Use of Bilateral Cook Zenith Iliac Branch Devices to Preserve Internal Iliac Artery Flow During Endovascular Aneurysm Repair

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.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry

PURPOSE

To evaluate the clinical utility of the Gore Excluder iliac branch endoprosthesis (IBE) for Japanese patients with aortoiliac aneurysms.

MATERIALS AND METHODS

This was a multicenter retrospective cohort study (J-Preserve Registry). Patients undergoing endovascular aortic repair using the Gore Excluder IBE for aortoiliac aneurysms between August 2017 and June 2020 were enrolled. Data pertaining to the baseline and anatomical characteristics, technical details, and clinical outcomes were collected from each institution. The primary endpoints were technical success, IBE-related complications, and reinterventions. Secondary endpoints were mortality, aneurysm size change, and reintervention during follow-up. Technical success was defined as accurate deployment of the IBE without type Ib, Ic, or III endoleaks on the IBE sides on completion angiography. A change in aneurysm size of 5 mm or more was taken to be a significant change.

RESULTS

We included 141 patients with 151 IBE implantations. Sixty-five IBE implantations (43.0%) had at least one instruction for use violation. Twenty-two patients (15.6%) required internal iliac artery (IIA) embolization for external iliac artery extension on the contralateral side. Of 151 IBE implantations, 19 exhibited IIA branch landing zones due to IIA aneurysms. Mean maximum and proximal common iliac artery (CIA) diameters were 32.9±9.9 mm and 20.5±6.9 mm, respectively. The mean CIA length was 59.1±17.1 mm. The IIA landing diameter and length were 9.0±2.3 mm and 33.8±14.6 mm. The overall technical success rate was 96.7%. There were no significant differences in IBE-related complications (2.3% vs 5.3%, p=0.86) or IBE-related reinterventions (1.5% vs 5.3%, p=0.33) between the IIA trunk and IIA branch landing groups. The mean follow-up period was 635±341 days. The all-cause mortality rate was 5.0%. There were no aneurysm-related deaths or ruptures during the follow-up. Most patients (95.7%) had sac stability or shrinkage.

CONCLUSION

The Gore Excluder IBE was safe and effective for Japanese patients in the midterm. Extending the IIA device into the distal branches of the IIA was acceptable, which may permit extending indications for endovascular aortic aneurysm repair of aortoiliac aneurysms to more complex lesions.

CLINICAL IMPACT

This study suggests clinical benefits of the Gore Excluder IBE for Japanese patients, despite 43% of the IBE implantations having at least one IFU violation.

The Use of an Iliac Branch Device: Single-Center Study of Endovascular Preservation of Internal Iliac Artery Flow

Purpose

To determine the efficacy and safety of iliac branch device (IBD) implantation and to evaluate its limitations based on 7 years of experience in a single center.

Materials and Methods

This single-center study included patients with bilateral common iliac artery aneurysms (CIAAs). We investigated follow-up CT and reviewed the internal iliac artery (IIA) patency and complications related to IBD. A retrospective analysis was performed and the overall survival rate and freedom from reintervention rate were reported according to the Kaplan-Meier method.

Results

Of the 38 patients with CIAAs, only 10 (12 CIAAs) were suitable for IBD treatment. Five patients underwent unilateral IBD insertion with contralateral IIA embolization, and three (60%) showed claudication; however, symptoms resolved within 6 months. The 7-year freedom from IBD-related reintervention rate was 77.8%. No procedure-related deaths occurred.

Conclusion

IBD has good technical success and long-term patency rates; however, anatomical factors frequently limit its application, particularly in Asians. Additionally, unilateral IIA embolization showed relatively mild complications and a good prognosis; therefore, it can be performed safely for anatomically complex aortoiliac aneurysms.

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.

Bilateral Implantation of Double-Branched Iliac Branch Devices for Endovascular Repair of Aorto-Bi-Iliac Aneurysm With Concomitant Hypogastric Aneurysms: The Quadruple Branch

PURPOSE

The purpose of this report is to describe the use of a double-branched custom-made iliac branch device (IBD) for the endovascular repair of an aorto-bi-iliac aneurysm with concomitant bilateral hypogastric aneurysms.

TECHNIQUE

A 61-year-old man on peritoneal dialysis underwent a computed tomography (CT) of the infrarenal aorta before planned kidney transplantation. The CT showed an asymptomatic aorto-bi-iliac aneurysm of 54 mm involving the hypogastric artery (HA) bilaterally (right HA 31 mm; left HA 40 mm). The treatment consisted of an endovascular aortic repair (EVAR) and the bilateral implantation of custom-manufactured IBDs with double inner branches to preserve both superior and inferior gluteal arteries. At 1 year follow-up, the patient remains free of symptoms and the postoperative CT showed a successfully excluded aneurysm with patent bridging stent grafts to all HA branches.

CONCLUSION

The bilateral implantation of double-branched IBDs is a feasible technique. Preservation of both hypogastric arteries and its branches can be achieved with this technique and therefore decrease the risk of buttock claudication and other ischemic complications.

A systematic review and meta-analysis of the clinical effectiveness and safety of unilateral versus bilateral iliac branch devices for aortoiliac and iliac artery aneurysms

OBJECTIVES

Iliac branch devices (IBDs) have been utilized in the treatment of aortoiliac and isolated iliac artery aneurysms. The aims of this systematic review and meta-analysis were to investigate the clinical effectiveness and safety of IBDs.

METHODS

A systematic review of the literature was conducted by identifying studies in the Medline, EMBASE, and Cochrane databases regarding the outcomes of IBDs in aortoiliac or isolated iliac artery aneurysms between May 2006 and December 2020. Individual studies were evaluated for the following major outcomes: technical success, 30-day mortality, primary patency, endoleak, reintervention, and rates of pelvic ischemia. Furthermore, sub-group meta-analyses were performed to compare the pelvic ischemic events in patients with bilateral IBDs, unilateral IBDs and bilateral internal iliac artery (IIA) embolization/coverage.

RESULTS

45 studies with a total of 2736 patients undergoing unilateral or bilateral IBDs met inclusion criteria and were included in the analysis. The pooled technical success rate of IBD was 98.0% (CI: 97.3-98.7%). Following IBD treatment, the 30-day mortality rate was 0.4% (CI: 0.07-0.70%); 30-day patency was 98.4% (CI: 97.7-99.0%); buttock claudication developed in 1.84% (CI: 1.26-2.41%); endoleak occurred in 11.9% (CI: 9.2-14.7%) and re-intervention in 7.6% (CI: 5.65-9.58%). Furthermore, in the patients with bilateral iliac artery involvement the pooled estimate rates of buttock claudication were 0.7% in bilateral IBD group, 7.9% in unilateral IBD with contralateral IIA embolization patients and 33.8% in bilateral IIA embolization/coverage patients, which were statistically significant among the three groups. Sexual dysfunction was 5.0% in bilateral IIA occlusion group, which was significantly higher than that in IBD groups.

CONCLUSIONS

The utilization of IBDs in treatment of aortoiliac or isolated iliac artery aneurysms is associated with high technical success rates as well as low incidences of pelvic ischemia. The risk of postoperative buttock claudication can be further decreased with both IIA preservation if patients are anatomically suitable for bilateral IBDs.

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.

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry

OBJECTIVE

To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry.

METHODS

For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak.

RESULTS

Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904).

CONCLUSIONS

Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.

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.

Morphological applicability of currently available stent grafts in the endovascular repair of asymptomatic abdominal aortic aneurysm in East-Central European patients

Introduction

Currently, there is a wide range of commercially available devices for endovascular aneurysm repair (EVAR) that differ in terms of both anatomical requirements and the technology and technique of deployment.

Aim

To assess the applicability of currently commercially available devices for EVAR in the treatment of an asymptomatic abdominal aneurysm (AAA).

Material and methods

The study group included 100 patients with infrarenal AAA with a maximum diameter ≥ 50 mm, qualified for invasive treatment at the University Hospital in 2013–2014. The aortoiliac morphological characteristics of the AAA were evaluated on preoperative computed tomography angiograms using the OsiriX DICOM viewer in the 3D-MPR mode. The morphological applicability of 14 types of CE-marked and FDA-approved stent grafts was determined based on their instructions for use (IFU).

Results

EVAR was feasible with at least one of the analysed devices in 68% of patients. The morphological applicability was as follows: Excluder Conformable (65%), Ovation iX (51%), Endurant II (47%), Treo (45%), Excluder C3 (45%), AFX 2 (45%), Incraft (44%), E-tegra (44%), Zenith Alfa (41%), Zenith Flex (40%), Anaconda (39%) Aorfix (37%), Altura (34%), and E-vita (20%). The differences in the stent graft applicability were statistically significant (p < 0.001). A wide diameter of the common iliac artery, angulated proximal neck, and diameter of proximal neck out of range constituted the most frequent causes of EVAR inapplicability.

Conclusions

The IFU-based applicability of currently available AAA stent graft systems differs significantly. Despite the constant evolution of EVAR technology, at least 32% of AAA will require a different therapeutic approach.

Treatment of a traumatic aortic bifurcation injury with an iliac branch endoprosthesis

We present the case of a 62-year-old man who sustained a traumatic distal aortic injury associated with an adjacent lumbar vertebral body fracture resulting from a 20-ft fall. Given the site of injury, an iliac artery branched endograft was deployed off-label to preserve the aortic bifurcation and cover a limited amount of healthy aorta to preserve the collaterals. The procedure was successful, with no intraoperative complications or evidence of an endoleak. The aortic bifurcation and distal iliac arteries remained widely patent by computed tomography angiography at the follow-up examination without evidence of sequelae.

Comparison of Two Iliac Branch Devices and Their Midterm Performance in Maintaining Blood Flow to the Internal Iliac Artery

Purpose: To compare and contrast the midterm outcomes of the E-liac and Zenith (ZBIS) iliac branch devices (IBDs) for the preservation of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: Between January 2014 and December 2018, 84 consecutive patients (median age 74 years; 76 men) were electively treated with the E-liac (n=44) or ZBIS (n=40) IBDs and were retrospectively analyzed to evaluate the technical success, patency, need for reintervention, and mortality associated with these devices. Results: Technical success was achieved in 95 of 99 implantations (95.9%) without any statistically significant difference between the groups (93.7% vs 98.0%, p=0.114). During the first 30 days, 3 occlusions in the ZBIS group and 1 in the E-liac group were identified. There was 1 perioperative death in the ZBIS group. The median follow-up was 37 months for the ZBIS group and 28 months for the E-liac group (p=0.657). Six patients from the ZBIS group and 7 from the E-liac group were lost to follow-up. Among the remaining, there were 2 further deaths recorded, 1 in each group. Four further reinterventions in the E-liac group and 2 in the ZBIS group were performed during follow-up. The Kaplan-Meier estimates of freedom from reintervention were 87.2% (95% CI 82.6% to 90.2%) for the ZBIS group and at 86.0% (95% CI 83.7% to 89.1%) for the E-liac group (p=0.563); the freedom from occlusion estimates were 89.7% (95% CI 85.8% to 94.5%) and 95.3% (95% CI 92% to 98.7%; p=0.317), respectively. Conclusion: The E-liac and the ZBIS IBDs showed equally high technical success, midterm patency, and low reintervention rates.

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.

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.

Endovascular Treatment of Complex Aneurysms with the Use of Covera Stent Grafts

PURPOSE

To characterize the short-term results of a newly available self-expanding covered stent (Covera; CR Bard Peripheral Vascular Inc., Murray Hill, New Jersey) for the reconstruction of target vessels in complex aneurysms.

MATERIALS AND METHODS

From August 2017 to November 2018, this self-expanding covered stent was used in 17 patients (mean 72.6 ± 7.6 years of age) during endovascular aneurysm repair (EVAR) with hypogastric preservation (11.8%), branched EVAR (29.4%), fenestrated (F)-EVAR (17.6%), chimney + F-EVAR (11.8%), or chimney EVAR (29.4%). In more than 48 stented arteries (2.8 ± 1.1/patient), 25 were preserved using this self-expanding covered stent.

RESULTS

All target vessels were successfully preserved. There was no 30-day mortality and 1 in-hospital death. Intraoperative aneurysm exclusion was successful in 14 patients (82.4%) with a perioperative technical success rate of 82.4%. The actuarial survival rate was 93.8% at 6 months and 85.9% at 12 months. Aneurysm sac regression of >5 mm was observed in 4 cases (23.5%), and the sac remained stable in the remaining patients (13 cases [76.5%]). At 12 months, the primary clinical success rate was 76.5%, and assisted primary clinical success rate was 82.4%. No type 3 endoleak was related to a disruption of the reconstruction with the self-expanding covered stent.

CONCLUSIONS

This new self-expanding covered stent provides good short-term patency in chimneys, branches, or fenestrations. Larger series with long-term follow-up are required to determine if the stent can sustain the mechanical stress to which it will be submitted in these repairs.

Total robotic iliac aneurysm repair with preservation of the internal iliac artery using sutureless vascular anastomosis

Objective

Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments.

Methods

Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft.

Results

The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m² (range, 23-26.4 kg/m²). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs.

Conclusions

Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.