Outcomes of bell-bottom technique compared to standard endovascular aneurysm repair

Initial Experience of the Covered Endovascular Reconstruction of Iliac Bifurcation Technique

INTRODUCTION

The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique.

METHODS

This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate.

RESULTS

Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB.

CONCLUSION

The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability.

CLINICAL IMPACT

The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.

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.

Incidence, Risk Factors, and Prognostic Impact of Type Ib Endoleak Following Endovascular Repair for Abdominal Aortic Aneurysm: Scoping Review

OBJECTIVE

The primary objectives of this scoping review were to assess the rate of and risk factors for type Ib endoleak and to evaluate the extent of the evidence base that links type Ib endoleak to short and long term outcomes in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).

METHODS

Potentially eligible studies were searched in the Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science Core Collection, SciELO Citation Index, Russian Science Citation Index, and KCI-Korean Journal Database. A scoping review was performed according to PRISMA extension for Scoping Reviews.

RESULTS

A total of 27 articles (four prospective registries and 23 retrospective cohort studies) dealing with type Ib endoleak were included in the final analysis. The number of patients reported on was 7 197, with follow up ranging between 12 months and 93 months. The reported frequency of type Ib endoleak in patients treated with EVAR ranged from 0% to 8%, Patient and or procedure related factors associated with risk of type Ib endoleak were (1) common iliac artery (CIA) diameter ˃ 18 mm requiring use of flared stent graft limbs (FLs) ˃ 20 mm, (2) length of CIA landing zone ˂ 20 mm, (3) marked iliac tortuosity, and (4) large initial AAA diameter. Depending on the study, 50 - 100% of type Ib endoleaks were corrected by endovascular means, with a reported immediate technical success of 100% in the studies providing this information.

CONCLUSION

Type Ib endoleak after EVAR has been reported to occur in 0 - 8% of cases. Several anatomical features, including CIA diameter ˃ 18 mm or requiring the use of FLs ˃ 20 mm, length of CIA landing zone ˂ 20 mm, marked iliac tortuosity, and large initial AAA diameter, could increase the risk of type Ib endoleak and may require alternative therapeutic options and or more stringent follow up. Therefore, this updated scoping review provides a comprehensive summary of the frequency, risk factors, prognosis, and treatment of type Ib endoleaks, and has identified knowledge gaps in the literature to guide further studies.

Treatment of Aortoiliac Aneurysms: Compatibility of the E-liac Stent Graft (Artivion®, Iliac Branch Device) with Endurant II or IIs (Medtronic®, EVAR)

PURPOSE

Iliac branch devices (IBD) are widely used to treat aortoiliac aneurysms with an unfit distal landing zone for standard endovascular aneurysm repair (EVAR). The aim of this retrospective study was to examine the treatment of aortoiliac aneurysms with the combination of the Endurant II(s) stent graft system (Medtronic^®) and the E-liac stent graft (Artivion^®).

MATERIALS AND METHODS

Data of all patients who underwent an EVAR combined with unilateral or bilateral IBD between January 2015 and January 2020 were analyzed. Primary outcomes were technical success at implantation (successful EVAR with IBD extension placement and patency of the grafts without type 1 or type 3 endoleak), and type 1b/3 endoleak, hypogastric artery patency and IBD-related reinterventions during follow-up. Secondary outcomes were all type 1 endoleak, all reinterventions, rupture, and mortality during follow-up.

RESULTS

A total of 38 patients were treated with a combination of EVAR with IBD. Technical success was 94.7% (n = 36/38). The 30-day survival was 100%. Median follow-up time was 31 months (range 8-56). During follow-up, no patients developed type 1b or type 3 endoleak and all hypogastric arteries at the side of IBD remained patent. The overall reintervention rate at 12 months follow-up was 5.3% (n = 2/38) and the IBD-related reintervention rate was 2.6% (n = 1/38).

CONCLUSION

The combination of the Endurant II(s) and the E-liac stent graft system is an effective and safe procedure for patients with an aortoiliac aneurysm. We confirm the high hypogastric artery patency rate using IBD. Furthermore, these devices have a high technical success rate even when it is combined with an Endurant II(s) EVAR main body.

Clampless In-Situ Immobilized Branching (CLIMB) to Reconstruct the Internal Iliac Artery

BACKGROUND

Surgical reconstruction of the internal iliac artery (IIA) or its branches is sometimes demanding because of difficulty in distal clamping and suturing in the narrow pelvic space. Here we present a hybrid technique of ClampLess In-situ imMobilized Branching (CLIMB) to reconstruct IIA.

METHODS

in the CLIMB technique, an 8 mm artificial graft is sutured onto the surface of the common iliac artery (CIA) without clamping. Following puncture of the CIA wall, stent grafts are bridged from IIA to the graft. Finally, the graft is sutured to the ipsilateral external iliac artery (EIA). Concomitant endovascular aneurysm repair or IIA branch embolization can also be performed. We applied this technique to the patients unsuited for other IIA reconstruction.

RESULTS

eleven patients underwent the current technique. All but one patient underwent contralateral IIA interruption. Seven patients had a history of aorto-iliac repair before the index surgery. Iliac extender, internal iliac component, Viabahn VBX or Fluency covered stent were used for bridging the graft. Simultaneous IIA branch embolization was performed in 2 patients. Distal landing zones were IIA in 7 grafts, superior gluteal artery in 4 grafts and inferior gluteal artery (IGA) in 1 graft. Technical success was achieved in all cases. No patient complained of buttock claudication or other ischemic symptoms on the treatment side. During a mean follow-up period of 38 months, 11 out of 12 grafts were patent without any related endoleak. One IGA graft occluded at 56 months after surgery.

CONCLUSIONS

the CLIMB technique is a viable alternative to preserve IIA with an acceptable mid-term durability.

Systematic Review on the Mid-Term Outcomes of Elective Endovascular Aneurysm Sealing in Comparison to Endovascular Aneurysm Repair

INTRODUCTION

The Nellix endovascular aneurysm sealing (EVAS) system has been a topic of discussion. Early results were promising but did not deliver on the long-term and the device has been recalled from the market. This study compares literature for EVAS and conventional endovascular aneurysm repair (EVAR).

METHODS

A systematic review and analysis was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed, Embase, and Cochrane Library were searched and identified the eligible studies. Proportion rates for the outcomes of interest were extracted. Subgroup analyses were performed for EVAS and EVAR.

RESULTS

A total of 12 studies were included (EVAS n = 4, EVAR n = 8) including 10,255 patients (EVAS n = 784, EVAR n = 9441). The longest duration of follow-up was 3.4 years for EVAS and 5.0 years for EVAR studies. Throughout follow-up the overall all-cause mortality rates were 6% for EVAS and 13% for EVAR, and endoleak of any type was described in 10% of EVAS and 17% of EVAR patients. The migration rate >10 mm was 8% for EVAS and 0% for EVAR and aneurysm growth >5 mm was found in 11% of EVAS and 3% of EVAR cases. Total reintervention rate was 13% for EVAS and 7% for EVAR patients. For all analyzed outcome parameters heterogeneity was >50%.

CONCLUSION

There is a tendency toward lower mortality and overall endoleak rates for EVAS compared to EVAR but with a higher rate of migration, aneurysm growth, and reintervention. Despite lower overall endoleak rates there was a tendency toward less type II and more type I endoleaks after EVAS compared to EVAR. Substantial heterogeneity however limits robust statistical analyses, and is probably caused by significant instructions for use breach in EVAS-treated patients. We call for more high-quality and long-term follow-up studies on both EVAS and EVAR in order to confirm the trends found in this study.