Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL IMPACT

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

Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature

PURPOSE

Internal iliac artery ligation (IIAL) has been used as a damage control procedure to treat hemodynamically unstable pelvic fracture for many years. However, there is ongoing debate regarding the effectiveness and safety of this hemostatic method. Therefore, we performed a systematic literature review to assess the efficacy and safety of IIAL for pelvic fracture hemostasis.

METHODS

Three major databases, PubMed, Embase, and Google Scholar, were searched to screen eligible original studies published in English journals. Two reviewers independently read the titles, abstracts, and full texts of all literature. Articles were included if they reported the use and effects of IIAL.

RESULTS

A total of 171 articles were initially identified, with 22 fully meeting the inclusion criteria. Among the analyzed cases, up to 66.7% of patients had associated abdominal and pelvic organ injuries, with the urethra being the most frequently injured organ, followed by the bowel. The outcomes of IIAL for achieving hemostasis in pelvic fractures were found to be satisfactory, with an effective rate of 80%. Hemorrhagic shock was the leading cause of death, followed by craniocerebral injury. Notably, no reports of ischemic complications involving the pelvic organs due to IIAL were found.

CONCLUSION

IIAL has a good effect in treating hemodynamically unstable pelvic fracture without the risk of pelvic organ ischemia. This procedure should be considered a priority for hemodynamically unstable pelvic fracture patients with abdominal organ injuries.

Incidence and Outcomes of Visceral Ischemia in Acute Aortic Occlusion

BACKGROUND

Acute aortic occlusion (AAO) is a morbid diagnosis in which mortality correlates with severity of ischemia on presentation. Visceral ischemia (VI) is challenging to diagnose and its presentation as a consequence of AAO is not well-studied. We aim to identify characteristics associated with VI in AAO to facilitate diagnosis.

METHODS

Patients diagnosed with AAO who underwent revascularization were identified retrospectively from institutional records (2006-2020). The primary outcome was the development of VI (intra-abdominal ischemia). Univariate analysis was used to compare demographic, exam, imaging, and intraoperative variables between patients with and without VI in the setting of AAO.

RESULTS

Ninety-one patients were included. The prevalence of VI was 20.9%. Preoperative comorbidities, time to revascularization, and operative approach did not differ between patients with and without VI. Patients with VI more frequently were transferred from outside institutions (100% vs. 53%, P = 0.02), presented with advanced acute limb ischemia (Rutherford III 36.9% vs. 7.5%, P < 0.01), and had elevated preoperative serum lactate (4.31 vs. 2.41 mmol/L, P < 0.01). VI patients had an increased occurrence of bilateral internal iliac artery (IIA) occlusion (47.4% vs. 18.1%, P = 0.01). Unilateral IIA occlusion, level of aortic occlusion, and patency of inferior mesenteric arteries were not associated with VI. Patients with VI had worse postoperative outcomes. In particular, VI conferred significant risk of mortality (odds ratio 5.45, P < 0.01).

CONCLUSIONS

Visceral ischemia is a common consequence of AAO. Elevated lactate, bilateral IIA occlusion, and advanced acute limb ischemia (ALI) should increase clinical suspicion for concomitant VI with AAO and may facilitate earlier diagnosis to improve outcomes.

Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis

BACKGROUND

Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA.

METHODS

Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate.

RESULTS

There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703).

CONCLUSIONS

The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair

Purpose

This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications.

Materials and Methods

Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors.

Results

IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication.

Conclusion

The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Intra-Operative Occlusion of the Contralateral Common Iliac Artery by the Gore Excluder Iliac Branch System

Introduction

During stent grafting, managing the internal iliac artery (IIA) becomes a significant issue when an abdominal aortic aneurysm (AAA) is complicated by bilateral common iliac artery (CIA) aneurysms. The iliac branch system (IBS) has a defined length; therefore, the CIA should be sufficiently long. However, situations arise where the IBS must be used even in patients with a short CIA. A case of contralateral CIA occlusion due to deviation of the proximal iliac branched component of the IBS is reported.

Report

A 73 year old man underwent stent grafting with inferior mesenteric artery coil embolisation and IBS for a 70 mm AAA and >30 mm bilateral CIA aneurysm. As standard procedure, the right iliac branched component and the internal iliac component were used. After removing the guidewire used for deploying the internal iliac component, the left 12 Fr Dryseal and guidewire were pulled down. The proximal end of the right iliac branched component deviated over the left CIA origin, resulting in CIA occlusion. As a solution, a 12 Fr Dryseal was inserted with a dilator and guidewire in the 16 Fr Dryseal from the left side, following which the tip of the 12 Fr Dryseal dilator was used to push the iliac branched component to create a gap. The guidewire was successfully inserted, and the surgery was subsequently completed as planned. The post-operative course of the patient was uneventful.

Conclusion

When deploying an iliac branched component in cases where the CIA is shorter than the length of the component, it is crucial to place the contralateral guidewire into the aorta before pulling down the contralateral sheath. The iliac branched component may follow the pull through wire and occlude the contralateral CIA. Furthermore, if the element occludes the contralateral CIA, it can be managed using this method.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Postoperative management in patients with complex aortic aneurysms

Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.

Hypogastric artery thrombectomy for spinal cord ischemia following fenestrated endovascular aortic repair

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Novel Clinically Based Classification System for the Profunda Femoris Artery and the Circumflex Femoral Arteries

OBJECTIVE

The profunda femoris artery (PFA) supplies important collateral branches to both the ipsilateral internal iliac and the distal superficial femoral artery (SFA). The size and patency of these collateral pathways can determine the risk of pelvic malperfusion, spinal cord ischemia, and lower extremity limb loss following vascular interventions. Despite its importance, the anatomy of the PFA is rarely characterized in clinical studies involving the pelvic or lower extremity circulation. This discussion may be limited by the lack of a comprehensive classification system. Our objective was to describe the most common PFA anatomic variants and present a classification system based on its branching patterns.

METHODS

We dissected 155 fixed and non-fixed femoral artery systems from 88 cadavers. Seventy-seven female and 78 male femoral exposures were performed. Vessel diameters, branch configurations and relative distances between the inguinal ligament, PFA, lateral circumflex femoral artery (LCFA), and medial circumflex femoral artery (MCFA) were recorded.

RESULTS

The mean diameters of the common femoral artery, SFA and PFA in males were 10.3mm, 8.0mm and 6.9mm, and 8.9mm, 6.9mm and 6.1 in females, respectively (p < 0.05). The mean distances from the inguinal ligament for PFA, MCFA and LCFA were 41mm, 41.7mm and 52.5mm respectively. No significant differences were noted relative to laterality or fixation. We developed a clinically applicable classification system based on the orientation of the PFA, LCFA, and MCFA. Six PFA, 5 LCFA and 5 MCFA variations were identified and ranked by frequency. The five most common combinations accounted for 56.1% of our cadaver series.

CONCLUSION

The anatomic orientation of the PFA and its branches is highly variable. We propose a novel classification system of this rich collateral system to facilitate consistent communication in academic and clinical vascular surgery.

Prevention of Buttock Claudication by Preserving Antegrade Bilateral Superior Gluteal Arterial Blood Flow in EVAR for Aorto-Iliac Aneurysm Accompanied by Bilateral Internal Iliac Artery Aneurysms

Buttock claudication (BC) is a complication of surgery for aorto-iliac aneurysms (AIAs) caused by sacrificing blood flow in the internal iliac artery (IIA). However, the preservation of antegrade blood flow of IIAs is often challenging when performing both open surgery and endovascular aneurysm repair (EVAR) for AIAs accompanied by IIA aneurysms. We performed EVAR and successfully preserved the antegrade blood flow of bilateral superior gluteal arteries using the GORE EXCLUDER iliac branch endoprosthesis with the VIABAHN endograft. BC did not occur, both subjectively and objectively, after surgery. This approach can be minimally invasive yet an effective procedure to prevent BC.

The Effect of Retrograde External Iliac Artery Runoff on Aortofemoral Bypass Limb Patency

BACKGROUND

Superficial femoral artery (SFA) and profunda patency has been shown to affect aortofemoral bypass (AFB) limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis.

METHODS

Institutional AFB data from 2000-2017 were gathered, excluding those where SFA/EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency; cox proportional-hazards model evaluated EIA patency while controlling for other factors.

RESULTS

Over the study period, there were AFB 557 limbs in 281 patients. Of the 435 AFB limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6±9.0. EIA occlusions were more common in male patients (59.9% vs 44.6%; p=0.001), patients with CAD (43.8% vs 34.1%; p=0.042), COPD (34.6% vs 20.5%; p=0.001), and CHF (14.8% vs 5.9%; p=0.002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs 24.2%; p<0.001) and simultaneous infrainguinal bypass (7.4% vs 0.7%; p<0.001). Median clinical follow-up was 4.4 years (IQR: 1.6-8.4). Five-year primary patency was 83.1% (95% CI: 74.5%-90.0%) for EIA occlusion limbs and 85.9% (95% CI: 80.2%-90.0%) with patent EIA limbs (p=0.96). While controlling for other factors, EIA stenosis or occlusion did not affect primary patency. For patients with a proximal occlusion (occluded aorta, occluded common iliac, or end-to-end proximal anastomosis) and occluded SFA (N=73), EIA occlusion had a HR of 1.92 for loss of patency, but this was not statistically significant.

CONCLUSION

EIA patency did not influence primary patency in the overall cohort Further investigation on the topic in specific patient subgroups is warranted to determine the effect of EIA patency.

Ipsilateral Iliac Branch Repair Using a Looped Wire, Precannulated Gate Technique

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.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

BACKGROUND

Ipsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications.

METHODS

The study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett's test.

RESULTS

The postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side.

CONCLUSIONS

The ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Hypogastric Artery Revascularization on Ischemic Colitis in Endovascular Aneurysm Repair

BACKGROUND

The objective of the study was to examine the effect of hypogastric revascularization maneuvers on the rate of postoperative ischemic colitis among patients undergoing endovascular aortoiliac aneurysm repair.

METHODS

Using the 2011-2018 Endovascular Aneurysm Repair Procedure-Targeted American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, we analyzed patients undergoing elective endovascular infrarenal aortoiliac aneurysm repairs. Using multivariable modeling techniques, a cohort of patients at high risk for postoperative ischemic colitis was identified. The outcomes of this group were then compared using Pearson's chi-square testing in accordance with whether or not they underwent hypogastric revascularization.

RESULTS

Of 4753 patients undergoing endovascular aortoiliac aneurysm repair in the National Surgical Quality Improvement Program cohort, 1161 had concomitant hypogastric revascularization procedures. High-risk predictors of ischemic colitis included chronic obstructive pulmonary disease and concurrent renal artery or external iliac artery stenting. There was not a significant association between pelvic revascularization and postoperative ischemic colitis [1.0% with versus 0.5% without pelvic revascularization; adjusted odds ratio of ischemic colitis with revascularization 2.07 (0.96, 4.46); P = 0.06] after adjustment for patient- and procedure-related factors. In a subgroup analysis of patients with a distal aneurysm extent beyond the common iliac artery, the incidence of ischemic colitis was significantly lower in patients without pelvic revascularization (0.1% versus 1.6%, P = 0.004).

CONCLUSIONS

Our analysis of patients undergoing elective endovascular repair of infrarenal aortoiliac aneurysmal disease did not find a reduced incidence of postoperative ischemic colitis in patients who received a concomitant pelvic revascularization procedure, suggesting instead that such procedural adjuncts may actually increase risk for this complication.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair

BACKGROUND

Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea.

METHODS

We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale.

RESULTS

The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis.

CONCLUSIONS

Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Decreased Ischemic Complications After Endovascular Aortic Aneurysm Repair With Newer Devices

Ischemic complications after endovascular abdominal aortic aneurysm repair (EVAR) are well-recognized and have been reported to be as high as 9%. The goal of our study was to examine the incidence, management, and outcome of ischemic complications at our institution after EVAR and to compare complications according to graft type and time period. This is a retrospective review of all EVARs performed at our institution from 1993 through 2005 (n = 430). EVAR was performed in asymptomatic patients in most cases. Follow-up consisted of a computed tomography scan and office visit at 1, 6, and 12 months and yearly thereafter. Ischemic complications after EVAR have decreased significantly with the advent of lower-profile devices with easier delivery systems and supported limbs. Simultaneous coil embolization of internal iliac artery at the time of EVAR implant does not appear to increase the risk of pelvic or lower-extremity ischemia, can be done safely, and does not need to be staged.

One Technique to Modulate a Device Implantation Path in a Short Treatment Length Using the Gore IBE Device

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, AZ, USA) applicability is limited by the aorto-iliac length (AOL). The shortage may be a major exclusion criterion. An 85-year-old male presented with an abdominal aortic and left common iliac arterial aneurysm. The left-side AOL was 146-mm, which was deemed 19-mm too short for IBE usage. To increase implantation length, the contra-lateral connection stent graft was deployed along the implantation line, wound half-circumferentially around the ipsilateral limb. Any form of endoleak, limb occlusion, and device migration has not been observed for twelve months.

Technical Tips for the Implantation of the Gore® Excluder® Abdominal Aortic Aneurysm and Iliac Branch Endoprosthesis in Short Aortoiliac Anatomies

The purpose of this article is to describe the techniques used to deploy a Gore® Excluder® abdominal aortic aneurysm (AAA) and iliac branch endoprosthesis (IBE) in a short aortoiliac anatomy, expanding treatment options of a patient otherwise unfit for endovascular repair. Four strategies were used to shorten the total length of the components, achieving a reduction of over 3 cm during deployment: a pull-pull technique on a through-and-through guidewire to accommodate the IBE onto the iliac bifurcation, deployment in a "cross-limb" configuration, foreshortening of the iliac bridging component during release, and final proximal shortening of the AAA main body thanks to the C3 repositionable delivery system.

Surgical Complications after Open Abdominal Aortic Aneurysm Repair: Intestinal Ischemia, Buttock Claudication and Sexual Dysfunction

While surgical treatment for abdominal aortic aneurysm (AAA) is a standard operation, prevention of complication is important. Intestinal ischemia of the sigmoid colon and/or rectum after AAA surgery is severe and has a high mortality rate although occurrence frequency is low. The most important thing to prevent is the preoperative and intraoperative evaluation of the left hemicolon and rectal circulation. Measurement of inferior mesenteric artery stump pressure is also useful. From the viewpoint of prevention of buttock claudication, it is desirable that internal iliac artery (IIA) blood flow is preserved, but aggressive IIA reconstruction adaptation is considered to be low. For erectile function, it is important that the antegrade blood flow from the IIA to the internal pudendal artery on at least one side is preserved or reconstructed. To prevent retrograde ejaculation, it is important to preserve the superior hypogastric plexus and one side of the lumbar splanchnic nerve, and the hypogastric nerve. Understanding and mastering local anatomy and pathophysiology is important in preventing complications, and we must also remember that we always keep watchful surgical operations in mind in order to prevent tissue damage. (This is a translation of Jpn J Vasc Surg 2019; 28: 99-103.).

Hypogastric artery coverage during endovascular aneurysm repair in octogenarian and younger patients

AIM

To report our experience about hypogastric artery coverage during endovascular aneurysm repair (EVAR) for aortoiliac aneurysms in patients younger than 80 years (group A) compared with octogenarian patients (group B).

METHODS

Data of consecutive EVAR with hypogastric artery coverage from 01/1998 to 12/2016 were retrospectively analyzed. Primary outcomes were the occurrence of ischemic colitis, type II endoleak and buttock claudication both at 30 days and in the long term. P values less than 0.05 were considered statistically significant.

RESULTS

The hypogastric artery was covered in 107 patients. Twenty-three (21.5%) were octogenarian (group B). At 30 days, one type II endoleak occurred in group B, whereas 16 patients of group A experienced buttock claudication. There were no cases of ischemic colitis. During follow-up (median 63.5 months), no cases of ischemic colitis occurred. Six new type II endoleaks were recorded (five in group B and one in group A, P = 0.0001). Buttock claudication persisted in four patients of group A. No new cases of buttock claudication were observed.

CONCLUSION

Unilateral hypogastric artery coverage during EVAR for aortoiliac aneurysms can be performed with an acceptable rate of postoperative complication. Postoperative buttock claudication was more frequent in younger patients, whereas a type II endoleak occurred mostly in octogenarian patients during follow-up.

Parallel Stent Graft Technique for Hypogastric Aneurysm Repair With Flow Preservation of Distal Pelvic Circulation

Hypogastric artery aneurysms (HAA) necessitate repair due to significant morbidity and potential mortality associated with rupture. Coverage or coiling of HAA are not always possible, as the risk of pelvic and spinal cord ischemia become especially significant in bilateral hypogastric disease as well as with prior extensive aortic coverage. We report 2 cases of endovascular HAA exclusion using parallel stent grafts for preservation of flow through the distal hypogastric artery branches and external iliac artery in patients with prior thoracic and abdominal aortic repairs, contralateral hypogastric disease, and significant anatomic constraints.

Isolated mycotic hypogastric artery aneurysm

Isolated iliac artery aneurysms are rare and commonly associated with aortic aneurysms. Hypogastric artery aneurysms (HAAs) are exceptionally rare. The general approach to HAAs has been exclusion and bypass, although when this is complicated by mycotic disease, endovascular techniques can provide unique approaches to management. We present the case of a patient with a mycotic HAA treated with endovascular coil and exclusion followed by aortic to external iliac artery bypass with cadaveric conduit.

Inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair

BACKGROUND

Ischemic colitis after an open abdominal aortic aneurysm (AAA) repair remains a serious complication with a nationally reported rate of 1% to 6% in elective cases and up to 60% after an aneurysmal rupture. To prevent this serious complication, inferior mesenteric artery (IMA) replantation is performed at the discretion of the surgeon based on his or her intraoperative findings, despite the lack of clear evidence to support this practice. The purpose of this study was to determine whether replantation of the IMA reduces the risk of ischemic colitis and improves the overall outcome of AAA repair.

METHODS

Patients who underwent open infrarenal AAA repair were identified in the multicenter American College of Surgeons National Surgical Quality Improvement Program Targeted AAA Database from 2012 to 2015. Emergency cases, patients with chronically occluded IMAs, ruptured aneurysms with evidence of hypotension, and patients requiring visceral revascularization were excluded. The remaining elective cases were divided into two groups: those with IMA replantation (IMA-R) and those with IMA ligation. We measured the 30-day outcomes including mortality, morbidity, and perioperative outcomes. A multivariable logistic regression model was used for data analysis, adjusting for clinically relevant covariates.

RESULTS

We identified 2397 patients who underwent AAA repair between 2012 and 2015, of which 135 patients (5.6%) had ischemic colitis. After applying the appropriate exclusion criteria, there were 672 patients who were included in our study. This cohort was divided into two groups: 35 patients with IMA-R and 637 patients with IMA ligation. There were no major differences in preoperative comorbidities between the two groups. IMA-R was associated with increased mean operative time (319.7 ± 117.8 minutes vs 242.4 ± 109.3 minutes; P < .001). Examination of 30-day outcomes revealed patients with IMA-R had a higher rate of return to the operating room (20.0% vs 7.2%; P = .006), a higher rate of wound complications (17.1% vs 3.0%; P = .001), and a higher incidence of ischemic colitis (8.6% vs 2.4%; P = .027). There were no significant differences in mortality, pulmonary complications, or renal complications between the two groups. In multivariable analysis, IMA-R was a significant predictor of ischemic colitis and wound complications.

CONCLUSIONS

These data suggest that IMA-R is not associated with protection from ischemic colitis after open AAA repair. The role of IMA-R remains to be identified.

Persistent Buttock Claudication after Endovascular Abdominal Aortic Aneurysm Repair

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

Endovascular management of iliac aneurysmal disease with hypogastric artery preservation

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

Novel Endovascular Approach Using the Gore Iliac Branch Endograft for Short Iliac Anatomy

PURPOSE

To report the use of a branched iliac endograft to maintain internal iliac artery (IIA) patency in a patient with an infrarenal aortic aneurysm and short common iliac arteries (CIA).

CASE REPORT

A 74-year-old man presented with an asymptomatic, fusiform, 67-mm infrarenal aortic aneurysm confirmed on computed tomography. The right CIA was funnel shaped and only 15 mm in length, providing no appropriate stent-graft landing zone. The left CIA measured 14 mm in diameter and 25 mm in length. Endovascular repair of the aneurysm with preservation of the IIAs was achieved using a Gore Iliac Branch Endoprosthesis for the short right CIA and a conventional limb to land in the left CIA. Follow-up scans to 24 months have shown continued patency of the IIA and no evidence of endoleak.

CONCLUSION

The Gore Iliac Branch Endograft can be used to successfully treat patients with short CIA anatomy while preserving flow to the ipsilateral IIA, with maintained early patency of the IIA limb.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

BACKGROUND

The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair.

METHODS

From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year.

RESULTS

A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention.

CONCLUSIONS

IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.