Conduits and endoconduits, percutaneous access

Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis

PURPOSE

The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies.

MATERIALS AND METHODS

A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality.

RESULTS

Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004).

CONCLUSION

Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.

Thoracic Endovascular Aortic Repair Through Cardiac Apex in the Setting of Thoracic Aortic Rupture

Treatment of thoracic aortic rupture poses a substantial challenge for the aortic surgeon. The advent of thoracic endovascular aortic repair (TEVAR) revolutionized the treatment of this heterogeneous group of diseases. Some patients suitable for TEVAR, however, present severe peripheral vascular diseases that can prevent standard retrograde delivery of the stent graft through the femoral artery. In this report, we present a case series of 5 patients with thoracic aortic rupture successfully treated with cardiac transapical TEVAR.

Perioperative Outcomes in Patients Requiring Iliac Conduits or Direct Access for Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Iliac conduit or direct iliac access (ICDA) can be used when anatomy is unfavorable for femoral access during abdominal endovascular aortic aneurysm repair (EVAR). The impact of this approach has not been adequately addressed. The objective of this study was to analyze perioperative outcomes of patients requiring use of ICDAs for EVAR.

METHODS

Patients undergoing EVAR with and without ICDA were identified in the 2005-2012 National Surgical Quality Improvement Program data sets. Perioperative morbidity and mortality were assessed by crude comparison of matched groups and multivariate analyses.

RESULTS

Of 15,082 patients undergoing infrarenal EVAR 147 (1%) required ICDA. The ICDA group had a higher proportion of females (25.9% vs. 17.8%, P = 0.017), peripheral vascular disease (12.9% vs. 5.5%, P = 0.001), and patients with a history of dyspnea (31.3% vs. 23.1%, P = 0.024). There was no difference in age (74.5 ± 8.4 conduit vs. 73.5 ± 8.5). On multivariate analysis, the ICDA cohort had a higher rate of mortality (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.4-5.4; P = 0.004) and an increase in other major complications including cardiac arrest and/or myocardial infarction (OR, 2.9; 95% CI, 1.3-6.3; P = 0.007), pulmonary complications (OR, 2.1; 95% CI, 1.2-3.9; P = 0.013), and postoperative length of stay (means ratio, 1.3; 95% CI, 1.1-1.4; P = 0.001). There was a trend toward increased bleeding complications with ICDA. Matched analyses of comorbidities revealed that patients requiring ICDA had higher perioperative mortality (6.8% vs. 2.3%, P = 0.008), cardiac (4.8% vs. 1%, P = 0.004), pulmonary (8.8% vs. 3.4%, P = 0.006), and bleeding complications (10.2% vs. 4.6%, P = 0.016).

CONCLUSIONS

Our results demonstrate that the use of ICDA during EVAR is associated with increased morbidity and mortality. In situations where anatomy mandates the use of iliac conduits or access for EVAR, surgeons should consider this increased risk. Open repair or the use of lower profile devices, if possible, should be considered as options for these patients.

Unfavorable iliac artery anatomy causing access limitations during endovascular abdominal aortic aneurysm repair: application of the endoconduit technique

Endovascular aneurysm repair (EVAR) is already considered the first choice treatment for abdominal aortic aneurysms (AAA). Several different strategies have been used to address limitations to arterial access caused by unfavorable iliac artery anatomy. The aim of this report is to illustrate the advantages and limitations of each option and present the results of using the internal endoconduit technique and the difficulties involved.