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Panthofer A, Bresler AM, Olson SL, Kuramochi Y, Eagleton M, Böckler D, Schneider DB, Lyden SP, Blackwelder WC, Meadows W, Pauli T, DeRoo E, Matsumura JS. Multicenter CT Image-Based Anatomic Assessment of Patients with Aortoiliac Aneurysm Undergoing Endovascular Repair with Iliac Branch Devices. Ann Vasc Surg 2024; 108:484-497. [PMID: 39009130 DOI: 10.1016/j.avsg.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 07/17/2024]
Abstract
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.
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Affiliation(s)
- Annalise Panthofer
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | | | - Sydney L Olson
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Yuki Kuramochi
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dittmar Böckler
- Department of Vascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sean P Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - William C Blackwelder
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Epidemiology & Public Health, University of Maryland, Baltimore, MD
| | - Wendy Meadows
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Tom Pauli
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Elise DeRoo
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jon S Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
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Volteas P, Giannopoulos S, Koudounas G, Asencio A, Chandrashekar A, Karkos C, Virvilis D. Endovascular Treatment of Aortoiliac Aneurysms With the Bell-Bottom Technique: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2024:15385744241284071. [PMID: 39254224 DOI: 10.1177/15385744241284071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
OBJECTIVE Aneurysmal degeneration of the common iliac artery (CIA) can pose a challenge to achieve distal landing zone sealing at the time of endovascular abdominal aortic aneurysm repair (EVAR). The aim of this study was to summarize the current literature regarding the bell-bottom technique (BBT) for ectatic CIAs during EVAR. METHODS This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible articles were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until April 2023. A meta-analysis was conducted using the random effects model and the I2 statistic was used to assess for heterogeneity. The primary endpoints were type Ib/III endoleak, graft occlusion/limb embolization, and reintervention rate. Secondary endpoints included perioperative adverse events and mortality. RESULTS Overall, twenty-six studies and 4332 patients with flared limbs were included. The pooled estimate for type Ib/III endoleak was 4% (95% CI: 2-6, I2 = 85.6%), for reintervention rate was 9% (95% CI: 6-12, I2 = 90.4%), and for overall mortality was 10% (95% CI: 4-19, I2 = 97.3%). No aneurysm related deaths were recorded. Comparative analysis showed similar type Ib/III endoleak, graft occlusion, and reintervention rates between the EVAR BBT, iliac branch endoprosthesis (IBE), and embolization of the internal iliac artery followed by extension of the iliac limb to the external iliac artery (EIE) groups. CONCLUSIONS The use of flared limbs could be considered a reasonable first line choice for EVAR cases with CIA ectasia as it is simpler, allows for future IBE or EIE and does not increase the risk for type Ib/III endoleak or graft occlusion. Further comparative studies with longer follow-up are needed.
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Affiliation(s)
- Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Georgios Koudounas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
- Vascular Unit, 5th Department of Surgery, Aristotle University Medical School, Hippokratio Hospital, Thessaloniki, Greece
| | - Anthony Asencio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Anirudh Chandrashekar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Christos Karkos
- Vascular Unit, 5th Department of Surgery, Aristotle University Medical School, Hippokratio Hospital, Thessaloniki, Greece
| | - Dimitrios Virvilis
- Department of Vascular and Endovascular Surgery, St Francis Hospital & Heart Center, Roslyn, NY, USA
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Ji J, Bi J, Chen Y, Zhang X, Zhao B, Liang H, Fan J, Dai X. Mid-term outcomes of different treatments of internal iliac artery in endovascular aneurysm repair. Sci Prog 2024; 107:368504241274998. [PMID: 39252493 PMCID: PMC11388315 DOI: 10.1177/00368504241274998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
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.
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Affiliation(s)
- Jie Ji
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bin Zhao
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hao Liang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jibo Fan
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Giese A, Heyligers JMM, Milner R. Five-year outcomes for bell bottom, iliac branch endoprosthesis, and coil and cover approaches from the GREAT registry. J Vasc Surg 2024; 79:1369-1378. [PMID: 38316346 DOI: 10.1016/j.jvs.2024.01.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE There are a variety of methods used today to treat common iliac aneurysms with endovascular techniques. Of these approaches, little is known about whether a particular limb strategy influences endoleak, reintervention, or aneurysm regression rates. We present 5-year data comparing endoleak, stent graft migration, fracture, aneurysm sac dynamics, and aortic rupture rates among patients treated with bell bottom limbs (BB), iliac branch endoprosthesis (IBE), and coil and cover (CC) approaches from the Global Registry for Endovascular Aortic Treatment registry. Secondary end points were all-cause mortality, stroke, reintervention, and paraplegia. METHODS Subjects from the GORE Global Registry for Endovascular Aortic Treatment were enrolled over a 5-year period from October 2017 to August 2022. We included 924 subjects in this study. Statistical data was generated on R software and limb groups were compared using the Pearson's χ2 test and the Kruskal-Wallis rank-sum test. RESULTS We found no statistical difference in endoleak rates, stent graft migration, fracture, or aortic rupture when stratified by limb strategy. There was no difference between limb approaches with regard to aneurysm sac dynamics among those with abdominal aortic aneurysms and common iliac aneurysms. Similarly, no statistical difference between limb strategies was found in all-cause mortality, stroke, paraplegia, or reintervention rates. Among patients that required an additional graft during reintervention, the highest rates were found within the IBE group 8.6%, compared with BB group 2.2% and CC group 1.3% (P = .006). CONCLUSIONS Overall, there was no difference among limb strategies in endoleak rates, stent graft migration, aneurysm sac dynamics, aortic rupture rates, or our secondary end points. Increased rates of reintervention requiring an additional graft within the IBE group is noteworthy and must be weighed against the adverse effects of hypogastric sacrifice with the CC approach or potentially less advantageous seal zones in the BB approach. This finding suggests that all limb approaches have equivalent effectiveness in managing the aneurysmal common iliac artery; thus, the choice of limb strategy should be individualized and remain at physician discretion. Future research should include a more robust sample size to reproduce these findings.
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Affiliation(s)
- Angela Giese
- Department of Vascular Surgery, University of Chicago, Chicago, CA.
| | - Jan M M Heyligers
- Department of Vascular Surgery, Elisabeth-TweeSteden Ziekenhuis Hospital, Tilburg, The Netherlands
| | - Ross Milner
- Vascular Surgery and Endovascular Therapy, Center for Aortic Diseases, University of Chicago, Chicago, CA
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Banks CA, Blakeslee-Carter J, Beck AW, Pearce BJ. Hybrid Pelvic Revascularization in Complex Aortoiliac Aneurysm Repair. Ann Vasc Surg 2024; 99:356-365. [PMID: 37890769 DOI: 10.1016/j.avsg.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/31/2023] [Accepted: 08/28/2023] [Indexed: 10/29/2023]
Abstract
Revascularization of complex pelvic vascular anatomy presents an ongoing clinical challenge when treating aortoiliac disease. As vascular surgeons continue to intervene upon increasingly complex aortoiliac pathology, the role of pelvic revascularization is important for the preservation of pelvic organ function and prevention of devastating spinal cord ischemia. In this study we describe the indications, techniques, and clinical outcomes of a novel hybrid pelvic revascularization repair that focuses on optimizing revascularization while limiting pelvic surgical dissection during the management of complex aortic pathology in patients physiologically or anatomically unsuitable for traditional pelvic revascularization techniques.
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Affiliation(s)
- C Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Ogawa Y, Fujimura N, Yamaguchi M, Banno H, Furuyama T, Yamaoka T, Sumi M, Fukuda T, Morikage N, Sohgawa E, Onitsuka S, Nishimaki H, Ichihashi S. Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry. J Endovasc Ther 2024; 31:55-61. [PMID: 35815459 DOI: 10.1177/15266028221109477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Yukihisa Ogawa
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Masato Yamaguchi
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Makoto Sumi
- Department of Vascular Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University, Ube, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Seiji Onitsuka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hiroshi Nishimaki
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
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Tatsuishi W, Shibuya K, Konishi Y, Oi A, Soda T, Abe T. Endovascular Aneurysm Repair Using Physician-Modified Fenestrated Endurant Contralateral Limb for Internal Iliac Artery Preservation. J Endovasc Ther 2023:15266028231215204. [PMID: 38041256 DOI: 10.1177/15266028231215204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
CLINICAL IMPACT We developed a novel Endovascular aortic repair technique for internal iliac artery preservation using a physician modified Endurant contralateral limb. This procedure was safe and reliable for preserving internal iliac artery flow in 24 patients with common and internal iliac artery aneurysms. We believe that our technique has the potential to expand the anatomic indications for internal iliac artery preserving procedures.
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Affiliation(s)
- Wataru Tatsuishi
- Division of Cardiovascular Surgery, Department of General Surgical Science, Gunma University, Maebashi, Japan
| | - Kei Shibuya
- Department of Radiology, Gunma University, Maebashi, Japan
| | - Yasunobu Konishi
- Division of Cardiovascular Surgery, Department of General Surgical Science, Gunma University, Maebashi, Japan
| | - Atsushi Oi
- Division of Cardiovascular Surgery, Department of General Surgical Science, Gunma University, Maebashi, Japan
| | - Takashi Soda
- Division of Cardiovascular Surgery, Department of General Surgical Science, Gunma University, Maebashi, Japan
| | - Tomonobu Abe
- Division of Cardiovascular Surgery, Department of General Surgical Science, Gunma University, Maebashi, Japan
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Brahmandam A, Guzman RJ, Nassiri N. Iliac branch endoprosthesis for repair of a common iliac artery aneurysm in Loeys-Dietz syndrome type 3. J Vasc Surg Cases Innov Tech 2023; 9:101131. [PMID: 36970132 PMCID: PMC10033979 DOI: 10.1016/j.jvscit.2023.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023] Open
Abstract
The commercial availability of the iliac branch endoprosthesis (IBE) has permitted endovascular repair of iliac artery aneurysms with the preservation of pelvic circulation. However, the device instructions for use require certain anatomic criteria that can limit deployment in ≤30% of patients. Moreover, branched endovascular treatment of common iliac artery aneurysms with IBE in patients with connective tissue disorders such as Loeys-Dietz syndrome has not been described. In the present report, we have described our technique of alternative endograft aortoiliac reconstruction to overcome anatomic barriers to IBE placement in a patient with a giant common iliac artery aneurysm in the setting of a rare pathogenic variant in the SMAD3 gene.
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Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Raul J. Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
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Jungi S, Papazoglou DD, Chan HL, Schmidli J, Makaloski V. Novel Surgeon-Modified Fenestrated Iliac Stent Graft. J Endovasc Ther 2023:15266028231173311. [PMID: 37191262 DOI: 10.1177/15266028231173311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE We describe the feasibility and early results of a novel endovascular approach with a surgeon-modified fenestrated iliac stent graft to preserve pelvic perfusion in patients with iliac aneurysms not suitable for iliac branch devices (IBDs). TECHNIQUE Seven high-risk patients, median age 76 years (range 63-83), with a complex aortoiliac anatomy with contraindications for commercially available IBDs were treated with a novel surgeon-modified fenestrated iliac stent graft between August 2020 and November 2021. The modified device was built using an iliac limb stent graft (Endurant II Stent Graft; Medtronic), which was partially deployed, surgically fenestrated with a scalpel, reinforced, re-sheathed, and inserted via femoral access. The internal iliac artery was cannulated and bridged with a covered stent. Technical success rate was 100%. After a median follow-up period of 10 months, there was 1 type II endoleak and no migrations, stent fractures, or loss of device integrity. One iliac limb occlusion occurred after 7 months, which needed a secondary endovascular intervention, restoring patency. CONCLUSION Surgeon-modified fenestrated iliac stent graft is feasible and might be used as an alternative in patients with a complex iliac anatomy not suitable to commercially available IBDs. Long-term follow-up is needed to evaluate stent graft patency and potential complications. CLINICAL IMPACT Surgeon modified fenetrated iliac stent grafts might be a promising alternative to iliac branch devices, extending endovascular solutions to a broader patient population with complex aorto-iliac anatomies preserving antegrade internal iliac artery perfusion. It is possible to treat small iliac bifurcations and large angulations of the iliac bifurcation safely and there is no need for a contralateral or upper-extremity access.
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Affiliation(s)
- Silvan Jungi
- Department of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | - Hon-Lai Chan
- Department of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
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10
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Bennett KM, Hurley L, Kyriakides TC, Matsumura JS. Analysis of Repair Type and Hypogastric Artery Antegrade Perfusion and Erectile Function Following Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2023:S0890-5096(23)00246-7. [PMID: 37164171 DOI: 10.1016/j.avsg.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/22/2023] [Accepted: 04/23/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Published reports suggest that exclusion of antegrade hypogastric artery flow may have deleterious effects on erectile function after abdominal aortic aneurysm repair. Off-label and open surgical hybrid procedures and, more recently, purpose-built branched devices have been developed to maintain antegrade pelvic perfusion in patients undergoing endovascular repair. Maintaining antegrade perfusion may reduce a spectrum of risks, including buttock claudication, colorectal ischemia, spinal cord ischemia when patients undergo subsequent thoracic aortic procedures, as well as erectile dysfunction. This project specifically focuses on erectile function, and analyzes baseline associations and relationships of hypogastric artery exclusion on changes in erectile function following aneurysm repair. METHODS Male patients in the Veterans Affairs Open Versus Endovascular Repair (CSP#498; OVER) Trial had erectile function assessed pre- and postoperatively by administration of the International Index of Erectile Function-5 questionnaire. Bayesian mixed-effects regression models were created with the outcome variable (erectile function) treated as a latent variable. Primary effects of differences in erectile function between groups with and without preservation of bilateral antegrade hypogastric flow were compared. RESULTS 876 men (442 randomized to endovascular repair) were enrolled in the trial and included in the analysis comparing treatment assignment. There is significant erectile dysfunction in elderly men with aortic aneurysm at baseline. Over five years of follow up, there is modest decrease in erectile function and the endovascular group has improved function compared to open repair (0.082; 95% credible interval 0.008 and 0.155). A fifth of patients did not have bilateral preservation of antegrade hypogastric artery perfusion, with no difference in erectile function by univariate analysis. A more detailed regression analysis was applied--and after adjustment for baseline score, age, beta blocker use, diabetes, activity level, ejection fraction, preoperative ABIs and time--preservation of both antegrade hypogastric arteries' perfusion showed transient improvement in survey scores compared to occlusion of at least one hypogastric artery at 6 months and 12 months after treatment, although this was not sustained at 60 months (score change: 0.046; 95% credible interval: -0.123, 0.215). Retesting this model in the cohort with complete data as a sensitivity analysis did not meaningfully change the conclusions. CONCLUSIONS In this large prospective aneurysm treatment trial with systematic measurement of erectile function with a validated instrument, endovascular repair is associated with improved erectile function. Preservation of antegrade hypogastric flow with any repair is associated with early improved erectile function; however, it is not a sustained benefit. There is limited benefit of maintaining bilateral hypogastric artery perfusion for this specific indication in unselected men undergoing AAA repair.
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Affiliation(s)
- Kyla M Bennett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Middleton Veterans Affairs Medical Center, Surgery Service, Madison, WI.
| | - Landon Hurley
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, West, Haven, CT; Department of Biostatistics, School of Public Health, Yale University, New Haven, CT
| | - Tassos C Kyriakides
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, West, Haven, CT
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Middleton Veterans Affairs Medical Center, Surgery Service, Madison, WI
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Comparison Study of Iliac Branch Endoprosthesis when Used on and off Label. Ann Vasc Surg 2023; 89:28-35. [PMID: 35339599 DOI: 10.1016/j.avsg.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/21/2022] [Accepted: 03/06/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The aim of this study is to compare how instructions for use (IFU) affected perioperative and intermediate term outcomes for common iliac artery aneurysms (CIAA) treated with the Gore Excluder iliac branch endoprosthesis (IBE). METHODS A retrospective analysis was performed of all patients treated at two affiliated academic centers from September 2016 to May 2020. Outcomes were compared between IFU and nonIFU IBE cases. Criteria for nonIFU included: (1) use with a nonGore aortic endoprosthesis (n = 10), (2) isolated IBE (n = 3), and (3) requiring nondedicated covered stents for additional extension into a more suitable landing zone in the ipsilateral internal iliac artery or one of its branches (n = 11). Perioperative and intermediate term data were collected for both groups. The primary end points were free from the major adverse event (MAE) at 30 days and primary effectiveness at 1 year. RESULTS A total of 51 CIAA (39 patients) were treated with an IBE. Overall, 15 patients were treated under IFU and 24 under nonIFU. The IFU group mean age was older (72 vs. 67 years, P = 0.03), and males (97%) were primarily treated. Comorbidities were similar except nonIFU had more patients with previous endovascular abdominal aortic aneurysm repair on presentation (0 vs. 4 cases, P = 0.04). Procedure (178 vs. 264 min, P = 0.02) and fluoroscopy (52 vs. 74 min, P = 0.04) times were longer in the nonIFU group. Technical success was 100% for both groups, and there was no difference in device related reintervention at 30 days (0 vs. 1, P = 0.44). There was no MAE in either group at 30 days. Intervention for any endoleak was similar between the groups (2 vs. 3, P = 0.94). Percent CIAA sac regression was similar between the groups (19% vs. 18%, P = 0.21). There was no difference for primary effectiveness at 1 year (93% vs. 92%, P = 0.85). There was one death per group at one year not related to an aortic or iliac cause. CONCLUSIONS In properly selected patients with complex anatomy, IBE can be used with nondedicated aortic and internal iliac components with good early term outcomes.
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Simmering JA, van Helvert M, van Herwaarden JA, Slump CH, Geelkerken RH, Reijnen MMPJ. Differences in Cardiac-Pulsatility-Induced Displacement and Geometry Changes between the Cook ZBIS and Gore IBE: Postoperative Comparison Using ECG-Gated CTA Scans. Diagnostics (Basel) 2023; 13:496. [PMID: 36766601 PMCID: PMC9914023 DOI: 10.3390/diagnostics13030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Jaimy A. Simmering
- Department of Surgery, Division of Vascular Surgery, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Majorie van Helvert
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
- Department of Surgery, Division of Vascular Surgery, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands
| | - Joost A. van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Cornelis H. Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Robert H. Geelkerken
- Department of Surgery, Division of Vascular Surgery, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Michel M. P. J. Reijnen
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
- Department of Surgery, Division of Vascular Surgery, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands
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Schneider DB, Matsumura JS, Lee JT, Peterson BG, Chaer RA, Oderich GS. Five-year outcomes from a prospective, multicenter study of endovascular repair of iliac artery aneurysms using an iliac branch device. J Vasc Surg 2023; 77:122-128. [PMID: 35842202 DOI: 10.1016/j.jvs.2022.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Jon S Matsumura
- Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brian G Peterson
- Heart and Vascular Institute, St. Luke's Hospital, Chesterfield, MO
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, TX
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Mehta V, Wooster M. Hypogastric artery thrombectomy for spinal cord ischemia following fenestrated endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:413-416. [PMID: 35942496 PMCID: PMC9356088 DOI: 10.1016/j.jvscit.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022] Open
Abstract
Spinal cord ischemia can be a devastating complication after thoracoabdominal aortic surgery. We report a case of a 56-year-old woman who had undergone multiple prior thoracic aneurysm repairs with an increase of a visceral segment aneurysm to 6 cm. The aneurysm was repaired using a physician-modified four-vessel fenestrated graft and iliac branch device. Postoperatively, she developed weakness in her right leg. Computed tomography angiography showed an occluded right hypogastric artery. We proceeded with aspiration thrombectomy with complete resolution of her right leg weakness within hours postoperatively. Our findings have illustrated the important role of hypogastric arteries in the development of spinal cord ischemia.
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Affiliation(s)
- Veena Mehta
- Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, Torrance
- Correspondence: Veena Mehta, MD, Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, 1000 W Carson St, Torrance, CA 90502
| | - Mathew Wooster
- Division of Vascular Surgery, Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston
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15
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van Helvert M, Simmering JA, Koenrades MA, Slump CH, Heyligers JM, Geelkerken RH, Reijnen MM. Evaluation of electrocardiogram-gated computed tomography angiography to quantify changes in geometry and dynamic behavior of the iliac artery after placement of the Gore Excluder Iliac Branch Endoprosthesis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:454-463. [PMID: 35005875 DOI: 10.23736/s0021-9509.22.11980-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE) is designed to treat iliac aneurysms with preservation of blood flow through the internal iliac artery (IIA). Little is known about the influence of IBE placement on the IIA geometry. This study aimed to provide detailed insights in the dynamic behavior and geometry of the common iliac artery (CIA) and IIA trajectory and how these are influenced after treatment with an IBE. METHODS Pre- and postoperative electrocardiogram-gated computed tomography angiography (ECG-gated CTA) scans were acquired in a prospective study design and analyzed with in-house written algorithms designed for aorto-iliac and endoprosthesis deformation evaluation. Cardiac pulsatility-induced motion patterns and pathlengths were computed by tracking predefined locations on the aorto-iliac tract. Centerlines through the CIA-IIA trajectory were used to investigate the static and dynamic geometry, including curvature, torsion, length and Tortuosity Index (TI). RESULTS Fourteen CIA-IIA trajectories were analyzed before and after IBE placement. Cardiac pulsatility-induced motion and pathlengths increased after IBE placement, especially at mid IIA and the first IIA bifurcation (P≤0.04). After IBE placement, static and dynamic curvature, length and TI decreased significantly (P<0.05). Furthermore, the average dynamic torsion increased significantly (P=0.030). The remaining geometrical outcomes were not statistically significant. CONCLUSIONS The placement of an IBE device stiffens and straightens the CIA-IIA trajectory. Its relation with clinical outcome is yet to be investigated, which can be done thoroughly with the ECG-gated CTA algorithms used in this study.
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Affiliation(s)
- Majorie van Helvert
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jaimy A Simmering
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands -
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Maaike A Koenrades
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Medical Technology, Medical 3D lab, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Jan M Heyligers
- Department of Vascular Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Robert H Geelkerken
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Michel M Reijnen
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
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Spangler EL, Jackson EA, Richman J. Mortality Trends in Contemporary Abdominal Aortic Aneurysm Repairs Among Veterans. J Surg Res 2022; 279:383-392. [PMID: 35820320 DOI: 10.1016/j.jss.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Clinical trials at the advent of endovascular aortic aneurysm repairs (EVARs) demonstrated improved early survival with EVAR compared to open repairs; however, characterizations of routine contemporary care have been limited. This study compares postoperative survival among Veterans in clinical care following abdominal aortic aneurysm (AAA) repair with EVAR versus open repairs since the widespread adoption of EVAR. MATERIALS AND METHODS This retrospective cohort analysis of Veterans with AAA repairs from 2007 to 2020 at Veterans Affairs (VA) facilities evaluated survival by a repair method. Administrative International Classification of Diseases 9/10 codes and sociodemographic characteristics from structured charting were used for characterization and adjusted analyses. Demographics were compared via Chi-squared and Wilcoxon rank-sum testing and mortality evaluated using Kaplan-Meier and Cox proportional hazard analyses. RESULTS Among 15,480 AAA repairs (3566 open, and 11,914 EVAR), patients receiving open repairs were younger with lower Charlson scores compared to EVARs. EVAR was associated with better survival until 2.4 y post-procedure. Mean long-term survival, however, was higher for open surgery (6.3 ± 3.8 versus 5.8 ± 3.1 y in EVAR). After adjustment for gender, race, and ethnicity, EVAR was associated with worse survival (mortality hazard ratio [HR] 1.17; 95% confidence interval [CI], 1.11-1.24) as was each increment in Charlson score (HR 1.11; CI 1.10-1.12), whereas service-connected care (HR 0.73; CI, 0.70-0.77) and age (HR 0.99; CI, 0.98-0.99) were associated with better survival. CONCLUSIONS In contemporary Veteran aneurysm repairs, although a higher early survival rate was observed in EVAR repairs, long-term survival was higher for open repairs. Service-connected care was independently associated with greater survival after aneurysm repair.
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Affiliation(s)
- Emily L Spangler
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama.
| | - Elizabeth A Jackson
- Birmingham VA Medical Center, Birmingham, Alabama; Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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Barnes JA, Eid MA, Moore K, Aryal S, Gebre E, Woodard JN, Kitpanit N, Mao J, Kuwayama DP, Suckow BD, Schneider D, Abushaikha T, Zusterzeel R, Vemulapalli S, Shenkman EA, Williams J, Sedrakyan A, Goodney P. Use of real-world data and clinical registries to identify new uses of existing vascular endografts: combined use of GORE EXCLUDER Iliac Branch Endoprosthesis and GORE VIABAHN VBX Balloon Expandable Endoprosthesis. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 4:e000085. [PMID: 35989872 PMCID: PMC9345049 DOI: 10.1136/bmjsit-2021-000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/21/2021] [Indexed: 11/06/2022] Open
Abstract
Objective To assess the feasibility of collecting, examining and reporting observational, real-world evidence regarding the novel use of the GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) in conjunction with the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (IBE+VBX stent graft). Design Multicentre retrospective cohort study. Setting Four real-world data sources were used: a national quality improvement registry, a statewide clinical research network, a regional quaternary health system and two tertiary academic medical centres. Participants In total, 30 patients with 37 IBE+VBX stent graft were identified. Of those, the mean age was 72±10.2 years and 90% were male. The cohort was 77% white, 10% black, 3% Hispanic and 10% other. Main outcome measures Outcome measures included: proportion of percutaneous vs open surgical access, intensive care admission, intensive care unit (ICU) length-of-stay (LOS), total LOS, postoperative complications, discharge disposition and 30-day mortality. Results The majority (89%) of cases were performed percutaneously, 5% required surgical exposure following failed percutaneous access and 6% required open surgical exposure outright. Nearly half (43%) required intensive care admission with a median ICU LOS of 1 day (range: 1–2). Median total LOS was 1 day (IQR: 1–2). There were zero postoperative myocardial infarctions, zero reported leg embolisations and no reported reinterventions. Access site complications were described in 1 of 28 patients, manifesting as a haematoma or pseudoaneurysm. Ultimately, 97% were discharged to home and one patient was discharged to a nursing home or rehabilitation facility. There were no 30-day perioperative deaths. Conclusions This project demonstrates the feasibility of identifying and integrating real-world evidence, as it pertains to an unapproved combination of endovascular devices (IBE+VBX stent graft), for short-term outcomes analysis. This new paradigm of evidence has potential to be used for device monitoring, submission to regulatory agencies, or consideration in indication expansions and approvals with further efforts to systematise data collection and transmission mechanisms.
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Affiliation(s)
- Jonathan Aaron Barnes
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark A Eid
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kayla Moore
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire, USA
| | - Suvekshya Aryal
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Eden Gebre
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jennifer Nicole Woodard
- Department of Health Outcomes & Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Napong Kitpanit
- Division of Vascular and Endovascular Surgery, New York - Presbyterian Hospital, New York, New York, USA
- Department of Surgery, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Jialin Mao
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - David P Kuwayama
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Bjoern D Suckow
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Darren Schneider
- Division of Vascular and Endovascular Surgery, New York - Presbyterian Hospital, New York, New York, USA
| | - Tiffany Abushaikha
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium (MDIC), Arlington, Virginia, USA
| | - Robbert Zusterzeel
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium (MDIC), Arlington, Virginia, USA
| | | | - Elizabeth A Shenkman
- Department of Health Outcomes & Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | | | - Art Sedrakyan
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Philip Goodney
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire, USA
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Outcomes of Unilateral Versus Bilateral Use of the Iliac Branch Endoprosthesis for Elective Endovascular Treatment of Aorto-iliac Aneurysms. Cardiovasc Intervent Radiol 2022; 45:939-949. [DOI: 10.1007/s00270-022-03166-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/05/2022] [Indexed: 12/19/2022]
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Zhang J, Chang H, Rockman C, Patel VI, Veeraswamy R, Berland T, Ramkhelawon B, Maldonado T, Cayne N, Jacobowitz G, Garg K. Hypogastric Artery Flow Interruption is Associated with Increased Mortality after Open Aortic Repair. Ann Vasc Surg 2022; 87:270-277. [PMID: 35654287 DOI: 10.1016/j.avsg.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jason Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian / Columbia University Irving Medical Center / Columbia University College of Physicians and Surgeons, New York, NY 10032
| | - Ravi Veeraswamy
- Division of Vascular and Endovascular Surgery, Medical University of South Carolina, Charleston, SC 29425
| | - Todd Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Bhama Ramkhelawon
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016.
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20
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Akagi D, Murase K. Successful endovascular repair of iliac artery aneurysms with unsuitable anatomy by combining unibody bifurcated endograft and iliac branch systems to preserve hypogastric artery blood flow: a report of two cases. J Cardiothorac Surg 2022; 17:93. [PMID: 35505409 PMCID: PMC9066821 DOI: 10.1186/s13019-022-01855-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background To overcome the anatomical limitation of a narrow aorta and short length from the renal artery to the terminal aorta, unibody endograft AFX2 and iliac branch endoprosthesis (IBE) can be combined. Case presentation Case 1: The first patient was an 89-year-old woman who had a right saccular common iliac artery (CIA) aneurysm (38 mm); the abdominal aorta was not aneurysmal (diameter, 19 mm). The right CIA’s origin was 10 mm in diameter. A bifurcated AFX2 was placed in an ordinary manner. Then, IBE was inserted in the right leg of the AFX2. Case 2: The second patient was an 87-year-old man diagnosed with an abdominal aortic aneurysm (55 mm), right dissecting CIA aneurysm (20 mm), and right hypogastric artery aneurysm (22 mm) extending to the bifurcation of the superior and inferior gluteal arteries. The length between the renal artery and terminal aorta was 107 mm. The beginning of the right CIA was segmentally stenotic (13 mm). A bifurcated AFX2 was placed in the infrarenal aorta; IBE was advanced to the origin of the right limb of the AFX2. To control the type 1b endoleak, the right superior gluteal artery was embolized with coils and internal iliac components were deployed toward the inferior gluteal artery. Satisfactory results were obtained in both cases. Conclusion The AFX2 main body and IBE could be combined to preserve hypogastric blood flow and overcome anatomical limitations.
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Affiliation(s)
- Daisuke Akagi
- Department of Vascular Surgery, Tokyo Metropolitan Geriatric Medical Center, Tokyo, Japan. .,Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki-city, Okayama, Japan.
| | - Kai Murase
- Department of Surgery, Tokyo Metropolitan Geriatric Medical Center, Tokyo, Japan
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21
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Liang S, Jia H, Zhang X, Guo W, Zhou G, Li S, Yuan P, Xiong J, Chen D. In-vitro and In-silico Haemodynamic Analyses of a Novel Embedded Iliac Branch Device. Front Cardiovasc Med 2022; 9:828910. [PMID: 35449876 PMCID: PMC9016111 DOI: 10.3389/fcvm.2022.828910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Iliac branch devices (IBDs) are valid tools for internal iliac artery preservation during endovascular abdominal aortic aneurysm and iliac aneurysm repair. The purpose of this study was to evaluate the effectiveness of a novel IBD with an embedded branch configuration. Method A typical iliac artery model was reconstructed, and two models were manufactured using three-dimensional printing technology. The novel IBD was deployed into one iliac artery model by an experienced vascular surgeon. A mock circulation loop (MCL) and a computational fluid dynamics (CFD) simulation were used to investigate the haemodynamic parameters of the iliac models without (Model A) and with (Model B) the IBD. A morphological analysis was conducted using computed tomography angiography and medical endoscopy. The flow distribution rate (FDR) and energy loss (EL) were used to quantify IBD performance. Results The FDR of the right internal iliac artery in the MCL of Model A and Model B was 18.88 ± 0.12% and 16.26 ± 0.09%, respectively (P = 0.0013). The FDR of the right internal iliac artery in the CFD simulation of Model A and Model B was 17.52 and 14.49%, respectively. The EL of Model A was greater than Model B in both the MCL and the CFD simulation. Compared with Model A, Model B had a larger region (8.46 vs. 3.64%) with a relative residence time of >20 Pa−1 at peak systole. Meanwhile, the area where the oscillatory flow index was >0.4 was significantly smaller in Model B than in Model A (0.46 vs. 0.043%). The region with an average wall shear stress of >4 Pa was greater in Model B than in Model A (0 vs. 0.22%). Conclusion The MCL and CFD simulation showed that the novel IBD had little impact on the FDR and EL of the iliac artery models. However, the IBD might be an effective tool for the treatment of abdominal aortic/iliac aneurysms that extend into branches. Further investigations are warranted to confirm whether this IBD could be useful in the clinic.
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Affiliation(s)
- Shichao Liang
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Heyue Jia
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xuehuan Zhang
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Guojing Zhou
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Shilong Li
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Panpan Yuan
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
- Jiang Xiong
| | - Duanduan Chen
- School of Life Science, Beijing Institute of Technology, Beijing, China
- School of Medical Technology, Beijing Institute of Technology, Beijing, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Tianjin, China
- *Correspondence: Duanduan Chen
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22
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Gouveia e Melo R, Fenelli C, Prendes CF, Öz T, Stavroulakis K, Rantner B, Stana J, Tsilimparis N. A Cross Sectional Study on the Anatomic Feasibility of Iliac Side Branch Grafts in a Real-World Setting. J Vasc Surg 2022; 76:724-732. [DOI: 10.1016/j.jvs.2022.02.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/10/2022] [Indexed: 12/31/2022]
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23
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Zhang LL, Pyun A, Magee GA, Ziegler KR, Weaver FA, Donnell KO, Paige J, Han SM. Early Results and Technical Tips of Combining Iliac Branch Endoprostheses with Fenestrated Aortic Stent Grafts during Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2021; 82:104-111. [PMID: 34933106 DOI: 10.1016/j.avsg.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/07/2021] [Accepted: 11/08/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Concomitant iliac artery aneurysms can pose challenges during repair of complex abdominal and thoracoabdominal aortic aneurysms. In fenestrated aortic aneurysm repairs (FEVAR), preservation of internal iliac perfusion is important to minimize risk of spinal cord ischemia. Currently, most commonly used fenestrated stent grafts and the only approved iliac branch devices are manufactured by different companies in the United States. We report our experience with combining Iliac Branch Endoprosthesis (IBE) (W.L. Gore and Associates, Flagstaff, AZ) and fenestrated stent grafts, using the Zenith platform (Cook Medical, Bloomington, IN). METHODS Retrospective review of consecutive patients who underwent FEVAR at a single institution from September, 2015 to June, 2020 was performed. Patients were deemed high-risk for open repair. Fenestrated aortic components implanted were either physician-modified or custom manufactured. Cases in which IBEs were deployed during FEVAR were specifically reviewed. Anatomic details were obtained from preoperative CT scans. Postoperative outcomes such as mortality, technical success, major adverse events (MAE), limb patency, limb-related endoleaks and re-intervention rates were assessed. RESULTS During the study period, 171 patients underwent FEVAR at our institution. Among those, 15 patients had unilateral IBE implantation during FEVAR, while one received bilateral IBE implantation. Fourteen cases involved physician-modified fenestrated endograft (PMEG), and Zenith Fenestrated (ZFEN) (Cook Medical, Bloomington, IN) in combination with Excluder bifurcated main body and IBE (W.L. Gore and Associates, Flagstaff, AZ). Mean operative, and fluoroscopy times were 340.2 minutes, and 65.4 minutes respectively. A total of 67 viscerorenal target vessels (mean=3.9, range=_3-5) and 15 internal iliac arteries were incorporated, with a mean of 160 cc contrast used. Completion angiograms were free of type 1 and type 3 endoleaks. Technical success was 100%. There was no perioperative mortality. One patient developed spinal cord ischemia post-operative day two with neurological recovery. At mean follow-up of 430 days, overall survival was 100% with no aneurysm-related mortalities. Limb patency remained 100%. There were no type 3 endoleaks while one patient had a type 1B endoleak that is currently being monitored. There was one re-intervention for type 1C renal branch graft endoleak. CONCLUSION Combining IBE with FEVAR allows internal iliac preservation during endovascular repair of complex abdominal aortic aneurysms, with encouraging early results.
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Affiliation(s)
- Louis L Zhang
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alyssa Pyun
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Gregory A Magee
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R Ziegler
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fred A Weaver
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Kathleen O' Donnell
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Jacquelyn Paige
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sukgu M Han
- Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, CA, USA.
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24
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Lima GB, Tenorio ER, Marcondes GB, Khasawneh MA, Mendes BC, DeMartino RR, Shuja F, Colglazier JJ, Kalra M, Oderich GS. Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis. J Vasc Surg 2021; 75:1616-1623.e2. [PMID: 34695551 DOI: 10.1016/j.jvs.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/06/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE The purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz). METHODS We retrospectively reviewed all consecutive patients treated for aortoiliac aneurysms using IBE between 2014 and 2020. IIA stenting was performed using either the IIA side branch SESG or a Gore VBX BESG (W. L. Gore). Indications for use of BESGs were "up-and-over" IBE technique for type IB endoleak after prior endovascular aortic aneurysm repair (EVAR), short IIA length, and need for IIA extension into divisional branches (outside instructions for use). End points included technical success, freedom from buttock claudication, primary IIA patency, and freedom from IIA branch instability (eg, branch-related death or rupture, occlusion, disconnection, or reintervention for stenosis, kink, or endoleak), freedom from type IC/IIIC endoleak, and freedom from secondary interventions. RESULTS There were 90 patients (86 males and 4 females) with a mean age of 74 ± 7 years treated by EVAR with 108 IBEs. Choice of stent was BESG in 43 and SESG in 65 targeted IIAs. BESGs were used more frequently in patients with prior EVAR (22% vs 2%; P = .003,), isolated IBEs (31% vs 2%; P < .001), and in patients with IIA aneurysms requiring stenting into divisional branches (36% vs 5%; P < .001). Technical success was similar for BESGs and SESGs (97% vs 100%; P = .40), respectively. The mean follow-up was 25 ± 16 months (range, 11-34 months). At 2 years, freedom from buttock claudication was 100% for BESG and 95 ± 3% for SESG (Log-rank 0.26), with no difference in primary patency (BESG, 100% vs SESG, 94 ± 4%; Log-rank 0.94). There were four (9%) IIA-related endoleaks in the BESG group and one (2%) in the SESG group (P = .08). Freedom from IIA branch instability was 87 ± 6% for BESG and 96 ± 3% for SESG at 2 years (Log-rank 0.043). Freedom from type IC/IIIC endoleak was 87 ± 7% for BESG and 98 ± 2% for SESG at the same interval (Log-rank 0.06). There was no difference in freedom from reinterventions for BESG and SESG (92 ± 6% vs 98 ± 2%; Log-rank 0.34), respectively. CONCLUSIONS BESGs were used more frequently during IBE procedures indicated for failed EVAR, isolated common iliac aneurysms, and IIA aneurysms requiring extension into divisional branches. Despite these differences and BESG being used outside instructions for use, both stent types had similar primary patency, freedom from buttock claudication, and freedom from reinterventions. However, BESGs were associated with higher rates of IIA-related branch instability.
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Affiliation(s)
- Guilherme B Lima
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Emanuel R Tenorio
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Giulianna B Marcondes
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | | | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex.
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25
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Oussoren FK, Maldonado TS, Reijnen MMPJ, Heyligers JMM, Akkersdijk G, Attisani L, Bellosta R, Heyligers JMM, Hoencamp R, Garrard L, Maldonado T, Naslund TC, Nolthenius RT, Oderich GS, Ponfoort ED, Reijnen MMPJ, Schouten O, Sybrandi JEM, Tenorio ER, Trimarchi S, Verhagen HJM, Veroux P, Wever J, Wiersema A, Wikkeling ORM. Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms. J Vasc Surg 2021; 75:1268-1275.e1. [PMID: 34655682 DOI: 10.1016/j.jvs.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/05/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Fieke K Oussoren
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Thomas S Maldonado
- Department of Vascular Surgery, New York University Langone Health, New York, NY
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth TweeSteden Hospital Tilburg, Tilburg, the Netherlands
| | - G Akkersdijk
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - L Attisani
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - R Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - J M M Heyligers
- Department of Vascular Surgery, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - R Hoencamp
- Department of Vascular Surgery, Alreine Hospital Leiderdorp, Leiderdorp, the Netherlands
| | - L Garrard
- Department of Vascular Surgery, New York University Langone Health, New York, NY
| | - T Maldonado
- Department of Vascular Surgery, Vanderbilt University Medical Centre, Nashville, Tenn
| | - T C Naslund
- Department of Vascular Surgery, Vanderbilt University Medical Centre, Nashville, Tenn
| | - R Tutein Nolthenius
- Department of Vascular Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - G S Oderich
- Department of Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - E D Ponfoort
- Department of Vascular Surgery, Gelderse Vallei Hospital, Ede, the Netherlands
| | - M M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - O Schouten
- Department of Vascular Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - J E M Sybrandi
- Department of Vascular Surgery, Gelderse Vallei Hospital, Ede, the Netherlands
| | - E R Tenorio
- Department of Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - S Trimarchi
- Thoracic Aortic Research Center, IRCCS (Scientific Institute of Recovery and Care) Policlinico San Donato, Milan, Italy
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - P Veroux
- Department of Vascular Surgery, University Hospital of Catania, Catania, Italy
| | - J Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - A Wiersema
- Department of Vascular Surgery, Dijklander Hospital, Hoorn, the Netherlands
| | - O R M Wikkeling
- Department of Vascular Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
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Chen RJ, Vaes RHD, Qi SD, J Westcott M, Robinson DR. Modalities of endovascular management for internal iliac artery aneurysms. ANZ J Surg 2021; 91:2397-2403. [PMID: 34595811 DOI: 10.1111/ans.17253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/11/2021] [Accepted: 09/17/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Internal iliac artery aneurysms (IIAA) are uncommon. Open repair is technically challenging and has been associated with increased morbidity and mortality compared with repair of abdominal aortic aneurysms. The aim of this study is to assess the outcomes of endovascular treatment of IIAA and incidence of postoperative pelvic ischaemia. METHODS A single-centre retrospective analysis was performed for IIAAs treated with endovascular repair between January 2005 and December 2017. Aneurysm morphology, mode of presentation and operative technique were evaluated. Primary outcomes were 30-day mortality and incidence of pelvic ischaemia. Secondary outcomes were technical success, major complications and reintervention. RESULTS Twenty-nine IIAAs were treated in 23 patients with a mean age of 74 */- 9 years. Six patients had isolated IIAAs (26%); the remaining 17 patients had aortoiliac aneurysms. Five patients (22%) required emergent repair for ruptured IIAAs. Mean IIAA size was 4.1 cm */- 1.8 and ruptures occurred at mean 6.1 cm */- 2.6. Endovascular techniques used: stent graft occlusion of the internal iliac artery (IIA) ostium (n = 16), deployment of iliac branch device (n = 9), and other endovascular techniques (n = 4). The 30-day mortality was zero. Three patients (13%) experienced post-operative pelvic ischemia which were all minor chronic gluteal claudication after IIA occlusion. Primary technical success was achieved in 27 repairs (93%). There was one late reintervention (3%). CONCLUSION IIAAs are often asymptomatic and diagnosed incidentally, however, a significant proportion present emergently. Endovascular treatment is feasible for both ruptured and non-ruptured aneurysms with low perioperative morbidity, mortality and reintervention rates.
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Affiliation(s)
- Reuben J Chen
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Roel H D Vaes
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sara D Qi
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Mark J Westcott
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Domenic R Robinson
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Brahmandam A, Chen JF, Tonnessen BH, Chaar CIO, Fischer U, Dardik A, Guzman RJ, Nassiri N. Alternative Endograft Aortoiliac Reconstruction for Iliac Branch Endoprostheses. Ann Vasc Surg 2021; 77:38-46. [PMID: 34455041 DOI: 10.1016/j.avsg.2021.05.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/08/2021] [Accepted: 05/31/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Endovascular treatment of complex common iliac artery (CIA) and internal iliac artery (IIA) aneurysms using iliac branch endoprostheses (IBE) has proven safe and effective. Instructions for use (IFU) require deployment of current IBE technology with the corresponding manufacturer's modular bifurcated aortic endograft. Concomitant aortoiliac occlusive disease, inadequate renal artery-iliac bifurcation length, and unfavorable aortic anatomy preclude on-label IBE deployment. This study aimed to evaluate the technical feasibility and safety of Alternative Endograft Aortoiliac Reconstruction (AEGAR) for branched endovascular treatment of complex iliac artery aneurysms. METHODS In 7 consecutive patients with CIA or IIA aneurysms, computed tomography angiography (CTA) and center-line reconstruction revealed aortoiliac anatomy incompatible with the current IBE IFU due to inadequate proximal CIA landing zone (n = 7), inadequate renal artery to iliac bifurcation length (n = 2), compromised aortic anatomy (n = 3), or short infrarenal neck <15 mm (n = 1), either alone or in combination. To overcome these restrictions and facilitate IBE deployment, aortoiliac reconstruction was performed using the Endologix AFX, Endologix Ovation limbs or the Medtronic Endurant II platforms (AEGAR technique). All internal iliac artery reconstructions and external iliac artery extensions were performed using the Gore VBX or Viabahn stent grafts. Technical success was defined as successful delivery of all endograft components without migration or endoleak. RESULTS The mean patient age was 69 years (range 52-82 years; 6 male). Four patients had bilateral CIA aneurysms and 3 patients had unilateral CIA aneurysms (mean diameter 4.3cm; range 2.2-7 cm). There were 13 IIA VBX stent grafts used for a total of 9 IIAs treated with IBE (bilateral IBE = 2 patients). The mean fluoroscopy time was 38.8 min (range 21.3-64.3 min) and the mean contrast volume was 168.5 mL (range 122-226 mL). Technical success was achieved in all patients and there were no perioperative complications. Mean hospital-stay was 2.2 days (range 1-3 days). Follow-up ranged from 82-957 days (mean = 487 days). At last follow-up, all patients were alive without cardiovascular morbidity; and CTA revealed stable or decreased aneurysm size, patent endografts, and no evidence of endoleak or migration. CONCLUSIONS The AEGAR technique can be used to safely and effectively overcome certain aortoiliac anatomic constraints that preclude use of current IBE technology. We encourage broader use of these alternative endografts in pertinent anatomic configurations.
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Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Julia Fayanne Chen
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Britt H Tonnessen
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Uwe Fischer
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
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28
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Stern J, Tran K, Li M, Lee J. Unique Complications and Failure Modes of Iliac Branch Devices. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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van der Veen D, Holewijn S, Bellosta R, van Sterkenburg SMM, Heyligers JMM, Ficarelli I, Gómez Palonés FJ, Mangialardi N, Mosquera NJ, Holden A, Reijnen MMPJ. One Year Outcomes of an International Multicentre Prospective Cohort Study on the Gore Excluder Iliac Branch Endoprosthesis for Aorto-Iliac Aneurysms. Eur J Vasc Endovasc Surg 2021; 62:177-185. [PMID: 34144884 DOI: 10.1016/j.ejvs.2021.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/19/2021] [Accepted: 04/03/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The Gore Excluder Iliac Branch Endoprosthesis (IBE) was developed to preserve perfusion in the hypogastric artery after endovascular repair of aorto-iliac aneurysms. This study reports the 12 month technical and clinical outcomes of treatment with this device. METHODS This study was a physician initiated international multicentre, prospective cohort study. The primary endpoint was primary patency of the hypogastric branch at 12 months. Secondary endpoints included technical and clinical outcomes. Patients with an indication for elective treatment with the Gore Excluder IBE were enrolled between March 2015 and August 2018. Baseline and procedural characteristics, imaging data, physical examinations and questionnaire data (Walking Impairment Questionnaire [WIQ], EuroQol-5-Dimensions [EQ5D], International Index of Erectile Function 5 [IIEF-5]) were collected through 12 month follow up. RESULTS One hundred patients were enrolled of which 97% were male, with a median age of 70.0 years (interquartile range [IQR] 64.5 - 75.5 years). An abdominal aortic aneurysm (AAA) above threshold for treatment was found in 42.7% and in the remaining patients the iliac artery diameter was the indication for treatment. The maximum common iliac artery (CIA) diameter on the Gore Excluder IBE treated side was 35.5 mm (IQR 30.8 - 42.0) mm. Twenty-two patients received a bilateral and seven patients had an isolated IBE. Median procedural time was 151 minutes (IQR 117 - 193 minutes) with a median hospital stay of four days (IQR 3 - 5 days). Primary patency of the IBE at 12 month follow up was 91.3%. Primary patency for patients treated inside and outside the instructions for use were 91.8% and 85.7%, respectively (p = .059). Freedom from secondary interventions was 98% and 97% at 30 days and 12 months, respectively. CIA and AAA diameters decreased significantly through 12 months. IIEF-5 and EQ5D scores remained stable through follow up. Patency of the contralateral internal iliac artery led to better IIEF-5 outcomes. WIQ scores decreased at 30 days and returned to baseline values through 12 months. CONCLUSION Use of the Gore Excluder IBE for the treatment of aorto-iliac aneurysms shows a satisfactory primary patency through 12 months, with significant decrease of diameters, a low re-intervention rate, and favourable clinical outcomes.
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Affiliation(s)
| | | | | | | | - Jan M M Heyligers
- Vascular Surgery, Elisabeth Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | | | | | | | - Nilo J Mosquera
- Department of Angiology and Vascular Surgery, Complexo Hospitelario Universitario de Ourense, Spain
| | - Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands.
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30
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Méndez Fernández A, Fernández Noya J, Mosquera Arochena NJ, Vidal Rey J, Calvin Álvarez P, Franco Meijide FJ, Villardefrancos Gil R. Results of the Galician registry in the treatment of complex aortoiliac aneurysms with GORE ® EXCLUDER ® Iliac Branch Endoprosthesis (GALIBER). Vascular 2021; 30:620-627. [PMID: 34114523 DOI: 10.1177/17085381211025173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Alba Méndez Fernández
- Department of Angiology and Vascular Surgery, 59535Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Galicia, Spain
| | - Jorge Fernández Noya
- Department of Angiology and Vascular Surgery, 59535Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Galicia, Spain
| | - Nilo J Mosquera Arochena
- Department of Angiology and Vascular Surgery, Complexo Hospitalario Universitario de Ourense, Ourense, Galicia, Spain
| | - Jorge Vidal Rey
- Department of Angiology and Vascular Surgery, Hospital Álvaro Cunqueiro, 96682Complexo Hospitalario Universitario de Vigo, Vigo, Galicia, Spain
| | - Pablo Calvin Álvarez
- Department of Angiology and Vascular Surgery, 16696Hospital Povisa, Vigo, Galicia, Spain
| | - Francisco José Franco Meijide
- Department of Angiology and Vascular Surgery, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - Rosa Villardefrancos Gil
- Department of Angiology and Vascular Surgery, Complexo Hospitalario Universitario de Ourense, Ourense, Galicia, Spain
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DeRoo E, Harris D, Olson S, Panthofer A, Meadows W, Pauli T, Peterson B, Schneider D, Matsumura J. Conformability of the GORE EXCLUDER iliac branch endoprosthesis is associated with freedom from adverse iliac events. J Vasc Surg 2021; 74:1558-1564.e1. [PMID: 34082005 DOI: 10.1016/j.jvs.2021.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Elise DeRoo
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
| | - Donald Harris
- Division of Vascular Surgery, Department of Surgery, University of Washington, Valley Medical Center, Seattle, Wash
| | - Sydney Olson
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Annalise Panthofer
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Wendy Meadows
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Thomas Pauli
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Brian Peterson
- St. Luke's Heart and Vascular Institute, St. Luke's Hospital, St. Louis, Mo
| | - Darren Schneider
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Jon Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
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Stern JR, Tran K, Li M, Lee JT. Unique Complications and Failure Modes of Iliac Branch Devices. Ann Vasc Surg 2021; 76:73-79. [PMID: 33836229 DOI: 10.1016/j.avsg.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Iliac branch devices (IBDs) are modular, bifurcated endografts designed to preserve hypogastric flow during endovascular aortoiliac aneurysm repair. We report our single center outcomes, and describe the unique complications of these devices: inability to cannulate the hypogastric artery (technical failure), occlusion of the internal branch, and type III endoleak from separation of components between the main body and IBD. METHODS A prospectively maintained institutional database of patients undergoing IBD implantation between 2014 and 2019 was reviewed. Technical and clinical outcomes were evaluated. We then identified patients having one of the IBD-specific complications and patient, anatomic, and procedural data were analyzed to identify factors associated with these failures. RESULTS Sixty-four IBDs were placed in 59 patients during the study period. Mean age was 71.2 ± 8.6, and 92% were male. A 74.6% of patients had a current or prior abdominal aortic aneurysm, and 9.4% had a hypogastric aneurysm. Technical success was achieved in 60/64 cases (93.8%); prior endovascular aortic repair was associated with technical failure (P = 0.04). There were 5 instances of component separation between the main body and the IBD: 3 occurred intraoperatively and were repaired with additional bridging components, and 2 occurred on late follow-up and required reintervention. Increased tortuosity index of both aortoiliac (1.7 ± 0.4 vs. 1.3 ± 02, P = 0.04) and iliac-specific (3.9 ± 2.4 vs. 1.9 ± 0.9, P = 0.03) segments were significantly associated with component separation, as was the use of larger internal iliac components (13.9 ± 2.4 vs. 11.1 ± 2.3 mm, P = 0.04). Internal branch occlusions occurred in 4 patients (6.7%). Two were successfully reopened with endovascular procedures, with two being asymptomatic. No specific factors were found to be predictive of branch occlusion. CONCLUSIONS IBD-specific complications occur rarely. History of prior endovascular aortic repair is associated with technical failure, while increased aortic and iliac tortuosity are predictive of component separation and type III endoleak. Severe tortuosity should be carefully considered when planning for IBD.
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Affiliation(s)
- Jordan R Stern
- Department of Surgery, Division of Vascular & Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Kenneth Tran
- Department of Surgery, Division of Vascular & Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Ming Li
- Department of Surgery, Division of Vascular & Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Department of Surgery, Division of Vascular & Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
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Finotello A, Schuurmann R, Di Gregorio S, Boschetti GA, Chakfé N, Pane B, Spinella G, de Vries JP, Palombo D, Pratesi G. Initial Clinical Experience With a New Conformable Abdominal Aortic Endograft: Aortic Neck Coverage and Curvature Analysis in Challenging Aortic Necks. J Endovasc Ther 2021; 28:407-414. [PMID: 33660576 DOI: 10.1177/1526602821996723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Aim of this work was to investigate precision of deployment and conformability of a new generation GORE EXCLUDER Conformable Endoprosthesis with active control system (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) by analyzing aortic neck coverage and curvature. METHODS All consecutive elective patients affected by abdominal aortic aneurysm or aortoiliac aneurysm treated at our institution between November 2018 and June 2019 with the new CEXC Device were enrolled. Validated software was adopted to determine the available apposition surface area into the aortic neck, apposition of the endograft to the aortic wall, shortest apposition length (SAL), shortest distance between the endograft fabric and the lowest renal arteries (SFD) and between the endograft fabric and the contralateral renal artery (CFD). Pointwise centerline curvature was also computed. RESULTS Twelve patients (10 men, median age 78 years (71.75, 81.0)) with available pre- and postoperative computed tomography angiography (CTA) were included. Technical success was obtained in all the cases. Preoperative median length of the proximal aortic neck was 16.1 mm (10.7, 21.7) and suprarenal (α) and infrarenal (β) neck angulation were, respectively, 28.9° (15.7°, 47.5°) and 75.0° (66.9°, 81.4°). Postoperative median apposition surface coverage was 79% (69.25%, 90.75%) of the available apposition surface. SFD and CFD were 1.5 mm (0.75, 5.25) and 7 mm (4.5, 21.5), respectively. Average curvature over the infrarenal aorta decreased from 25 m-1 (21.75, 29.0) to 22.5 m-1 (18.75, 24.5) postoperatively (p=0.02). Maximum curvature did not decrease significantly from 64.5 m-1 (54.25, 92.0) to 62 m-1 (41.75, 71.5) (p=0.1). CONCLUSIONS Our early experience showed that deployment of the CEXC Device is safe and effective for patients with challenging proximal aortic necks. Absence of significant changes between pre- and postoperative proximal aortic neck angulations and curvature confirms the high conformability of this endograft.
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Affiliation(s)
- Alice Finotello
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Richte Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, the Netherlands
| | - Sara Di Gregorio
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Gian Antonio Boschetti
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France.,GEPROVAS, Strasbourg, France
| | - Bianca Pane
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Giovanni Spinella
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Jean-Paul de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, the Netherlands
| | - Domenico Palombo
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
| | - Giovanni Pratesi
- Clinic of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Italy
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Stern JR, Lyden SP, Agrusa CJ, Schneider DB. Ipsilateral Iliac Branch Repair Using a Looped Wire, Precannulated Gate Technique. J Endovasc Ther 2021; 28:373-377. [PMID: 33478350 DOI: 10.1177/1526602821989335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe a novel, entirely ipsilateral femoral technique for distal endograft extension using the Gore Iliac Branch Endoprosthesis. TECHNIQUE Femoral arterial access is obtained on the side of the intended repair, and a 16F sheath is inserted over a stiff wire. A looped wire is used to pre-cannulate the internal gate of the IBE device prior to insertion, and the device is then positioned and deployed. This through-wire guides access over the IBE flow divider and into the internal gate with a steerable sheath. The internal iliac artery is then selected, and a Viabahn VBX balloon-expandable stent (W.L. Gore, Flagstaff, AZ) is advanced into position and deployed. We present the successful completion of this technique in 4 patients. CONCLUSION This novel technique allows distal endograft extension with an IBE device using only ipsilateral femoral access and is particularly useful for patients with aneurysmal iliac degeneration in the setting of prior open or endovascular aneurysm repair. This eliminates the need for upper extremity access or contralateral femoral access and navigation across the steep flow divider.
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Affiliation(s)
- Jordan R Stern
- Division of Vascular & Endovascular Surgery, Stanford University, Stanford, CA, USA
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher J Agrusa
- Division of Vascular & Endovascular Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Darren B Schneider
- Division of Vascular Surgery & Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
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Kurose S, Matsubara Y, Yoshino S, Nakayama K, Yamashita S, Morisaki K, Furuyama T, Mori M. Influence of Internal Iliac Artery Embolization during Endovascular Aortic Repair Regarding Postoperative Sarcopenia and Midterm Survival. Ann Vasc Surg 2020; 74:148-157. [PMID: 33248242 DOI: 10.1016/j.avsg.2020.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/28/2020] [Accepted: 10/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postoperative sarcopenia is a risk factor for postoperative mortality. Internal iliac artery embolization (IIAE) during endovascular aortic repair (EVAR) has ischemic effects on pelvic skeletal muscles because IIAE causes buttock claudication. The long-term effects of IIAE on pelvic skeletal muscle, however, have not been well investigated. We hypothesized that IIAE after EVAR induces a decrease in skeletal muscle, which leads to postoperative sarcopenia. MATERIALS AND METHODS Patients with abdominal aortic aneurysms who underwent EVAR from 2009 to 2014 were retrospectively reviewed. Skeletal muscle areas (SMAs) at the third lumbar level and the mid-femoral level were measured on transverse computed tomographic images. Postoperative sarcopenia was defined as a >10% decrease in the L3 SMA as established in a previous study. We assessed the association between postoperative sarcopenia and IIAE. RESULTS Altogether, 102 eligible patients who underwent elective EVAR comprised the study group. The L3 SMA at the 3-year follow-up evaluation was significantly smaller in patients with than without IIAE (P < 0.05). The SMAs of the psoas, lumbar, and thigh muscles were significantly smaller on the IIAE than non-IIAE side (P < 0.05). IIAE was thus revealed as an independent risk factor for postoperative sarcopenia (hazard ratio, 4.69; P = 0.008). In addition, patients who developed postoperative sarcopenia had a lower overall survival rate than those without postoperative sarcopenia (P < 0.001). CONCLUSIONS IIAE during EVAR is a risk factor for postoperative sarcopenia, which is in turn associated with mortality. Hence, we should preserve the internal iliac artery whenever possible. Alternatively, if IIAE is deemed necessary, we should postoperatively institute protocols to prevent sarcopenia from developing.
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Affiliation(s)
- Shun Kurose
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Vascular Biology and Therapeutics, School of Medicine, Yale University, New Haven, CT
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Nakayama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Yunoki J, Kamohara K, Koga S, Tanaka A, Takeuchi Y, Uchino M, Nogami E, Morokuma H, Koga Y, Yoshitake S, Itoh M. Early results of expanding the anatomical indications for using a Gore Iliac branch endoprosthesis to treat aortoiliac and iliac aneurysms. Surg Today 2020; 51:1028-1035. [PMID: 33237376 DOI: 10.1007/s00595-020-02183-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess the safety and anatomical suitability of using a Gore Iliac Branch Endoprosthesis (IBE) in aortoiliac and iliac aneurysm repair. METHODS Between 2017 and 2020, 20 patients underwent endovascular aneurysm repair (EVAR) with a Gore IBE device (bilateral IBE, n = 1) after expanding the instructions for use (IFU) criteria. We evaluated the early clinical outcomes and suitability of the IFU criteria, retrospectively. RESULTS Six patients (30%) met all the IFU criteria. Anatomical suitability according to the IFU criteria for the collective total of 21 IBE limbs was confirmed for 10 (47.6%) proximal common iliac arteries, 21 (100%) external iliac arteries, 18 (85.7%) internal iliac arteries, and in the length from the lowest renal artery to the iliac bifurcation in 15 (71.8%) patients. Assisted primary technical success was achieved in all patients with various bail-out techniques. One patient (5%) required a bare-stent insertion 7 days after EVAR for severe stenosis in the ipsilateral limb caused by a small terminal aorta. There was no case of occlusion of an iliac branch component device. CONCLUSIONS Gore IBEs were implanted safely and effectively with various bail-out techniques to repair aortoiliac and iliac aneurysms in our Japanese patients with a low rate of inclusion IFU criteria.
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Affiliation(s)
- Junji Yunoki
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Keiji Kamohara
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Shugo Koga
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Atsuhisa Tanaka
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yuki Takeuchi
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Motonori Uchino
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Eijiro Nogami
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Hiroyuki Morokuma
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yuichi Koga
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Syuichiro Yoshitake
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Manabu Itoh
- Department of Thoracic and Cardiovascular Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Late outcomes of different hypogastric stent grafts in aortoiliac endografting with iliac branch device: Results from the pELVIS Registry. J Vasc Surg 2020; 72:549-555.e1. [DOI: 10.1016/j.jvs.2019.09.065] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022]
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Fargion AT, Masciello F, Pratesi G, Torsello G, Donas KP, Pratesi C. Results of Iliac Branch Devices in Octogenarians Within the pELVIS Registry. J Endovasc Ther 2020; 28:157-164. [PMID: 32715874 DOI: 10.1177/1526602820942210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate if the elderly could benefit from the implantation of iliac branch devices (IBDs) to preserve the patency of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: From January 2005 to April 2017, 804 patients enrolled in the pELVIS registry underwent endovascular aneurysm repair with 910 IBDs due to aneurysmal involvement of the iliac bifurcation. Among the 804 patients, 157 (19.5%) were octogenarians (mean age 82.9±2.5 years; 157 men) with 171 target IIAs for preservation. Outcomes at 30 days included technical success, death, conversion to open surgery, and major complications. Outcomes evaluated in follow-up were patency of the IBD and target vessels, type I and type III endoleaks, aneurysm-related reinterventions, aneurysm-related death, and overall patient survival. Kaplan-Meier analyses were employed to evaluate the late outcome measures; the estimates are presented with the 95% confidence interval (CI). Results: Technical success was 99.4% with no intraoperative conversions or deaths (1 bridging stent could not be implanted, and the IIA was sacrificed). Perioperative mortality was 1.9%. The overall perioperative aneurysm-related complication rate was 8.9% (14/157), with an early reintervention rate of 5.1% (8/157). Median postoperative radiological and clinical follow-up were 21.8 months (range 1-127) and 29.3 months (range 1-127), respectively. Estimated rates of freedom from occlusion of the IBD, the IIA, and the external iliac artery at 60 months were 97.7% (95% CI 96.1% to 99.3%), 97.3% (95% CI 95.7% to 98.9%), and 98.6% (95% CI 97% to 99.9%), respectively. Estimated rates of freedom from type I and type III endoleaks and device migration at 60 months were 90.9% (95% CI 87% to 94.3%), 98.7% (95% CI 97.5% to 99.8%), and 98% (95% CI 96.4% to 99.6%), respectively. Freedom from all cause reintervention at 60 months was 87.4% (95% CI 82.6% to 92.2%). The estimated overall survival rate at 60 months was 59% (95% CI 52.4% to 65.6%). Conclusion: IBD implantation in octogenarians provided acceptable perioperative mortality and morbidity rates, with satisfying long-term freedom from IBD-related complications and should be considered a feasible repair option for selected elderly patients affected by aneurysms involving the iliac bifurcation.
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Affiliation(s)
- Aaron Thomas Fargion
- Department of Vascular Surgery, Division of Vascular Surgery, Azienda Ospedaliera Universitaria Careggi, University of Florence, Italy
| | - Fabrizio Masciello
- Department of Vascular Surgery, Division of Vascular Surgery, Azienda Ospedaliera Universitaria Careggi, University of Florence, Italy
| | - Giovanni Pratesi
- Department of Vascular Surgery, Division of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Italy
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital Münster, Germany
| | - Konstantinos P Donas
- Department of Vascular Surgery and Vascular Research Centre, Asclepios Clinic Langen, Teaching Hospital University of Frankfurt, Germany
| | - Carlo Pratesi
- Department of Vascular Surgery, Division of Vascular Surgery, Azienda Ospedaliera Universitaria Careggi, University of Florence, Italy
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Wang SK, Motaganahalli RL, Maijub JG, Sawchuk AP. Treatment of a traumatic aortic bifurcation injury with an iliac branch endoprosthesis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:317-319. [PMID: 32685793 PMCID: PMC7355387 DOI: 10.1016/j.jvscit.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/08/2020] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - John G Maijub
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alan P Sawchuk
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
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Mylonas SN, Ioannides G, Ahmad W, Brunkwall JS. Comparison of Two Iliac Branch Devices and Their Midterm Performance in Maintaining Blood Flow to the Internal Iliac Artery. J Endovasc Ther 2020; 27:818-825. [PMID: 32580623 DOI: 10.1177/1526602820934762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Spyridon N Mylonas
- Department of Vascular and Endovascular Surgery, University of Cologne, Germany
| | - Giorgos Ioannides
- Department of Vascular and Endovascular Surgery, University of Cologne, Germany
| | - Wael Ahmad
- Department of Vascular and Endovascular Surgery, University of Cologne, Germany
| | - Jan S Brunkwall
- Department of Vascular and Endovascular Surgery, University of Cologne, Germany
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D'Oria M, Tenorio ER, Oderich GS, DeMartino RR, Kalra M, Shuja F, Colglazier JJ, Mendes BC. Outcomes after Standalone Use of Gore Excluder Iliac Branch Endoprosthesis for Endovascular Repair of Isolated Iliac Artery Aneurysms. Ann Vasc Surg 2020; 67:158-170. [PMID: 32234400 DOI: 10.1016/j.avsg.2020.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/07/2020] [Accepted: 03/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of our study was to describe outcomes of stand-alone use (i.e., without concomitant implantation of an aortic stent graft) of the Gore Excluder iliac branch endoprosthesis (IBE) for elective endovascular repair of isolated iliac artery aneurysms. METHODS We evaluated all consecutive patients electively treated for isolated iliac artery aneurysms using standalone Gore Excluder IBE (January 2014-December 2018). Early (i.e., 30-day) endpoints were technical success, mortality, major adverse events (MAEs), and major access-site complications. Late endpoints were survival, freedom from aortic-related mortality (ARM), internal iliac artery (IIA) primary patency, IIA branch instability, graft-related adverse events (GRAEs), secondary interventions, endoleaks (ELs), aneurysm sac behavior, and new-onset buttock claudication (BC). RESULTS A total of 11 consecutive patients (10 men; median age 75 years) were included. The technical success rate was 100%. At 30 days, mortality, MAEs, and major access-site complications were all 0%. Survival and freedom from ARM were 91% and 100%, respectively; only one nonaortic related death was recorded during follow-up. At a median follow-up of 14 months, IIA primary patency, IIA branch instability, and GRAEs were 100%, 0%, and 0%, respectively. No instances of graft migration ≥10 mm were detected. No graft-related secondary interventions were recorded, and 2 patients required a procedure-related secondary intervention 3 months after the index procedure (1 common femoral artery endarterectomy and 1 external iliac artery stenting). Although new-onset type 1 or type 3 ELs were never noted, one patient developed a new-onset type 2 EL. Aneurysm sac regression ≥5 mm was noted in 6 patients (55%), whereas in the remaining ones, the sac size was stable. No instances of new-onset BC were noted. CONCLUSIONS Use of standalone Gore Excluder IBE for elective endovascular repair of isolated iliac artery aneurysms is a safe, feasible, and effective treatment option. These results may support use of the technique as an effective means of endovascular reconstruction in patients with suitable anatomy.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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A propensity score-matched comparison of two commercially available iliac branch devices in patients with similar clinical and anatomic preoperative features. J Vasc Surg 2020; 71:1207-1214. [DOI: 10.1016/j.jvs.2019.07.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/12/2019] [Indexed: 11/24/2022]
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Shintani T, Mitsuoka H, Hasegawa Y, Hayashi M, Natsume K, Ookura K, Sato Y, Obara H. Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone. Ann Vasc Surg 2020; 66:120-131. [PMID: 31953142 DOI: 10.1016/j.avsg.2020.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure. METHODS We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA. RESULTS Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P = 0.02). CONCLUSIONS Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.
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Affiliation(s)
- Tsunehiro Shintani
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan.
| | - Hiroshi Mitsuoka
- Department of Cardiovascular Surgery, Shizuoka Hospital, Shizuoka, Japan
| | - Yuto Hasegawa
- Department of Cardiac Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Masanori Hayashi
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Kayoko Natsume
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Kazuhiro Ookura
- Department of Cardiac Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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D'Oria M, Mendes BC, Bews K, Hanson K, Johnstone J, Shuja F, Kalra M, Bower T, Oderich GS, DeMartino RR. Perioperative Outcomes After Use of Iliac Branch Devices Compared With Hypogastric Occlusion or Open Surgery for Elective Treatment of Aortoiliac Aneurysms in the NSQIP Database. Ann Vasc Surg 2020; 62:35-44. [DOI: 10.1016/j.avsg.2019.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 12/20/2022]
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Oliveira-Pinto J, Martins P, Mansilha A. Endovascular treatment of iliac aneurysmal disease with internal iliac artery preservation: a review of two different approaches. INT ANGIOL 2019; 38:494-501. [PMID: 31782280 DOI: 10.23736/s0392-9590.19.04215-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The feasibility of endovascular aneurysm repair (EVAR) is often challenged by the concurrent presence of common iliac artery aneurysms, which prevent the attainment of a successful distal sealing. The present review aims to portray the safety and efficacy of two internal iliac artery (IIA) preservation strategies in the endovascular treatment of aortoiliac aneurysms: the iliac branch extension device (IBED) and the parallel graft - "sandwich" technique (PG-ST). EVIDENCE ACQUISITION A comprehensive literature review was conducted to identify publications on endovascular treatment of iliac aneurysmal disease using IBED or PG-ST. Primary endpoints were freedom from endoleak, IIA branch occlusion and secondary interventions. EVIDENCE SYNTHESIS Twenty-eight studies were selected for analysis describing a total of 1316 patients, 1169 in the IBED group and 147 in the PG-ST group. The technical success rates were akin for IBED and PG-ST (83.9-100% versus 81.3-100%). The defined primary endpoints were reported by fourteen articles. Freedom from endoleak, IIA branch occlusion and reintervention, at 6 months, were as follows: 82-100% versus 86%, 90-94% versus 88%, and 90-98% versus 87%, respectively for IBED and PG-ST. Later outcomes were only recorded in the IBED group, and freedom from endoleak, IIA branch occlusion and reintervention, at 9 years, were 83%, 81-90%, and 64-75%, respectively. CONCLUSIONS Both IBED and PG-ST have proven to be safe and valid approaches. However, while IBED has established as a durable procedure, mid-term data lacks on PGs performance and further studies are required to attest durability of the latter procedure.
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Affiliation(s)
- José Oliveira-Pinto
- Department of Surgery and Physiology, Faculty of Medicine of Porto, Porto, Portugal -
| | - Pedro Martins
- Department of Surgery and Physiology, Faculty of Medicine of Porto, Porto, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculty of Medicine of Porto, Porto, Portugal
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Colvard B, Georg Y, Lejay A, Ricco JB, Swanstrom L, Lee J, Bismuth J, Chakfé N, Thaveau F. Total robotic iliac aneurysm repair with preservation of the internal iliac artery using sutureless vascular anastomosis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:218-224. [PMID: 31297470 PMCID: PMC6598873 DOI: 10.1016/j.jvscit.2019.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 01/31/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Benjamin Colvard
- Institut Hospitalo-Universitaire de Strasbourg, Strasbourg, France.,Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Lee Swanstrom
- Institut Hospitalo-Universitaire de Strasbourg, Strasbourg, France
| | - Jason Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Jean Bismuth
- Houston Methodist Cardiovascular Surgery Associates, Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Fabien Thaveau
- Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Mendes BC, Oderich GS, Sandri GA, Johnstone JK, Shuja F, Kalra M, Bower TC, DeMartino RR. Comparison of Perioperative Outcomes of Patients with Iliac Aneurysms Treated by Open Surgery or Endovascular Repair with Iliac Branch Endoprosthesis. Ann Vasc Surg 2019; 60:76-84.e1. [PMID: 31220590 DOI: 10.1016/j.avsg.2019.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/19/2019] [Accepted: 05/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE. METHODS The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions. RESULTS Sixty-seven patients (96% male) were treated with OS (n = 25, mean age 68 ± 8 years) or IBE (n = 42, mean age 73 ± 8 years; P = 0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P = 0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5 ± 3.4 vs. 1.7 ± 1.4 days for IBE, P < 0.0001 and ICU LOS 3.3 ± 2.1 vs. 0.1 ± 0.4 days, P < 0.0001). Estimated blood loss was higher for patients undergoing OS (4,732 ± 2,540 mL) compared to patients treated with IBE (263 ± 451 mL, P < 0.0001), resulting in higher RBC transfusion requirements (1.5 ± 2.4 vs. 0.2 ± 0.8 units, P = 0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P = 0.09). CONCLUSIONS Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.
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Affiliation(s)
- Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Giuliano A Sandri
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill K Johnstone
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Lawrence PF. Journal of Vascular Surgery – February 2019 Audiovisual Summary. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2018.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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