Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device

Endovascular Abdominal Aortic Aneurysm Repair

A great majority of abdominal aortic aneurysm are treated with endovascular aortic repair (EVAR) in current practice. EVAR has lower peri-procedural mortality and morbidity compared to open surgical repair. Anatomic factors such as aneurysm neck morphology, iliac anatomy, and access vessel anatomy need careful assessment for the successful performance of EVAR. Evolving technology and techniques are allowing more patients to be treated with EVAR with better long-term outcomes.

The Bell-Bottom Technique Versus Branched Stent Grafts in Endovascular Treatment of Diseased Common Iliac Artery: A Systematic Review and Meta-Analysis

BACKGROUND

To evaluate whether the use of iliac branched endoprosthesis reduces perioperative complications compared to the bell-bottom technique (BBT) in patients with common iliac artery aneurysm or ectasia.

METHODS

We conducted a systematic search of studies in the PubMed, Embase, and Cochrane databases up to March 2024. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol, 91 articles were analyzed. A restricted maximum likelihood model with random effects with odds ratios and 95% confidence intervals was applied for binary outcomes. Heterogeneity was assessed using the Cochrane Q test and Higgins and Thompson's I2 statistic. Significance was defined as a P value < 0.05.

RESULTS

Six cohort studies involving 2,899 patients were included, of which 863 underwent repair with branched endoprosthesis. There was no statistically significant difference observed for endoleaks: of any type (odds ratio [OR] 0.41; 95% confidence interval [CI] 0.10-1.60; P = 0.20), type 1a (OR 1.12; 95% CI 0.20-6.40; P = 0.90), type 1b (OR 0.63; 95% CI 0.20-1.97; P = 0.42), and type 2 (OR 0.52; 95% CI 0.10-2.71; P = 0.44). However, type 3 endoleaks were less frequent in the bell-bottom group (OR 9.00; 95% CI 1.09-74.17; P = 0.04). Additionally, perioperative mortality (OR 0.73; 95% CI 0.41-1.27; P = 0.26), mesenteric ischemia (OR 0.14; 95% CI 0.01-2.54; P = 0.18), iliac artery injury (P = 0.06), and buttock claudication (OR 0.14; 95% CI 0.02-1.08; P = 0.06) also did not statistically differ between the 2 groups.

CONCLUSIONS

Branched endoprosthesis and BBTs did not differ regarding perioperative mortality rates, internal iliac artery occlusion, and mesenteric ischemia rates. However, the use of branched endoprostheses was associated with a higher incidence of type 3 endoleaks compared to the BBT.

Case Report: Gutter endoleak embolization in a patient with bilateral common iliac artery aneurysms treated with sandwich parallel grafts

Background

Current guidelines recommend preserving at least one of the bilateral pelvic flows in patients with aortoiliac aneurysms. The sandwich parallel graft, using commercially available devices, provides a viable option for patients who fall outside the instructions for use of iliac branch devices. However, gutter endoleak remains a significant challenge.

Case report

A 78-year-old woman with an incidentally discovered small AAA and bilateral CIAAs experienced aneurysmal growth to 42 mm for the abdominal aortic aneurysm (AAA) and 41 mm and 33 mm for the right and left common iliac artery aneurysms (CIAAs), respectively. Morphologic assessment of the aortoiliac aneurysm revealed the nearly 90-degree angles of the bilateral iliac bifurcations and the tortuous path of the internal iliac arteries. The iliac branch device was considered relatively contraindicated and ineligible; therefore, to preserve pelvic blood flow, the decision was made to employ the sandwich parallel graft technique in the left iliac arteries. Following the placement of the sandwich graft within the iliac limb, standard procedures were carried out. However, completion angiography revealed a type IA endoleak and a significant gutter endoleak in the left CIAA extending to the AAA sac. Despite the extension of overlapping zone, the gutter endoleak persisted after a 10 min waiting period. Therefore, we then advanced an 014 wire and a microcatheter to selectively access the gutter endoleak and performed embolization using multiple detachable coils. The final angiography showed complete resolution of the gutter endoleak and computed tomography angiography 1-month postoperatively confirmed the absence of any endoleaks.

Conclusion

This case report highlights that targeted embolization is a feasible and effective treatment for significant gutter endoleak following the sandwich parallel graft technique.

Outcomes of the Gore® Excluder® Iliac Branch Endoprosthesis Using Self Expanding or Balloon-Expandable Stent Grafts for the Internal Iliac Artery Component

OBJECTIVE

The GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Arizona) was developed to be used in combination with a self-expanding stent graft (SESG) for the internal iliac artery (IIA) bridging stent. Balloon-expandable stent grafts (BESGs) are an alternative for the IIA, offering advantages in sizing, device tracking, precision, and lower profile delivery. We compared the performance of SESG and BESG when used as the IIA bridging stent in patients undergoing EVAR with IBE.

METHODS

This is a retrospective review of consecutive patients who underwent EVAR with IBE implantation at a single center from October 2016 to May 2021. Anatomic and procedural characteristics were recorded via chart review and computed tomography (CT) postprocessing software (Vitrea® v7.14). Devices were assigned to SESG vs. BESG groups based on the type of device landing into the most distal IIA segment. Analysis was performed per device to account for patients undergoing bilateral IBE. The primary endpoint was IIA patency, and secondary endpoint was IBE-related endoleak.

RESULTS

During the study period, 48 IBE devices were implanted in 41 patients (mean age 71.1 years). All IBE devices were implanted in conjunction with an infrarenal endograft. There were 24 devices in each of the self-expanding internal iliac component (SE-IIC) and balloon-expandable internal iliac component (BE-IIC) groups. The BE-IIC group had smaller diameter IIA target vessels (11.6±2.0 mm vs. 8.4±1.7 mm, p<0.001). Mean follow-up was 525 days. Loss of IIA patency occurred in 2 SESG devices (8.33%) at 73 and 180 days postprocedure, and in zero BESG devices, however, this difference was not statistically significant (p=0.16). There was 1 IBE-related endoleak requiring reintervention during the study period. A BESG device required reintervention due to Type 3 endoleak at 284 days.

CONCLUSIONS

There were no significant differences in outcomes between SESG and BESG when used for the IIA bridging stent in EVAR with IBE. The BESGs were associated with using 2 IIA bridging stents and were more often deployed in smaller IIA target arteries. Retrospective study design and small sample size may limit the generalizability of our findings.

CLINICAL IMPACT

This series compares postoperative and midterm outcomes of self expanding stent grafts and balloon expandable stent grafts (BESG) when used as the internal iliac stent graft as part of a Gore® Excluder® Iliac Branch Endoprosthesis (IBE). With similar outcomes between the two stent-grafts, our series suggests that some of the advantages of BESG, device sizing, tracking, deployment, and profile, may be able to be leveraged without impacting the mid-term performance of the IBE.

Clinical Study of a Physician Modified Y-Type Iliac Branch Device (PMYIBD) in the Endovascular Repair of Abdominal Aortic Aneurysms to Preserve the Internal Iliac Artery

OBJECTIVES

To report the method and curative effect of using a physician modified Y-type iliac branch device (PMYIBD) to preserve the internal iliac artery during the endovascular repair of abdominal aortic aneurysms.

METHODS

From September 2018 to April 2022, 24 patients with abdominal aortic aneurysms or dissecting aneurysms, including 19 true aneurysms and 5 dissecting aneurysms involving the common iliac artery were treated in our department. The average age was (65.3 ± 7.6) years. All patients underwent preoperative evaluation by enhanced computed tomography. Combined with intraoperative angiography, a Y-type stent graft was prepared during surgery to perform endovascular repair of abdominal aortic aneurysms.

RESULTS

All operations were successfully completed. The average operative duration was (224.8 ± 44.1) minutes. A total of 24 internal iliac arteries were reconstructed. The average follow-up time was (27.1 ± 13.5) months. During the follow-up, there was no expansion of aneurysm cavity, no endoleak or stent displacement, and no death occurred in all patients.

DISCUSSION

The physician-modified Y-type iliac branched device (PMYIBD) provides an effective method for full-cavity repair. It has a wide range of indications and convenience. According to follow-up results, the early and mid-term had good curative effects; however, the long-term effects require further follow-up.

CONCLUSION

The modified Y-type IBD technique is safe and effective for aortic diseases involving internal iliac artery especially with complex anatomy.

CLINICAL IMPACT

It is meaningful to preserve the IIA during EVAR. The use of PMYIBD provides a simple and effective method for the total endovascular repair of aortic diseases involving the IIA. Several advantages such as minimal trauma, low mortality, low complication rates and perfect short- and medium-term effects emerge in clinical practice. PMYIBDs are good choices for clinicians before suitable commercial stents are available in markets.

Multicenter CT Image-Based Anatomic Assessment of Patients with Aortoiliac Aneurysm Undergoing Endovascular Repair with Iliac Branch Devices

BACKGROUND

The Global Iliac Branch Study (NCT05607277) is an international, multicenter, retrospective cohort study of anatomic predictors of adverse iliac events (AIEs) in aortoiliac aneurysms treated with iliac branch devices (IBDs).

METHODS

Patients with pre-IBD and post-IBD computed tomography imaging were included. We measured arterial diameters, stenosis, calcification, bifurcation angles, and tortuosity indices using a standardized, validated protocol. A composite of ipsilateral AIE was defined, a priori, as occlusion, type I or III endoleak, device constriction, or clinical event requiring reintervention. Paired t-test compared tortuosity indices and splay angles pretreatment and post-treatment for all IBDs and by device material (stainless steel and nitinol). Two-sample t-test compared anatomical changes from pretreatment to post-treatment by device material. Logistic regression assessed associations between AIE and anatomic measurements. Analysis was performed by IBD.

RESULTS

We analyzed 297 patients (286 males, 11 females) with 331 IBDs (227 stainless steel, 104 nitinol). Median clinical follow-up was 3.8 years. Iliac anatomy was significantly straightened with all IBD treatment, though stainless steel IBDs had a greater reduction in total iliac artery tortuosity index and aortic splay angle compared to nitinol IBDs (absolute reduction -0.20 [-0.22 to -0.18] vs. -0.09 [-0.12 to -0.06], P < 0.0001 and -19.6° [-22.4° to -16.9°] vs. -11.2° [-15.3° to -7.0°], P = 0.001, respectively). There were 54 AIEs in 44 IBDs in 42 patients (AIE in 13.3% of IBD systems), requiring 35 reinterventions (median time to event 41 days; median time to reintervention 153 days). There were 18 endoleaks, 29 occlusions, and 5 device constrictions. There were no strong associations between anatomic measurements and AIE overall, though internal iliac diameter was inversely associated with AIE in nitinol devices (nAIE, nitinol = 8).

CONCLUSIONS

Purpose-built IBDs effectively treat aortoiliac disease, including that with tortuous anatomy, with a high patency rate (91.5%) and low reintervention rate (9.1%) at 4 years. Anatomic predictors of AIE are limited.

Outcome of different endovascular modalities to treat common iliac artery aneurysms, single center study

INTRODUCTION

Iliac aneurysms occur in 10% of patients with abdominal aortic aneurysms (AAA). There are three different endovascular approaches to their treatment in the context of infrarenal Endovascular Aortic Aneurysm Repair (EVAR): occlusion by coiling the internal iliac, incorporation using an iliac branch device, and delaying repair using a bell bottom limb. We sought to determine outcomes associated with these three strategies in our practice.

METHODOLOGY

The study was a combined prospective cohort study with a retrospective arm: prospective patient recruitment was done for 1 year from September 2019 and ended by September 2020, and retrospective data was collected from 2017 to 2019. Demographic, procedural, and imaging data was collected. SPSS was used to analyze data as patients were classified by limbs in four groups: iliac branched, bell bottom, coil and cover technique, and standard treated limbs.

RESULTS

There were 65 male and 4 female patients included in this study incorporating 137 limbs with a mean age of 78 years (SD ± 8 years). Two patients died after discharge (at 3 and 21 months postoperatively, without hospital admission) and five patients were lost to long-term follow-up. Three patients had operations that deviated from the plan: one was an IBD converted to bell bottom, one was an IBD that was converted to coil and cover, and one was a bell bottom that did not seal. Follow-up revealed late type IB endoleak in three bell bottom limbs and one limb treated with coil and cover. Common iliac occlusion occurred in one IBD, three bell bottom limbs, and two limbs treated with coil/cover technique. There were four additional ischemic events (buttock claudication in three and intestinal ischemia in one): all ischemic events occurred in the coil and cover group (p = .001).

CONCLUSIONS

Given the small population size examined in this study, there is no statistical difference between treatment groups; however, there was a trend toward bell bottom technique being associated with higher incidence of type IB endoleak. Coil and cover technique was associated with decreased IB endoleak; however, Buttock claudication and intestinal ischemia occurred more significantly in this group. Using IBD may be the best strategy to improve short- and long-term outcomes in patients with iliac aneurysms.

Iliac Branch Devices in the Repair of Ruptured Aorto-iliac Aneurysms: A Multicenter Study

PURPOSE

To evaluate the outcomes of preserving the internal iliac artery (IIA) with iliac branched devices (IBDs) during acute endovascular repair of ruptured aortoiliac aneurysms.

MATERIAL AND METHODS

This is a multicenter retrospective review of all consecutive patients undergoing acute endovascular repair of ruptured aortoiliac aneurysm with an IBD at 8 aortic centers between December 2012 and June 2020. A control group was used where the IIA was intentionally occluded from the same study period. The main outcome measures were 30-day mortality, major adverse events, technical success, and clinical success. Secondary outcomes were buttock claudication, primary patency, primary-assisted and secondary patency of the IBD, occurrence of endoleak types I/III, and reintervention. Values are presented as numbers and percentages or interquartile range in parenthesis.

RESULTS

Forty-eight patients were included in the study: 24 with IBD and 24 with IIA occlusion. There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. Twenty (83%) of them were hemodynamically stable during the procedure as opposed to 14 (58%, p=.23) with the IIA occlusion. Technical success was achieved in all cases with a procedure time of 180 (133-254) minutes, 45 (23-65) of which were from IBD. There were 2 (8%) deaths during the first 30 days and 2 (8%) major complications unrelated to the IBD, whereas in the IIA occlusion, the figures were 10 (42%) and 7 (29%), respectively. No patient in the IBD group developed buttock claudication compared to 8 (57%, p<.0001) in the IIA occlusion group; 1 (4%) patient developed bowel ischemia on both groups, with 1 in the IIA occlusion group needing resection. The median follow-up duration was 17 months (interquartile range 2-39) for the IBD group, with a primary patency of 60±14% at 3 years that went up to 92±8% with reinterventions (8 reinterventions in 6 patients). When the first 90 days were disregarded, there were no differences in survival between the groups.

CONCLUSION

IBD is a valid alternative for maintaining the pelvic circulation for endovascular aortic aneurysm repair of ruptured aortoiliac aneurysms. The technical success and midterm outcomes are very satisfactory but require patient selection particularly regarding hemodynamic stability. The reintervention rate is considerable, mandating continuous follow-up.

CLINICAL IMPACT

This multicenter study demonstrates that ruptured aortoiliac aneurysms do not necessarily require mandatory occlusion of hypogastric arteries. Iliac branch devices are shown to be a valid alternative in highly selected cases, with good midterm results, even if reinterventions are required in a significant proportion of patients.

Mid-term outcomes of different treatments of internal iliac artery in endovascular aneurysm repair

OBJECTIVE

To evaluate the mid-term outcomes of different treatment strategies for the internal iliac artery (IIA) during EVAR.

METHODS

This was a retrospective study. All patients undergoing EVAR, who required treatment of at least one side of IIA from January 2013 to July 2022 in a single center, were included. According to the different treatment strategies for IIA, the patients were divided into UP (unilateral preservation), BP (bilateral preservation) and BE (bilateral embolization) groups. The primary outcomes included buttock claudication, bowel ischemia and iliac-related reintervention. Then patients who underwent IIA reconstruction were divided into IPG (iliac parallel stent graft) and IBG (iliac branch stent graft) groups according to the reconstruction technique. The primary outcomes included endoleak, iliac branch occlusion and iliac-related reintervention.

RESULTS

A total of 237 patients were included, including 167 in the UP group, 9 in the BP group and 61 in the BE group. The mean follow-up time was 39.0 ± 27.7, 50.0 ± 22.1 and 25.8 ± 18.9 months in UP, BP and BE groups, respectively. Thirty cases (12.7%) of buttock claudication occurred, and it was significantly higher in the BE group than the UP group (26.2% vs. 7.8%, p < 0.001). There were no significant differences in the other follow-up outcomes among three groups. The K-M analysis indicated that the patients in the BE group had a lower survival rate than those in the other two groups (p = 0.024). 24 patients underwent IIA reconstruction, including 8 in the IPG group and 16 in the IBG group. The endoleak in the IBG group was significantly lower than that in the IPG group (0% vs. 25.0%, p = 0.041). The iliac-related reintervention, iliac occlusion and mortality were similar between the two groups.

CONCLUSION

Overall it is beneficial for patients to preserve at least one side of IIA during EVAR as much as possible. Compared with IPG, IBG might be more applicable for IIA reconstruction.

Results Following Stent-Graft Coverage of the Hypogastric Artery in the Management of Aortoiliac Aneurysms in Endovascular Aneurysm Repair

<b><br>Aim:</b> The aim of our study was to assess the outcomes of stent-graft coverage of the hypogastric artery in the management of aortoiliac aneurysms with endovascular aneurysm repair (EVAR).</br> <b><br>Material and methods:</b> From January 2013 to March 2017, a total of 93 patients with aortoiliac aneurysms were treated with EVAR, which required occlusion of one or both of the hypogastric arteries. The patients of the Department of General, Vascular, Endocrine and Transplant Surgery were included in the study continuously and all procedures were elective.</br> <b><br>Results:</b> A total of 93 patients with aortoiliac aneurysms required a unilateral or bilateral procedure. Six patients were excluded from our study because they did not appear at their follow-up appointments. The study included 87 patients (80 men; mean age 71.9 (7.9) years, range 54-88), of which 30 had a unilateral procedure and 57 had a bilateral procedure. In 8 procedures (5.55%, n = 7) there was a type II endoleak that resolved during follow-up and required no surgical intervention. In 10 procedures (6.94%, n = 10) there was a type IB endoleak, with 8 procedures requiring surgical re-intervention in the form of an extension. In 12 procedures (8.33%, n = 9), the hypogastric artery thrombosed.</br> <b><br>Conclusion:</b> Coverage of the hypogastric artery by stent-graft has been proven to be a safe procedure, but there is still a risk of type II endoleak. Although 5.55% (n = 7) of the procedures in our study had a type II endoleak, none required surgical intervention.</br>.

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.

A multicenter experience of three different "iliac branched" stent grafts for the treatment of aorto-iliac and/or iliac aneurysms

BACKGROUND

The aim of study was to assess the safety and effectiveness of 3 different commercial iliac branch devices (IBDs): the Zenith Branch Iliac Endovascular Graft; the Gore Excluder Iliac Branch System and the E-liac Stent Graft System for the treatment of aorto-iliac or iliac aneurysms.

METHODS

From January 2017 to February 2020, a retrospective reviewed was conducted on a total of 96 patients. Primary endpoint was IBD instability rate at 24-months. Secondary endpoints included onset of any endoleaks, buttock claudication, IBD-related reintervention and all-death rates, post-operative acute kidney and changes in maximum diameter from baseline of the aortic aneurysmal sac.

RESULTS

At 24 months, the branch instability rate was similar amongst the three IBDs employed [Jotec 1/24 (4.1%), Gore 1/12 (8.3%), Cook 6/47 (12.7%), p-value = 0.502]. As well, no statistical difference in terms of branch-occlusion and branch-related endoleaks was observed. The Jotec group showed a significant decrease in maximum diameter from the baseline of the aortic aneurysmal sac when compared to the Gore group alone. No other differences were found relevant to the onset of any endoleaks, reinterventions and all-death rates. At 24-months, the Kaplan-Meier estimate of survival freedom from any branch instability was 95.8%, 91.6% and 86.8% for Jotec, Gore and Cook groups, respectively.

CONCLUSIONS

The use of IBDs represents a safe method for preserving patency of the IIA during treatment of aorto-iliac or iliac aneurysms providing a low rate of IBD instability.

Differences in Cardiac-Pulsatility-Induced Displacement and Geometry Changes between the Cook ZBIS and Gore IBE: Postoperative Comparison Using ECG-Gated CTA Scans

To what extent the stentgraft design of iliac branch devices (IBDs) relates to dynamic deformation is currently unknown. Therefore, this study aimed to quantify and compare displacement and geometry changes during the cardiac cycle of two common IBDs. This paper presents a two-center trial with patients treated with a Zenith bifurcated iliac side (ZBIS) or Gore iliac branch endoprosthesis (IBE). All patients underwent a retrospective electrocardiogram (ECG)-gated computed tomographic angiography (CTA) during follow-up. Cardiac-pulsatility-induced displacement was quantified for the following locations: (neo) bifurcation of the aorta, IBD flow divider, distal markers of the internal iliac artery (IIA) component and first IIA bifurcation. Geometrical parameters (length, tortuosity index, curvature and torsion) were quantified over centerlines. Displacement was more pronounced for the IBE than the ZBIS, e.g., craniocaudal displacement of 0.91 mm (0.91-1.13 mm) vs. 0.57 mm (0.40-0.75 mm, p = 0.004), respectively. The IBDs demonstrated similar geometrical parameters in the neo-common iliac artery and distal IIA, except for the larger dynamic curvature and torsion of the distal IIA in IBEs. The IBEs showed more dynamic length and curvature change compared to the ZBIS in the stented IIA. The IIA trajectory showed more pronounced deformation during the cardiac cycle after placement of an IBE than a ZBIS, suggesting the IBE is more conformable than the ZBIS.

Five-year outcomes from a prospective, multicenter study of endovascular repair of iliac artery aneurysms using an iliac branch device

OBJECTIVE

We have reported the 5-year results of a pivotal prospective, multicenter study conducted in the United States of a specifically designed iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) for endovascular repair of aortoiliac aneurysms and common iliac artery aneurysms.

METHODS

A total of 63 patients (98.4% male; mean age, 70 years) with aortoiliac or common iliac artery aneurysms had undergone implantation of a single IBE device and a bifurcated aortoiliac stent graft. Patients with bilateral common iliac artery aneurysms (n = 22; 34.9%) had undergone either staged occlusion or surgical revascularization of the contralateral internal iliac artery before study enrollment. At 5 years, 36 of the 63 patients had completed the final study follow-up examinations, including clinical examinations (n = 35) and computed tomography (n = 32), with the results evaluated by an independent core laboratory and adverse events adjudicated by a clinical events committee.

RESULTS

At 5 years, freedom from all-cause mortality was 85.7% and freedom from aneurysm-related mortality was 100%. The nine deaths that had occurred (range, 132-1898 days) were adjudicated as unrelated to the aneurysm or procedure. Primary patency of the internal and external iliac artery IBE limbs was 95.1% and 100%, respectively. No patients had experienced new-onset buttock claudication on the IBE side or self-reported new-onset erectile dysfunction. The common iliac artery diameter on the IBE side was either unchanged or had decreased by ≥5 mm in 30 of the 31 patients (96.8%) with a baseline (1 month) and 5-year (range, 1641-2006 days) computed tomography scan available. Of the 31 evaluable patients, 9 (29.0%) had had an increase of ≥5 mm in the aortic diameter, 5 of whom had had a concurrent type II endoleak. No type I or type III endoleaks or device migration were identified by the core laboratory. Six patients had undergone eight secondary interventions, including five interventions for a type II endoleak. The freedom from secondary intervention was 90.5%.

CONCLUSIONS

The 5-year results of our prospective, multicenter study have confirmed the safety, efficacy, and durability of the IBE device for the treatment of aortoiliac and iliac artery aneurysms. The device effectively prevented common iliac artery aneurysm rupture, maintained the patency of the internal iliac artery, and avoided the complications associated with internal iliac artery sacrifice. Although common iliac artery aneurysm enlargement was rare, abdominal aortic enlargement was more common, suggesting that the outcomes of endovascular aneurysm repair might be different for patients with or without associated common iliac artery aneurysms.

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.

Internal Iliac Artery Embolization within EVAR Procedure: Safety, Feasibility, and Outcome

BACKGROUND

This study is focused on Internal Iliac Artery (IIA) embolization in patients undergoing Endovascular Aneurysm Repair (EVAR). Our aims were: to establish the feasibility of the procedure; to assess the presence of endoleak (EL) and increase in the size of the sac at follow-up; to define the need for reintervention; and to evaluate mortality rate.

METHODS

In this retrospective single-center study, EVAR-treated patients with an embolization of IIA were chosen. Coils and vascular plug were used as embolizing agents.

RESULTS

A total of 49 participants were enrolled in the study (48 men and one woman) with a median age of 76 ± 12 years. Patients had no early EL in 87.75% of cases, 8.16% had type 1a EL, 2.04% type 1b EL, and 2.04% type 2 EL, with a comprehensive technical success of 95.91%. In the follow-up, at 1 month 72.22% remained without EL, at 6 months 70.97%, and at 1 year 81.48%. In the same period, the trend of type 1 EL was 5.56% (1 month), 3.23% (6 months), and 0% (1 year). For EL type 2: 22.22% at 1 month, 25.81% at 6 months, and 16.7% at 1 year. The overall mortality was 35.58% and the re-intervention rate was 16.33%.

CONCLUSIONS

IIA embolization is a feasible and safe procedure. The presence of EL is not superior to EVAR procedures that do not involve embolization.

Midterm Results of Iliac Branch Devices in a Newly Established Aortic Center

The first-line treatment of common iliac artery aneurysms is endovascular repair. International guidelines recommend the preservation of the internal iliac artery, which is best achieved by the implantation of an iliac bifurcation device (IBD). Our aim was to evaluate the initial midterm results of IBDs in the leading vascular center of Hungary. In this single-center retrospective study, relevant clinical data and the results of the imaging examinations were collected and analyzed in all patients who underwent IBD implantation between December 2010 and July 2021. Thirty-five patients (31 males, mean age: 67.9 ± 8.5 years) underwent endovascular treatment with 37 IBD implantations. Technical success was achieved in 88.2% of the patients, with no perioperative mortality or open surgical conversion. One patient was lost during follow-up. Internal iliac artery occlusion was detected in three (8.8%) patients, and reintervention was performed in five (14.7%) patients. Primary patency of the internal iliac branch was 97.1% at 1 month, 93% at 2 months, and 89.0% at 5 years. The average follow-up time was 20.1 ± 26.2 months, during which two (5.9%) deaths occurred. Our initial experience with iliac branch devices was associated with a low complication rate and a favorable outcome, which confirms the midterm success of this intervention.

Iliac branch device to treat type IB endoleak with a brachial access or an "up-and-over" transfemoral technique

PURPOSE

This study aimed to review the results of secondary IBD (iliac branch device) implantation in patients with type IB endoleak after prior fenestrated and/or branched or infrarenal endovascular aortic repair (F/B-EVAR or EVAR), using either brachial access or an "up-and-over" transfemoral technique.

METHODS

A retrospective single centre analysis was conducted between Jan 2016 and Oct 2021 including consecutive patients that underwent IBD to correct a type IB endoleak after prior EVAR or F/B-EVAR. Groups were defined by arterial access which was either brachial (group 1) or transfemoral (group 2). All IBD implanted were manufactured by Cook Medical (INC, Bloomington, IN, USA). Demographics, anatomical features, technical success, and 30-day major adverse events (MAE) were recorded according to the current SVS standards. Survival curves according to Kaplan-Meier were calculated. Branch instability was a composite endpoint of any IIA branch-related complication or reintervention indicated to treat endoleak, kink, disconnection, stenosis, occlusion or rupture.

RESULTS

Overall, 28 patients (93% male, median age 74 years) receiving 32 IBDs were included, with 14 patients in each group. Prior endovascular aortic repairs were 23 EVAR and 5 F/B-EVAR, with time from initial repair being 58 months [48, 70]. Median pre-IBD maximal aneurysm diameter was 63.5 mm [59.0, 78.0]. Patients' baseline characteristics were similar in both groups except for pulmonary status. All procedures were performed in a hybrid operative room. Median total operating time, fluoroscopy time and dose area product were 120 min [86, 167], 23 min [15, 32] and 54 Gy.cm2 [40, 62], respectively. Total operating time was shorter in group 2 (p=0.006). Technical success rate was 100% and no early death reported. One 30-day MAE occurred including a medically treated colonic ischemia (group 2). Aortic-related secondary interventions were required in 7 patients (5 in group 1 and 2 in group 2) including 3 surgical explantations. Median follow-up was 31 months [24, 42] and 6 months [3, 10] in group 1 and 2, respectively. In group 1, 2-year freedom from aortic-related secondary intervention and IIA branch instability were 84.6% [67.1-100] and 92.3% [78.9-100], respectively. In group 2, 6-month freedom from aortic-related secondary intervention and IIA branch instability were 87.5% [67.3-100] and 91.7% [77.3-100], respectively.

CONCLUSION

The secondary implantation of IBD to correct distal type I endoleak of previous aortic stent-graft is safe with a high technical success rate. The "up-and-over" technique could be considered as an alternative to the brachial access in patients with suitable anatomy.

Hypogastric Artery Flow Interruption is Associated with Increased Mortality after Open Aortic Repair

OBJECTIVES

Potential complications of pelvic flow disruption during aortic aneurysm repair include buttock ischemia and mesenteric ischemia. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally to facilitate aneurysm repair, is considered problematic in endovascular repair; however, it has not been well studied in open abdominal aortic aneurysm (AAA) repair (OAR). We sought to examine the effect of interruption of flow to one or both hypogastric arteries on outcomes after OAR.

METHODS

The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. (redundant) Patients with appropriate data on their hypogastric arteries postoperatively were stratified into two groups - patent bilaterally (normal pelvic perfusion, NPP), and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion, CPP). Primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, renal injury, and lower extremity or intestinal ischemia) and mortality.

RESULTS

During the study period, 9.492 patients underwent elective open AAA repair - 860 (9.1%) with compromised pelvic perfusion and 8,632 (90.9%) with patent bilateral hypogastric arteries. The groups had similar cardiac risk factors, including history of coronary artery disease, prior coronary intervention and use of P2Y12 inhibitors and statins. A majority of patients in the CPP cohort had concurrent iliac aneurysms (63.3% versus 24.8%; p<.001). The perioperative mortality was significantly higher in patients with compromised pelvic perfusion (5.5% versus 3.1%; p<.001). Bilateral flow interruption had a trend toward higher perioperative mortality compared to unilateral interruption (7.1% versus 4.7%; p<.147). The CPP group also had increased rates of myocardial injury (6.7% versus 4.7%; p=.012), renal complications (18.9% versus 15.9%; p=.024), leg and bowel ischemia (3.5% versus 2.1%;, p=.008; and 5.7% versus 3.4%; p<.001, respectively). On multivariable analysis, CPP was associated with increased perioperative mortality (OR 1.47, CI 1.14-1.88, p=.003). On Kaplan-Meier analysis, there was no difference in survival at 2 years post discharge, between the NPP and CPP cohorts (86.1% versus 87.5%, logrank-p=0.275).

CONCLUSIONS

Compromised pelvic perfusion is associated with increased perioperative complications and higher mortality in patients undergoing OAR. The sequalae of losing pelvic perfusion in addition to the presence of more complex atherosclerotic and aneurysmal disease resulting in more difficult dissection likely contribute to these findings. Thus, patients considered for OAR who have occluded hypogastric arteries or aneurysmal involvement of the hypogastric artery preoperatively may be candidates for more conservative management beyond traditional size criteria.

Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms

INTRODUCTION

Isolated iliac artery aneurysms (IAA), accounting for 2-7 percent of all abdominal aneurysms, are nowadays often treated with the use of iliac branched endografts. Although outside of the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an EVAR device, for the treatment of isolated IAA. In this study we aim to describe the outcomes of the use of the Gore IBE device, without support of an infrarenal EVAR device, for the exclusion of isolated IAA.

DESIGN

This study is an international multicenter retrospective cohort analysis.

METHOD

All patients that were treated with a solitary IBE for IAA exclusion from 11-01-2013 up to 31-12-2018 were retrospectively reviewed. The primary outcome was technical success. Secondary outcomes included mortality, intraoperative and postoperative complications, and re-interventions.

RESULTS

In total 18 European and American centers participated, including 51 patients in which 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. There was no 30-day mortality and a 98.1% patency of both the internal and external iliac artery was found at 24-months follow-up. At 24-months follow-up, 81.5% of patients were free of complications and 90% were free of a secondary intervention.

CONCLUSION

Treatment with a solitary IBE is a safe and, at midterm, effective treatment strategy in selected patients with a solitary IAA.

Conformability of the GORE EXCLUDER iliac branch endoprosthesis is associated with freedom from adverse iliac events

OBJECTIVE

The GORE EXCLUDER iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz) is designed to preserve internal iliac artery (IIA) patency during endovascular treatment of aneurysms involving the common iliac artery. The device is intended to conform to iliac tortuosity, which may decrease adverse iliac events (AIE). The objective of this study was to evaluate risk factors for AIE after IBE implantation.

METHODS

This was a post hoc analysis of the prospective, multicenter GORE 12-04 IBE pivotal trial. Patients with preoperative and postoperative axial imaging were included, with analysis based on each treated iliac system. An independent core laboratory performed all scan measurements, including iliac diameters, lengths, and tortuosity. Conformability was analyzed by the changes in tortuosity after IBE deployment, with less change indicating greater conformation. The end point was AIE, defined as ipsilateral radiographic or clinical complications. Critical nonconformation was defined as a threshold change in tortuosity associated with a significant increase in AIE.

RESULTS

We included 98 patients with 101 treated iliac systems. There were eight AIE (8%; six IIA component occlusions, one iliac branch component occlusion, and one EIA dissection requiring reintervention). Patients with AIE had smaller IIA diameters and less IBE conformability. After multivariable logistic regression analysis, an IIA diameter of less than 10 mm and a change in total iliac tortuosity beyond -15% were independently associated with AIE (odds ratio, 12 [interquartile range, 1.4-110] and odds ratio, 8.2 [interquartile range, 1.5-46], respectively), and the latter was used to define critical nonconformation. Critical nonconformation occurred in 11% of treated systems, and was associated with a high rate of AIE (36% vs 4%; P = .004).

CONCLUSIONS

Endograft conformation is a novel device property and technical outcome that, along with a larger IIA diameter, is associated with freedom from AIE after IBE deployment. An evaluation of these risk factors may better inform the management of patients with iliac aneurysmal disease. Further research on endograft conformation and patient outcomes is warranted, particularly for those with challenging anatomy undergoing complex procedures.

Gluteal Blood Flow Monitoring in Endovascular Aneurysm Repair With Internal Iliac Artery Embolization

BACKGROUND

When an internal iliac artery (IIA) has to be embolized during endovascular aneurysm repair (EVAR), buttock claudication sometimes poses problems. However, there is no established method to evaluate intraoperative blood flow to the gluteal muscles.

METHODS AND RESULTS

Gluteal regional oxygen saturation (rSO2) was monitored using near-infrared spectroscopy (NIRS) during surgery, and changes in rSO2were compared with treatment results. Twenty-seven patients who underwent EVAR and IIA embolization at our institution between April 2019 and May 2020 were included in this study. The association between intraoperative changes in rSO2and postoperative incidence of buttock claudication was analyzed. Furthermore, the presence or absence of communication between the superior and inferior gluteal arteries and the intraoperative changes in rSO2were compared to ascertain whether rSO2reflects blood flow change. Postoperative buttock claudication occurred in 4 of 19 patients (21%) with unilateral occlusion of IIA and in 4 of 8 patients (50%) with bilateral occlusion of IIAs. rSO2was found to decrease significantly further in patients with buttock claudication than in patients without buttock claudication (-15±12% vs. -4±16%, P<0.05). In addition, rSO2was predominantly lower in patients without the communication between the superior and inferior gluteal arteries than in those with the communication.

CONCLUSIONS

Gluteal rSO2is useful as an indicator of intraoperative gluteal blood flow.

Preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery

Bilateral absence of the common iliac artery is an extremely rare congenital vascular malformation in which the distal aorta divides directly into two external iliac arteries and two internal iliac arteries. In the case of the presence of this vascular malformation in association with an aortic aneurysm, preservation of the internal iliac artery flow during endovascular aortic repair represents a technical challenge. We have reported a case in which the bilateral absence of the common iliac artery associated with an infrarenal abdominal aortic aneurysm was successfully treated by endovascular aortic repair using commercially available iliac branched devices to maintain pelvic perfusion.

The Effect of Manufacturer's Instructions for Use Compliance on Cook ZBIS Iliac-Branched Endograft Long-Term Outcomes

BACKGROUND

Current guidelines indicate iliac-branched endografts (IBDs) as the ideal means to preserve pelvic perfusion during endovascular aortic repair. Because patient vascular anatomy represents the main limitation to extensive use of these devices, off-label application may be considered to expand the number of patients being treated. The aim of this study is to evaluate long-term outcomes obtained using the Cook ZBIS endograft in the treatment of aortoiliac aneurysms as per or outside manufacturer's instruction for use (IFU).

METHODS

Data from all patients who underwent IBD implant in a single center were reviewed. Study population was divided into two subgroups: Group I treated as per manufacturer's IFU and group II treated outside IFU.

RESULTS

During the study period (2008-2018), 119 patients were treated with 130 IBDs. Eighty-six patients were treated as per IFU (group I) and 44 outside IFU (group II). Overall technical success was 99.2%. Mean follow-up was of 63.5 ± 38.3 months for group I and 58.3 ± 35.9 months for group II (P = 0.45). Freedom from reintervention at ten years was 79.8% in group I and 69.6% in group II (P = 0.29). Freedom from IBD-related reintervention rate was 98.7% and 95.3% in groups I and II, respectively (P = 0.240). Iliac-branched module thrombosis occurred significantly more in patients treated outside IFU with 4 cases in group I (4.7%) and 10 cases in group II (22.7%), (P = 0.005). Cox regression analysis identified hypogastric artery aneurysm as the only independent predictor for both IBD thrombosis and hypogastric artery occlusion during follow-up.

CONCLUSIONS

When used by an experienced team, Cook IBDs are safe and effective in the treatment of aortoiliac aneurysms both inside and outside IFU. Anyway a lower target hypogastric patency rate should be expected when treating patients with hypogastric aneurysms.

Midterm Results After Abandoning Routine Preemptive Coil Embolization of the Internal Iliac Artery During Endovascular Aneurysm Repair

PURPOSE

To analyze the results of endovascular repair of common iliac artery (CIA) aneurysms without preemptive coil embolization of the internal iliac artery (IIA).

MATERIALS AND METHODS

Between January 2010 and July 2016, 79 patients (mean age 74.3±8.4 years; 76 men) underwent endovascular repair extending into the external iliac artery owing to a CIA aneurysm. The procedure was performed for a ruptured aneurysm in 22 (28%) patients. Eighty-one IIAs were intentionally covered. The median CIA diameter was 37 mm (range 20-90). The primary outcomes were the occurrence of type II endoleaks and the incidence of buttock claudication.

RESULTS

Five (6%) patients died within 30 days (4 with ruptured aneurysms and 1 elective case). Two type II endoleaks originating from a covered IIA were recorded; one required an endovascular intervention because of aneurysm growth. The other patient died of a rupture based on an additional type III endoleak. Mean follow-up was 37.6±26.3 months. Nineteen (26%) patients required a secondary intervention. Buttock claudication was reported in 21 (28%) of 74 patients and persisted after 1 year in 7. No severe ischemic complications as a result of IIA coverage were recorded, and no revascularization was required during follow-up.

CONCLUSION

Treatment of CIA aneurysms by overstenting the IIA without preemptive coil embolization is safe and has a low risk of type II endoleak and aneurysm growth. Persisting buttock claudication is rare.

Endovascular Abdominal Aortic Aneurysm Repair

Most abdominal aortic aneurysms are treated with endovascular repair (EVAR) in current practice. EVAR has lower periprocedural mortality and morbidity than open surgical repair. Aneurysm neck morphology, iliac anatomy, and access vessel anatomy need careful assessment for the successful performance of EVAR. Regular and long-term follow-up with imaging is mandatory after EVAR, and patients who are less likely to comply are less favorable EVAR candidates. Endoleaks are the most frequent complication of EVAR. Most can be managed with transcatheter or endovascular means. Evolving technology and techniques are allowing more patients to be treated with EVAR with better long-term outcomes.

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.

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.

Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan

Purpose

The outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population.

Materials and Methods

We conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed.

Results

A total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes.

Conclusion

EVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.

[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.

Endovascular treatment of bilateral isolated aneurysm of the internal iliac artery

Isolated aneurysms of the iliac arteries comprise less than 2% of abdominal aneurysms. The internal iliac artery is involved in 10-30% of cases. In most cases patients are asymptomatic, unless rupture occurs. They can be diagnosed by Doppler ultrasonography, magnetic resonance imaging or, preferably, angiotomography. Significant expansion, diameter of 3 cm or greater, and symptomatic cases are indications for surgery. We present the case of a patient with an incidental ultrasonographic finding of bilateral aneurysm of the internal iliac arteries, both with indications for surgery. The patient was successfully treated with endovascular techniques, first repairing the right internal iliac with a branched iliac stent graft, preserving patency, then embolizing the left internal iliac artery. Knowledge of the various different techniques and devices and their limitations is fundamental to adequate planning of endovascular treatment, even in rare cases.

A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees

BACKGROUND

There has been a shift toward competency-based surgical education programs to improve trainee performance and achieve better patient outcomes. Endovascular procedures comprise a significant volume of vascular surgery, but the current methods for assessing the endovascular competence of vascular trainees in Australia and New Zealand are suboptimal. The objective of this study was to perform a need assessment to define the scope of endovascular expertise required by vascular surgical trainees to later aid in the development of novel surgical training assessment tools.

METHODS

A modified Delphi method was used to achieve expert consensus. Fifty-three key stakeholders in vascular surgical education and training (SET) in Australia and New Zealand were invited to take part in the 2-stage survey. Experts were asked which procedures they considered to be requisite for vascular surgery trainees and at which SET level competence should be achieved. The results were reiterated to the expert panel in the second stage, and consensus considered achieved if over 75% of experts were in agreement.

RESULTS

In the first stage 25 experts reached consensus that competence in 18 of the 26 procedures should be requisite for SET trainees. Twenty-two experts responded to the second stage and consensus was achieved for 12 out of 14 of the procedural items with mean percentage of experts in agreement being 90%.

CONCLUSIONS

A need assessment using a modified Delphi method has achieved consensus among experts in vascular surgery regarding the endovascular procedures considered to be requisite for vascular surgery trainees in Australia and New Zealand.

Insights and Clinical Implications from the pELVIS Registry for the Treatment of Aneurysms Involving the Iliac Bifurcation

The pErformance of iLiac branch deVIces for aneurysmS (pELVIS) Registry is the largest retrospective analysis of prospectively collected data on the use of iliac branch devices (IBD) for the treatment of iliac and aortoiliac aneurysms. It shows the feasibility of the technique with good short- and mid-term results. The most common anatomical challenge for IBD use is the presence of aneurysmal deterioration of the internal iliac arteries (IIA). Experience acquired in the registry treating concomitant aneurysmal lesions of the IIA provides significant information on the performance of IBDs for this specific clinical presentation. Treatment of isolated aneurysms in the common iliac artery without extension to the infrarenal aorta showed favourable results with lower costs, and lower use of irradiation and contrast media. Overall, the relatively low procedure-related complications and repeat interventions show broad applicability of the technique. Further analysis is required to evaluate the longstanding performance of IBD.

Longer bridging stent-grafts in iliac branch endografting does not worsen outcome and expands its applicability, even in concomitant diseased hypogastric arteries

BACKGROUND

The iliac side branch device (IBD) is a valid method for the treatment of abdominal aorto-iliac aneurysms. However there is still a lack of evidence regarding the optimal length of the bridging stent graft (BSG) since aneurysmal degeneration of the hypogastric artery (HA) is an exclusion criterion. The aim of this study was to analyse the impact of longer BSG compared to the widely used 38mm stent-grafts in terms of reintervention rate and primary patency.

METHODS

We retrospectively analyzed our prospectively collected database of all patients who underwent an endovascular aneurysm repair using an IBD in our center between April 2005 and May 2015. The used BSGs were divided into 2 groups. In group A, the BSG was ≤38 mm, and group B>38 mm. The primary endpoint was BSG-related events, including stenosis, occlusion or endoleak. Secondary endpoints were technical success, primary patency and 30-day mortality.

RESULTS

Two hundred sixty IBDs were implanted in 215 consecutive patients. Ninetyseven (37%) in group A and 163 (63%) in group B. The technical success rate was 100%. The 30-day mortality was 1% (N.=1) and 1.2% (N.=2) respectively for group A and B (P=0.8). The freedom from BSG-related events amounted to 84% at 60 months for the total cohort. The comparison between the two groups shows no significant difference, while a slight favorable trend for group B (75% vs. 91% at 60 months, P=0.081) was observed. No differences were found as to primary patency (96% and 99% at 60 months respectively for group A and B, P=0.237).

CONCLUSIONS

The use of longer stent-grafts (>38 mm) seems not to affect the performance of BSG even in the long run, expanding the indication for IBD also for aneurysms of the hypogastric artery.

Prospective study of the E-liac Stent Graft System in patients with common iliac artery aneurysms: 30-Day results

OBJECTIVES

To study the safety and feasibility of the E-liac Stent Graft System® in patients with aorto/iliac aneurysms.

METHODS

A prospective multicentric European registry of patients receiving the E-liac Stent Graft System® was conducted. Endpoints of the study included the technical success as well as periprocedural events and 30-day endoleaks, reinterventions, internal and external iliac artery patency and mortality.

RESULTS

Between July 2014 and June 2016, a total of 45 patients (93% men, mean age 72 years, range 53-90 years) were enrolled at 11 sites in four European countries. Five patients received an isolated iliac treatment. Thirty-seven patients were treated with a combination of an abdominal stent graft and a unilateral E-liac and three in combination with bilateral E-liac. All E-liac Stent Grafts (48) were implanted in the intended position and the internal iliac arteries were successfully bridged. Two patients did not receive clinical success, due to endoleak type Ia of the aortic stent graft. At 30-day follow-up, clinical success rate was 96%. Three successful endovascular reinterventions were performed within the 30-day follow-up: one due to a type Ia endoleak in the common iliac artery, one due to type Ia endoleak of the aortic stent graft, and one due to bilateral lower limb claudication provoked by stent graft limb stenosis. At 30-day, a 100% survival rate and complete absence of pelvic or buttock ischemia/claudication were reported. Primary patency at 30 days was 100% for the internal iliac artery and 98% for the external iliac artery with an assisted patency of 100% in the latter.

CONCLUSIONS

The high clinical success rate, low rates of device-related reinterventions (2%), and excellent patency rate demonstrate the safety and feasibility of the E-liac Stent Graft System. Long-term results are awaited to state efficacy and durability. Clinical Trials.gov. Identifier no. NCT02209194.

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.

Persistent Buttock Claudication after Endovascular Abdominal Aortic Aneurysm Repair

We describe the successful surgical treatment of a 71-year-old man affected by right buttock claudication after a right internal iliac artery (IIA) coil embolization as an adjunct to endovascular iliac artery aneurysm repair. Computed tomography angiography revealed extensive aortoiliac calcifications and thrombus in the vessel walls. Despite patency of the contralateral IIA and preservation of right distal collateral flow through ipsilateral hypogastric branches, the symptom was persistent and disabling. The high-risk patient underwent an "open" repair of the infrarenal abdominal aneurysm with removal of the entire stent-graft and concomitant revascularization of the right IIA. Post-operative recovery was uneventful, and the patient remained asymptomatic during a 30-month follow-up. This case underscores the importance of considering all potential solutions, including open surgery, to preserve pelvic inflow after aortoiliac stent grafting, particularly for high-risk patients with vulnerable plaque and higher risk of thrombus embolization.

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.