extracted from electronic databases. Technical success was defined as successful implantation of the Iliac Branch Endoprosthesis device with exclusion of aortoiliac aneurysm, as well as patency of Iliac Branch Endoprosthesis in the follow-up. Iliac Branch Endoprosthesis patency was evaluated by Doppler ultrasound and/or computed tomography based on the protocol of each participant center. Follow-up was 731 days +/- 499.

RESULTS

Between January 2014 and May 2019, 105 iliac arteries were treated with GORE^® IBE device, in 81 patients (79 men, two women; mean age 71, range 52-91). Only seven patients (8.6%) were symptomatic. 60 patients (74%) had aortic and iliac enlargement. Thirty-three patients presented bilateral iliac aneurysms (40.7%): In twenty-four (29.6%) patients, an Iliac Branch Endoprosthesis device was implanted in both sides, and in nine patients (11.1%), one Iliac Branch Endoprosthesis was used with the embolization of the contralateral hypogastric artery. Technical success was achieved in the 99% (104/105 iliac branch device implanted). There were no procedural deaths or type I or III intraoperative endoleaks observed. During the follow-up (range 55-1789 days), 28 (34.5%) type II endoleaks were observed and one (1.2%) type Ia was observed. The patency of the hypogastric arteries treated with the iliac branch device was 98.1% during the follow-up (range 55-1789 days). In 30% of the patients with contralateral hypogastric embolization, some kind of complications was observed in the embolizated side: one developed ischemic colitis and two buttock claudication.

CONCLUSIONS

Preservation of internal iliac artery with the Iliac Branch Endoprosthesis device can be performed safely with excellent technical success and good medium-term patency rates. These results support hypogastric preservation whenever possible to prevent ischemic complications.

Bilateral internal iliac branch device with ipsilateral deployment

Iliac branch endograft devices offer an elegant solution to preserve perfusion to the internal iliac artery when treating aortoiliac aneurysms; however, they are difficult to perform when bilateral access is not available owing to aortoiliac anatomy or previous endovascular aortic aneurysm repair. We present a technique to perform iliac branch endograft deployment from ipsilateral access in a patient with a prior EVAR endovascular aortic aneurysm repair, obviating the need for a difficult up-and-over access.

Common Iliac Artery Aneurysm Repair with Hypogastric Preservation via Balloon-Expandable Covered Stents Using the Eyelet Technique-Iliac Branched Devices Still Inappropriate in Many Patients

BACKGROUND

Common iliac artery aneurysms (CIAAs) are seen in 20-40% of patients with abdominal aortic aneurysms. Historically treated with sacrifice of the hypogastric artery, which can result in significant morbidity related to pelvic ischemia, new devices have made hypogastric artery preservation more feasible but are only applicable to a small subset of aneurysm anatomy. We sought to assess the safety and efficacy or a novel technique for hypogastric artery preservation applicable to a wider variety of patients with CIAAs.

METHODS

We conducted a retrospective review of a prospectively maintained database of all patients with CIAAs treated with a novel endovascular technique at the UC San Diego Sulpizio Cardiovascular Center or the San Diego Veterans Affairs Hospital between March 2016 and December 2017. The endovascular technique involved stent placement in both the internal and external iliac arteries, with balloon expansion to minimize gutters between the endografts. Primary end points included technical success, limb patency, and presence of endoleaks (ELs).

RESULTS

A total of 14 limbs (12 patients) were treated for CIAAs with 100% technical success and limb patency at an average of 6.8 months of follow-up. No patients experienced type I or type III ELs or evidence of pelvic ischemia. Two patients required reintervention, and one patient died of causes unrelated to the procedure.

CONCLUSIONS

This technique was performed with excellent short- and mid-term safety in patients with varying aneurysm anatomy. The high rates of technical success and low rate pelvic ischemia represent improvement over conventional techniques that sacrifice the hypogastric artery and warrant further testing in a larger patient series with longer term follow-up.

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.

Endoluminal Management of Infra-renal Aortic and Aorto-iliac Aneurysms

This paper reviews the development of endovascular aneurysm repair (EVAR) of infra-renal aortic and iliac artery aneurysms and considers the current status and best treatment options. The vast majority of devices are bifurcated and exclude the aneurysm utilizing the same techniques for fixation and seal. The modern EVAR procedure is usually performed in a hybrid operating theatre, utilizing image fusion and other radiation-reducing techniques and using optimized procedural techniques, including percutaneous access. The best outcomes are achieved in patients whose anatomy is within device "instructions for use", but these are most commonly breached due to "hostile" neck anatomy. Endovascular options for these cases include the use of fenestrated endografts, chimney grafts and endoanchors. Concomitant iliac artery aneurysms often occur with abdominal aortic aneurysms, and endovascular options include limb extensions with internal iliac embolization as well as iliac branch devices. The durability of EVAR has recently been called into question by long-term results from early EVAR randomized trial. Findings such as infra-renal neck dilatation and aneurysm sac expansion are relatively common and associated with adverse outcomes. This durability concern mandates regular and long-term imaging and clinical surveillance. It also indicates that EVAR technology is not fully evolved with a need for further development to improve patient applicability and long-term durability.

Outcomes after Standalone Use of Gore Excluder Iliac Branch Endoprosthesis for Endovascular Repair of Isolated Iliac Artery Aneurysms

BACKGROUND

The aim of our study was to describe outcomes of stand-alone use (i.e., without concomitant implantation of an aortic stent graft) of the Gore Excluder iliac branch endoprosthesis (IBE) for elective endovascular repair of isolated iliac artery aneurysms.

METHODS

We evaluated all consecutive patients electively treated for isolated iliac artery aneurysms using standalone Gore Excluder IBE (January 2014-December 2018). Early (i.e., 30-day) endpoints were technical success, mortality, major adverse events (MAEs), and major access-site complications. Late endpoints were survival, freedom from aortic-related mortality (ARM), internal iliac artery (IIA) primary patency, IIA branch instability, graft-related adverse events (GRAEs), secondary interventions, endoleaks (ELs), aneurysm sac behavior, and new-onset buttock claudication (BC).

RESULTS

A total of 11 consecutive patients (10 men; median age 75 years) were included. The technical success rate was 100%. At 30 days, mortality, MAEs, and major access-site complications were all 0%. Survival and freedom from ARM were 91% and 100%, respectively; only one nonaortic related death was recorded during follow-up. At a median follow-up of 14 months, IIA primary patency, IIA branch instability, and GRAEs were 100%, 0%, and 0%, respectively. No instances of graft migration ≥10 mm were detected. No graft-related secondary interventions were recorded, and 2 patients required a procedure-related secondary intervention 3 months after the index procedure (1 common femoral artery endarterectomy and 1 external iliac artery stenting). Although new-onset type 1 or type 3 ELs were never noted, one patient developed a new-onset type 2 EL. Aneurysm sac regression ≥5 mm was noted in 6 patients (55%), whereas in the remaining ones, the sac size was stable. No instances of new-onset BC were noted.

CONCLUSIONS

Use of standalone Gore Excluder IBE for elective endovascular repair of isolated iliac artery aneurysms is a safe, feasible, and effective treatment option. These results may support use of the technique as an effective means of endovascular reconstruction in patients with suitable anatomy.

Adjunctive Procedures for Challenging Endovascular Abdominal Aortic Repair: When Needed and How Effective?

Endovascular aneurysm repair (EVAR) is now considered the first choice treatment modality for abdominal aortic aneurysm (AAA) treatment. Advocates for endovascular strategies will try to treat all AAA by EVAR, regardless if the anatomy is conducive for treatment or not. However, the long-term outcomes of EVAR outside the instructions for use (IFU) due to a hostile aneurysmal neck or iliac artery anatomy are known to be poor. The EVAR procedures can be classified according to the technical difficulty, IFU, and need for visceral revascularization: standard, adjunctive, and complex EVAR. The situation required for adjunctive procedures can be classified as the following four steps: a hostile neck (i.e., short or severely angled); large inferior mesenteric or lumbar artery; tough iliac artery anatomy, such as a short common iliac artery and stenotic external iliac artery; and limitations in vascular access. This article will discuss the adjunctive procedures to overcome hostile aneurysm neck and unsuitable iliac artery anatomy.

Anatomic Suitability of Iliac Branched Devices for Chinese Patients with Abdominal-Iliac Aortic Aneurysm

BACKGROUND

Preserving internal iliac flow is the key to preventing ischemic complications during endovascular aneurysm repair (EVAR). The aim of this study is to determine the morphological features of abdominal aortic aneurysms (AAAs) that have been reported in clinical trials in Chinese patients to identify unique features of iliac branched systems.

METHODS

The data for patients who had common iliac aneurysms suitable for imaging review from 2014 to 2017 at 1 institution in China were reviewed. Three-dimensional workstations were used to measure the centerline diameters and lengths of aortoiliac structures, which were screened for suitability for both Cook iliac branch devices (IBD) and Gore iliac branch endoprosthesis (IBE).

RESULTS

A total of 102 lesions of common iliac aneurysms were suitable for imaging review. The anatomic standards for the Gore IBE and Cook IBD were met by 13.7% (14/102) and 9.8% (10/102) of the cases, respectively, and 3 cases were suitable for both devices. The most common cause of not meeting the criteria was the same for both the Cook IBD (78.4%) and Gore IBE (48.03%), which was a limitation of the diameter of the target internal iliac artery. Of the 92 lesions excluded from the Cook IBD trial, 11 (11.9%) were eligible for the Gore IBE trial. Likewise, 7.95% (7/88) of the lesions excluded from the Gore IBE trial would have been eligible for the Cook IBD graft. In a practice that is able to enroll patients in both trials, a total of 20.6% (21/102) of the patients would be eligible for treatment, based on the anatomic criteria.

CONCLUSIONS

The high incidence of iliac artery involvement in AAAs makes EVAR more complicated. Cook IBD and Gore IBE are only suitable for the treatment of a total of 20.6% Chinese patients based on the anatomic criteria. A limitation in the diameter of the target internal iliac artery is the most common cause of failure to meet the criteria for both devices. Future generations of iliac branch technologies should be designed with diameter accommodations for the hypogastric branch stent to reach a wider group of patients with aortoiliac aneurysmal disease.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis Using Division Branches of the Internal Iliac Artery as Distal Landing Zones

Purpose: To evaluate the outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) using division branches of the internal iliac artery (IIA) as distal landing zones. Materials and Methods: Between January 1, 2014, and December 31, 2018, 74 patients (mean age 74±7 years; 72 men) treated for aortoiliac or common iliac artery aneurysms had an IBE deployed with distal landing of the side branch within the main trunk (n=60) of the internal iliac artery (IIA) vs within a division branch (n=25). Thirteen (17%) patients received bilateral IBE implantations for a total of 85 vessels evaluated. Early endpoints were technical success, 30-day mortality, 30-day major adverse events (MAEs), and 30-day major access complications. Late endpoints were survival, primary and secondary IIA patency, freedom from IIA branch instability, freedom from new-onset buttock claudication, and aneurysm sac diameter changes. Time-dependent outcomes were reported as Kaplan-Meier curves with differences assessed using the log-rank test. Estimates are presented with the 95% confidence interval (CI). Results: The overall technical success rate was 97%, with 1 technical failure per group (p=0.43). Two patients, one from each group, died within 30 days (p=0.43). No significant differences were seen in the rates of 30-day MAEs (7% vs 17%, p=0.35) or major access complications (9% vs 11%, p>0.99) for patients receiving distal landing in the main trunk vs a division branch, respectively. The mean follow-up for the entire cohort was 19±12 months. The overall 1-year survival rate was 94% (95% CI 74% to 99%). The primary and secondary patency rates at 1 year were 98% (95% CI 88% to 99%) vs 95% (95% CI 72% to 99%, p=0.72) and 98% (95% CI 88% to 99%) vs 100% (p=0.41) for the main trunk vs division branch groups, respectively. Freedom from IIA branch instability estimates were also similar at 1-year follow-up [93% (95% CI 82% to 97%) vs 90% (95% CI 66% to 97%), p=0.29], as were the freedom from new-onset buttock claudication estimates [98% (95% CI 86% to 99%) and 94% (95% CI 67% to 99%), respectively; p=0.62]. Mean sac diameter change was 5.4±5.3 mm, not significantly different between the groups (p=0.85). Conclusion: Use of the posterior or anterior division of the IIA as a distal landing zone for the Gore Excluder IBE was safe and efficacious in the midterm. This technique may permit extending indications for endovascular repair of aortoiliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Long-term assessment is needed to affirm the efficacy of this technique.

Endovascular treatment of iliac aneurysmal disease with internal iliac artery preservation: a review of two different approaches

INTRODUCTION

The feasibility of endovascular aneurysm repair (EVAR) is often challenged by the concurrent presence of common iliac artery aneurysms, which prevent the attainment of a successful distal sealing. The present review aims to portray the safety and efficacy of two internal iliac artery (IIA) preservation strategies in the endovascular treatment of aortoiliac aneurysms: the iliac branch extension device (IBED) and the parallel graft - "sandwich" technique (PG-ST).

EVIDENCE ACQUISITION

A comprehensive literature review was conducted to identify publications on endovascular treatment of iliac aneurysmal disease using IBED or PG-ST. Primary endpoints were freedom from endoleak, IIA branch occlusion and secondary interventions.

EVIDENCE SYNTHESIS

Twenty-eight studies were selected for analysis describing a total of 1316 patients, 1169 in the IBED group and 147 in the PG-ST group. The technical success rates were akin for IBED and PG-ST (83.9-100% versus 81.3-100%). The defined primary endpoints were reported by fourteen articles. Freedom from endoleak, IIA branch occlusion and reintervention, at 6 months, were as follows: 82-100% versus 86%, 90-94% versus 88%, and 90-98% versus 87%, respectively for IBED and PG-ST. Later outcomes were only recorded in the IBED group, and freedom from endoleak, IIA branch occlusion and reintervention, at 9 years, were 83%, 81-90%, and 64-75%, respectively.

CONCLUSIONS

Both IBED and PG-ST have proven to be safe and valid approaches. However, while IBED has established as a durable procedure, mid-term data lacks on PGs performance and further studies are required to attest durability of the latter procedure.

Endovascular Repair of Aortoiliac or Common Iliac Artery Aneurysm Using the Lifetech Iliac Bifurcation Stent Graft System: A Prospective Multicenter Clinical Study

BACKGROUND

Sacrifice of the internal iliac artery (IIA) may result in ischemic manifestations after aortoiliac aneurysm (AIA) or common iliac artery aneurysm (CIAA) endovascular repair. This study sought to evaluate the safety and efficacy of a new Iliac Bifurcation Stent Graft (IBSG; Lifetech Scientific, Shenzhen, China) system for revascularization of the IIA.

METHODS

Patients who underwent implantation of the IBSG at 8 centers in China from September 2015 to June 2018 were enrolled. Clinical and computed tomography angiography follow-up assessments were conducted at 30 and 180 days postoperatively. The primary end point was the IIA patency rate of the IBSG device at 180 days postoperatively. Secondary end points comprised the postoperative technical success rate and clinical success rate at 30 and 180 days. Descriptive statistics and the Clopper-Pearson exact method were used to analyze the data.

RESULTS

Seventy-three patients (mean age, 69.6 years; 91.8% men) were eligible for this trial, and 59 patients were eligible for primary effectiveness end-point analysis. AIA was present in 55 patients (75.34%) and CIAA in 18 patients (24.66%). The iliac artery aneurysms were unilateral in 69 patients (94.52%) and bilateral in 4 patients (5.48%). Overall technical success was 89.04% (65 of 73 patients). IIA patency at 180 days was 96.61% (57 of 59 patients). Sexual dysfunction occurred in 1 patient (1.69%), and 2 patients (3.39%) experienced buttock claudication. There was no mortality, type III endoleak, stent migration, kinking, or fracture during the procedure and follow-up.

CONCLUSIONS

The IBSG implantation system is a safe and effective technique for IIA preservation during AIA or CIAA endovascular repair. The high technical success rate, IIA patency rate, and low complication rate are promising. Follow-up will be continued for 5 years to confirm the durability of the device.

Preservation of pelvic perfusion with iliac branch devices does not decrease ischemic colitis compared with hypogastric embolization in endovascular abdominal aortic aneurysm repair

OBJECTIVE

Ischemic colitis is a rare but devastating complication of endovascular repair of infrarenal abdominal aortic aneurysms. Although it is rare (0.9%) in standard endovascular aneurysm repair (EVAR), the incidence increases to 2% to 3% in EVAR with hypogastric artery embolization (HAE). This study investigated whether preservation of pelvic perfusion with iliac branch devices (IBDs) decreases the incidence of ischemic colitis.

METHODS

We used the targeted EVAR module in the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing EVAR of infrarenal abdominal aortic aneurysm from 2012 to 2017. The cohort was further stratified into average-risk and high-risk groups. Average-risk patients were those who underwent elective repair for sizes of the aneurysms, whereas high-risk patients were repaired emergently for indications other than asymptomatic aneurysms. Within these groups, we examined the 30-day outcomes of standard EVARs, EVAR with HAE, and EVAR with IBDs. The primary outcome was the incidence of ischemic colitis. Secondary outcomes included mortality, major organ dysfunction, thromboembolism, length of stay, and return to the operating room. The χ² test, Fisher exact test, Kruskal-Wallis test, and multivariate regression models were used for data analysis.

RESULTS

There were 11,137 patients who had infrarenal EVAR identified. We designated this the all-risk cohort, which included 9263 EVAR, 531 EVAR-HAE, and 1343 EVAR-IBD procedures. These were further stratified into 9016 cases with average-risk patients and 2121 cases with high-risk patients. In the average-risk group, 7482 had EVAR, 411 had EVAR-HAE, and 1123 had EVAR-IBD. In the high-risk group, 1781 had EVAR, 120 had EVAR-HAE, and 220 had EVAR-IBD. There was no significant difference in 30-day outcomes (including ischemic colitis) between EVAR, EVAR-HAE, and EVAR-IBD in the all-risk and high-risk groups. In the average-risk cohort, EVAR-HAE was associated with a higher mortality rate than EVAR (2.2% vs 1.0%; adjusted odds ratio, 2.58; P = .01). Although EVAR-IBD was not superior to EVAR-HAE in 30-day mortality, major organ dysfunction, or ischemic colitis in this average-risk cohort, EVAR-IBD exhibited a trend toward lower mortality compared with EVAR-HAE in this cohort, but it was not statistically significant (1.0% vs 2.2%; adjusted odds ratio, 0.42; P = .07).

CONCLUSIONS

Ischemic colitis is a rare complication of EVAR. HAE does not appear to increase the risk of ischemic colitis, and preservation of pelvic perfusion with IBDs does not decrease its incidence. Although HAE is associated with significantly higher mortality than standard EVAR in average-risk patients, the preservation of pelvic perfusion with IBDs does not appear to improve mortality over HAE.

Tailor-made iliac branched device for preserving the internal iliac artery in patients with common iliac artery aneurysm

BACKGROUND

Endovascular repair with stent-graft is a treatment option for patient with common iliac artery aneurysm (CIAA). However, the preservation of the internal iliac artery (IIA) is a concern. The commercially available iliac branched device (IBD) requires a common iliac length of at least 5 cm, which is usually too long for Asian people. Here, we report our medium-term results of using tailor-made IBD for patients with short common iliac artery (CIA) with and without abdominal aortic aneurysm (AAA).

METHODS

A selected iliac limb of the AAA stent-graft was unloaded from the delivery system. A 6-mm fenestration hole was made at the length of the CIA from the proximal end. The edge of the hole was reinforced with the soft and radiopaque tip of a 0.014´´ wire. Then, the iliac limb was reloaded into the introduced sheath as the tailor-made IBD. It was inserted from the selected side of the femoral artery and deployed. The ipsilateral IIA was cannulated through the fenestration hole. Then, a balloon-expandable or self-expandable covered stent with an appropriate size was deployed as the bridging stent-graft.

RESULTS

Between March 2013 and March 2017, a total of 10 patients received the tailor-made IBDs. One patient died of systemic thromboembolism 2 days after the operation. The bridging stent-grafts remained patent in all patients, except one occluded at 1 year after operation.

CONCLUSION

A tailor-made IBD is an easy-to-apply, alternative option for preserving the IIA perfusion in short CIAA patients with and without AAA.

Bifurcated unibody aortic endografts can overcome unfavorable aortoiliac anatomy for deployment of bilateral iliac branch endoprostheses

In conjunction with traditional modular bifurcated aortic endografts, bilateral iliac branch endoprostheses have been safely and effectively used for treatment of bilateral iliac artery aneurysms. However, anatomic constraints, such as inadequate renal artery to iliac bifurcation lengths and unfavorable aortic anatomy, can preclude deployment in certain configurations and limit use in many patients. We present an innovative technique to overcome such anatomic constraints and to extend the reach of iliac branch endoprosthesis technology in patients with iliac artery aneurysms.

Hypogastric Preservation During Treatment of Aortoiliac Aneurysms

The advent of endovascular technology for treating aortoiliac aneurysms has sometimes necessitated the occlusion of the hypogastric artery to prevent an endoleak or to achieve an adequate distal seal, resulting in significant morbidity for some patients. The use of iliac branch devices, in conjunction with aortic stent grafts, has made it possible to preserve the hypogastric arteries in select patients with suitable anatomy. The purpose of this review will be to discuss the indications for hypogastric preservation during treatment of aortoiliac aneurysms, as well as highlight the key procedural steps and potential technical challenges encountered during this procedure.

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 management of iliac aneurysmal disease with hypogastric artery preservation

Common iliac artery aneurysms (CIAAs) pose a challenge in endovascular aneurysm repair. Aneurysm repair of CIAA traditionally requires embolization of the ipsilateral hypogastric artery (HA). Symptoms of buttock claudication and more feared complications of pelvic ischemia make HA preservation an appealing addition to aneurysm repair. In this review, we discuss various methods of CIAA repair with devices specifically designed for aneurysm repair and other custom techniques of HA preservation.

Bifurcated-bifurcated aneurysm repair is a novel technique to repair infrarenal aortic aneurysms in the setting of iliac aneurysms

BACKGROUND

Up to 40% of abdominal aortic aneurysms (AAAs) have coexistent iliac artery aneurysms (IAAs). In the past, successful endovascular repair required internal iliac artery (IIA) embolization, which can lead to pelvic or buttock ischemia. This study describes a technique that uses a readily available solution with a minimally altered off-the-shelf bifurcated graft in the IAA to maintain IIA perfusion.

METHODS

From August 2009 to May 2015, 14 patients with AAAs and coexisting IAAs underwent repair with a bifurcated-bifurcated approach. A 22-mm or 24-mm bifurcated main body device was used in the IAA with extension of the "contralateral" limb into the IIA. Intraoperative details including operative time, fluoroscopy time, and contrast agent use were recorded. Outcome measures assessed were operative technical success and a composite outcome measure of IIA patency, freedom from reintervention, and clinically significant endoleak at 1 year.

RESULTS

Fourteen patients underwent bifurcated-bifurcated repair during the study period. Technical success was achieved in 93% of patients, with successful treatment of the AAA and IAA and preservation of flow to at least one IIA. The procedure was performed with a completely percutaneous bilateral femoral approach in 92% of patients. Three patients had a type II endoleak on initial follow-up imaging, but none were clinically significant. There were no cases of bowel ischemia or erectile dysfunction. One patient had buttock claudication ipsilateral to IIA coil embolization (contralateral to bifurcated iliac repair and preserved IIA) that resolved by 6-month follow-up. Two patients required reinterventions. One patient presented to his first follow-up visit on postoperative day 25 with thrombosis of the right external iliac limb ipsilateral to the bifurcated iliac repair, which was successfully treated with thrombectomy and stenting of the limb. This same patient presented at 83 months with growth of the preserved IIA to 3.9 cm and underwent coil embolization of the aneurysm. Another patient presented for surveillance 44 months after his original repair with component separation of the mating stent and the iliac bifurcated stent grafts. This was treated with a limb extension and endoanchors to fuse the endografts. Of the 13 patients who underwent bifurcated-bifurcated repair, 100% of the preserved IIAs remained patent at last follow-up. The composite outcome measure of IIA patency and freedom from reintervention and clinically significant endoleak at 1 year was 92% (n = 12/13).

CONCLUSIONS

In this small retrospective review, bifurcated-bifurcated aneurysm repair of aortoiliac aneurysms with preservation of perfusion to the IIA is technically feasible and safe with good short-term and midterm results in male patients.

Parallel-Stenting Technique in a Sandwich Configuration for Hypogastric Artery Preservation during Endovascular Aneurysm Repair: An In Vitro Study

BACKGROUND

The aim of the study was to identify the best conditions in iliac sandwich procedure for hypogastric artery preservation during endovascular aneurysm repair, testing different devices, different oversizing (OS) degrees as well as different methods to measure it.

METHODS

Four external iliac devices (16-mm Endurant and 12-mm Aorfix limb extensions; 11- and 13-mm Viabahn endografts) were tested with 2 distinct internal iliac stent grafts (8-mm Advanta V12 and 8-mm Viabahn) inside different proximal silicon iliac limb models (10, 12, 14, 16, and 18 mm), simulating an iliac sandwich procedure for hypogastric preservation. After remodeling all devices in a saline bath at 37°C, the combinations were computed tomography scanned. Gutter size, parallel-stent compression, and inadequate parallel-stent deployment or infolding were recorded. Oversizing between both parallel stents and the iliac limb models were examined in terms of added diameter, perimeter, and area being additionally compared.

RESULTS

All three sizing methods (diameter, perimeter, and area) were highly correlated (diameter OS to perimeter and area OS correlation coefficient 0.998 and 0.997, respectively, P < 0.001 for both); thus, diameter OS was used for further comparisons. Increasing diameter OS (< 30%, 30-55%, 55-75%, and > 75%) showed a significant tendency toward smaller gutters (38.9, 12.2, 5.4, and 2.6 mm², respectively, P < 0.001) but also increasing parallel-stent compression (13.5%, 28.9%, 43.9%, and 55.1%, P < 0.001) and infolding (0%, 0%, 38%, and 60%, P < 0.001). There were no significant differences between the analyzed devices.

CONCLUSIONS

In iliac sandwich procedures, better apposition is usually achieved when using 30-55% diameter OS; higher OS is related to smaller gutters but higher rates of malpositioning and parallel-stent compression. No clear recommendations in material selection can be performed. All sizing methods are highly correlated and predictable.

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass

BACKGROUND

Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass.

METHODS

Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded.

RESULTS

The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent.

CONCLUSIONS

Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.

Outcomes of Endovascular Repair of Aortoiliac Aneurysms and Analyses of Anatomic Suitability for Internal Iliac Artery Preserving Devices in Japanese Patients

BACKGROUND

Understanding that the common iliac arteries (CIA) are shorter in Asian patients, we investigated whether this anatomic difference affects the clinical outcomes of internal iliac artery (IIA) exclusion during endovascular aneurysm repair (EVAR) of aortoiliac aneurysm and thus limits the use of IIA-preserving devices in Japanese patients.Methods and Results:From 2008 to 2014, 69 Japanese patients underwent EVAR of aortoiliac aneurysms with 53 unilateral and 16 bilateral IIA exclusions. One patient had persistent buttock claudication during follow-up; however, colonic or spinal cord ischemia was not observed. Anatomic suitability was investigated for the iliac branch device (IBD) by Cook Medical and the iliac branch endoprosthesis (IBE) by WL Gore: 87 aortoiliac segments were analyzed, of which 17% met the criteria for the IBD, 25% met the criteria for the IBE and 40% met the criteria for either. Main exclusions for the IBD were IIA diameter >9 mm or <6 mm (47%) and CIA length <50 mm (39%). Main exclusions for the IBE were proximal CIA diameter <17 mm (44%) and aortoiliac length <165 mm (24%).

CONCLUSIONS

EVAR with IIA exclusions in Japanese patients showed low incidence of persistent buttock claudication and no major pelvic complications. Aorto-iliac morphology demonstrated smaller proximal CIA diameters and shorter CIA lengths, limiting the use of IIA-preserving devices.