Relocation of the iliac artery bifurcation to facilitate endoluminal treatment of abdominal aortic 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.

Bifurcated-bifurcated aneurysm repair is a novel technique to repair infrarenal aortic aneurysms in the setting of iliac aneurysms

BACKGROUND

Up to 40% of abdominal aortic aneurysms (AAAs) have coexistent iliac artery aneurysms (IAAs). In the past, successful endovascular repair required internal iliac artery (IIA) embolization, which can lead to pelvic or buttock ischemia. This study describes a technique that uses a readily available solution with a minimally altered off-the-shelf bifurcated graft in the IAA to maintain IIA perfusion.

METHODS

From August 2009 to May 2015, 14 patients with AAAs and coexisting IAAs underwent repair with a bifurcated-bifurcated approach. A 22-mm or 24-mm bifurcated main body device was used in the IAA with extension of the "contralateral" limb into the IIA. Intraoperative details including operative time, fluoroscopy time, and contrast agent use were recorded. Outcome measures assessed were operative technical success and a composite outcome measure of IIA patency, freedom from reintervention, and clinically significant endoleak at 1 year.

RESULTS

Fourteen patients underwent bifurcated-bifurcated repair during the study period. Technical success was achieved in 93% of patients, with successful treatment of the AAA and IAA and preservation of flow to at least one IIA. The procedure was performed with a completely percutaneous bilateral femoral approach in 92% of patients. Three patients had a type II endoleak on initial follow-up imaging, but none were clinically significant. There were no cases of bowel ischemia or erectile dysfunction. One patient had buttock claudication ipsilateral to IIA coil embolization (contralateral to bifurcated iliac repair and preserved IIA) that resolved by 6-month follow-up. Two patients required reinterventions. One patient presented to his first follow-up visit on postoperative day 25 with thrombosis of the right external iliac limb ipsilateral to the bifurcated iliac repair, which was successfully treated with thrombectomy and stenting of the limb. This same patient presented at 83 months with growth of the preserved IIA to 3.9 cm and underwent coil embolization of the aneurysm. Another patient presented for surveillance 44 months after his original repair with component separation of the mating stent and the iliac bifurcated stent grafts. This was treated with a limb extension and endoanchors to fuse the endografts. Of the 13 patients who underwent bifurcated-bifurcated repair, 100% of the preserved IIAs remained patent at last follow-up. The composite outcome measure of IIA patency and freedom from reintervention and clinically significant endoleak at 1 year was 92% (n = 12/13).

CONCLUSIONS

In this small retrospective review, bifurcated-bifurcated aneurysm repair of aortoiliac aneurysms with preservation of perfusion to the IIA is technically feasible and safe with good short-term and midterm results in male patients.

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass

BACKGROUND

Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass.

METHODS

Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded.

RESULTS

The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent.

CONCLUSIONS

Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.

A Comparison of AneuRx Aortic Cuff and Zenith Distal Flare Exclusion of Common Iliac Artery Ectasia for Endovascular Aneurysm Repair

Stent-grafts are ideally terminated within the common iliac artery (CIA). However, CIA ectasia may require hypogastric artery occlusion, with stent-graft extension to the external iliac artery. Alternatively, the diameter of the distal stent-graft may be increased, or flared, to allow exclusion of the abdominal aortic aneurysm. This report details the authors’ experience with this technique. Forty-one patients received bifurcated stent-grafts (BSG): 20 received an AneuRx device, and 21 received a Zenith device. CIA ectasia (diameter 15–25 mm) was treated with a distal flare of 2–4 mm greater than the CIA diameter. Patients were followed up with computed tomography scan at 1, 6, and 12 months. Statistical analysis was performed using ANOVA within groups and unpaired two-tailed t test between groups. A p value of <0.05 was considered significant. Eight of 20 patients (40%) (11 CIA) received an AneuRx device and 13/21 (62%) (17 CIA) received a Zenith device, with a distal flare. Values are (n) mean (mm) ± SE. There were no deaths, endoleaks, migrations, or conversions to open repair. Follow-up mean was 24.7 and 20.6 (range 15–28) months for AneuRx and Zenith groups, respectively. In comparing initial and 12-month CIA diameters, AneuRx grafts 20 ±0.8 vs 21.5 ±1.0 were not significantly different, p= 0.2, nor was the same comparison for Zenith, 17 ±0.5 vs 19.1 ±0.4, significant, p= 0.57. At a mean follow-up of 12 months, distal flare of iliac limbs with either AneuRx or Zenith devices affords a seal for CIA ectasia and/or aneurysms complicating EVAR.

Complex common and internal iliac or aortoiliac aneurysms and current approach: individualised open-endovascular or combined procedures

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates.

Challenging the evidence for pre-emptive coil embolisation of the internal iliac artery during endovascular aneurysm repair

OBJECTIVES

We retrospectively analysed the results of a strategy in which coverage of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR) was routinely performed without coil embolisation.

METHODS

From January 2010 until May 2012, 32 patients (96.9% men; mean age 73.0 years, range 52-89 years) underwent EVAR with stent grafts extended into the external iliac artery (EIA), all without prior coil embolisation. Aneurysm morphology was determined on preoperative computed tomography (CT) images. During follow-up, patients were interviewed about buttock claudication, and the occurrence of endoleaks and evolution of aneurysm diameter were recorded.

RESULTS

At baseline, the mid-common iliac artery (CIA) diameter was 33.5 ± 16.8 mm and seven patients presented with ruptured aneurysms. Mean follow-up was 14.3 ± 7.4 months. There were eight deaths, none related to IIA coverage. Buttock claudication occurred in seven (22.6%) patients, which persisted after 6 months in two cases of bilateral IIA coverage. No Type-I or -II endoleaks occurred related to IIA coverage. Aneurysm growth was not observed.

CONCLUSION

Endovascular treatment of aortoiliac and iliac aneurysm without pre-emptive coil embolisation of the IIA appears safe and effective. No IIA-related endoleaks or re-interventions occurred in our series. This approach saves operating time, contrast load and costs and may reduce complications. However, a larger population and longer follow-up is required to confirm our findings.

Endovascular treatment of abdominal aortic aneurysms combined with bilateral common and internal iliac aneurysms

INTRODUCTION

Combined aneurysms of aortic and iliac arteries are rare with a prevalence of less than 0.1%. However, these combined aneurysms are associated with a high incidence of thrombosis, distal embolism, or rupture. Endovascular repair is a therapeutic option and includes embolization of the internal iliac artery in numerous cases. Embolization of the internal iliac artery may cause severe ischemia with hip and buttock complications in 2-5%. Therefore, preservation of internal iliac arteries is essential to reduce complications.

PATIENT AND METHOD

We describe in detail an endovascular procedure for combined abdominal aortic (diameter of 8.6 cm) and bilateral common and internal iliac aneurysm (diameter of the left side: 6.4 cm; diameter of the right side: 4.3 cm) in a 44-year-old patient caused by media necrosis Erdheim-Gsell. The blood flow of both internal arteries was preserved in this patient.

RESULT

Operation was done without any complications. Conversion to an open procedure was not necessary. During follow up (3, 6, and 12 months after operation) the patient did not develop any signs of severe hip and buttock complications. Furthermore, sonography and CT angiography revealed a good blood flow via the internal and external iliac arteries.

CONCLUSION

Endovascular repair of abdominal aortic aneurysms combined with bilateral common and internal iliac aneurysms offers a promising minimal invasive procedure. Most importantly, this technique is less invasive than open operations and reduces complications by preserving the pelvic perfusion.

Iliac branch graft in the treatment of complex aortoiliac aneurysms: early results from a North American institution

PURPOSE

To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair.

MATERIALS AND METHODS

From July 2007 to August 2009 (25 months), 14 patients (13 men, one woman) with a mean age of 70.1 years (range, 59.3-80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n = 11), juxtarenal aortic aneurysm with CIA involvement (n = 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6-35 mo).

RESULTS

Technical success rate, as defined by successful implantation of IBG with no intraprocedural type I or type III endoleak, was 86% (12 of 14). A total of 14 IBGs were successfully deployed in 12 patients. Two cases of technical failure were related to excessive iliac tortuosity. The mean hospitalization duration was 6.5 days (range, 3-14 d), with zero mortality at 30 days. There were two cases of type II endoleak treated conservatively and a single case of IBG-related type III endoleak that required repeat intervention. The rest of the stent-implanted aortic and iliac aneurysms remained stable in size, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up. None of the patients who received IBGs had new symptoms of pelvic ischemia.

CONCLUSIONS

Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of aortoiliac aneurysms.

Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation

PURPOSE

To describe a new endovascular approach to preserve internal iliac artery (IIA) flow in patients with abdominal aortic aneurysm (AAA) involving the common iliac artery(ies) (CIA) or in cases of isolated CIA/IIA aneurysm.

TECHNIQUE

The sandwich technique for isolated CIA/IIA aneurysms or aortoiliac aneurysms extending to the IIA includes 5 steps: (1) bifurcated stent-graft main body insertion through an ipsilateral femoral approach and positioned such that the distal end of the iliac limb is 1 cm above the IIA origin; (2) catheterization of the ipsilateral IIA through a left brachial access with a long 5-F multipurpose catheter and a 0.035-inch extra stiff floppy tip guidewire; (3) placement of a covered self-expanding stent 2 cm inside the IIA with a 6-cm overlap into the iliac limb, followed by positioning of an iliac limb extension 1 cm below the covered stent's proximal end (the iliac limb extension is deployed first and then the covered stent); (4) modeling of the iliac limb stent-grafts using a latex balloon and dilation of the covered stent with an angioplasty balloon; and (5) deployment of the contralateral iliac limb. For bilateral CIA aneurysms extending to both IIAs, repeat steps 2-4.

CONCLUSION

This technique was developed to overcome current anatomical and device constraints, expanding the limits of endovascular aneurysm repair (EVAR) in a safe, easy to perform, and cost-effective manner. The sandwich technique appears a promising tool in the EVAR armamentarium, but more experience with the method is warranted.

Endovascular preservation of full pelvic circulation with external iliac-to-internal iliac artery "cross-stenting" in patients with aorto-iliac aneurysms

Common iliac artery (CIA) aneurysms that extend into the iliac bifurcation and internal iliac artery (IIA) usually require exclusion of the IIA, exposing pelvic ischemic complication risks. This case report presents an endovascular technique of "cross-stenting" in a short proximal landing zone with complete exclusion of the CIA aneurysm using a covered stent graft with a longer uncovered stent extending into one branch of the IIAs, maintaining full pelvic circulation. External iliac artery to IIA cross-stenting with an additional uncovered stent warrants further investigation, because it seems to extend graft stent placement indications, increase stability, and help avoid IIA exclusion.

Hypogastric artery bypass in open repair of abdominal aortoiliac aneurysm: a safe procedure

OBJECTIVES

The aim of this study is to assess the immediate and mid-term results of hypogastric artery bypass (HAB) in open repair of abdominal aortic aneurysm (AAA).

METHODS

The clinical data of 24 patients with an average age of 70.4 years [standard deviation (S.D.)+/-8.1 years] with AAA treated between January 2005 and December 2008 with HAB during open repair of aortoiliac aneurysm were reviewed. Eighteen patients received unilateral and six bilateral hypogastric bypasses, using a segment of Dacron graft prosthesis. Concomitant hypogastric eversion endarterectomy was associated in six cases (25%). Follow-up was complete in all the 24 patients and averaged 16.2 months (range 1-35). Postoperative imaging protocol involved a conventional Echocolordoppler and CT-scan. With respect to the operating time, the blood loss, the intensive care unit (ICU) and the length of ward admission (LWA) stay, we compared the 24 patients who underwent hypogastric bypass (group A) with the 50 patients who had bifurcated graft without hypogastric bypass (group B).

RESULTS

Between the two groups, statistically different results were demonstrated only with respect to the duration of operation (h) (group A 5.19+/-1.38 vs. group B 4.39+/-1.32, P=0.0195). No statistical differences were noted for ICU stay (h) (group A median 21.50 vs. group B median 21.3, range 1 degrees -3 degrees quartile 19.75-23.50) and LWA stay (days) (group A median 8.50, range 1 degrees -3 degrees quartile 7.00-11.50 vs. group B median 8.0, range 1 degrees -3 degrees quartile 7.00-9.00). There were no operative deaths, bowel or intestinal ischemia in the early postoperative period between the two groups. In group A, one patient had transient renal failure and one patient had an acute coronary syndrome. In group B, one patient had a peripheral ischemia who required tibioperoneal embolectomy. The patency of the hypogastric grafts was demonstrated in all cases.

CONCLUSIONS

In our experience, direct revascularization of the hypogastric artery to ensure pelvic vascularization in aortoiliac surgery appears a safe procedure.

Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device

OBJECTIVES

Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution.

DESIGN

Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review.

RESULTS

Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85-100%. Median operating times were 101-290min and median contrast dose was 58-208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients.

CONCLUSION

IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.

[Endovascular repair of aortic aneurysm--preliminary results]

INTRODUCTION

Endovascular aneurysm repair (EVAR) has been introduced into clinical practice at the beginning of the 90's of the last century. Because of economic, political and social problems during the last 25 years, the introduction of this procedure in Serbia was not possible.

OBJECTIVE

The aim of this study was to present preliminary experiences and results of the Clinic for Vascular Surgery of the Serbian Clinical Centre in Belgrade in endovascular treatment of thoracic and abdominal aortic aneurysms.

METHODS

The procedure was performed in 33 patients (3 female and 30 male), aged from 42 to 83 years. Ten patients had a descending thoracic aorta aneurysm (three atherosclerotic, four traumatic--three chronic and one acute as a part of polytrauma, one dissected, two penetrated atherosclerotic ulcers), while 23 patients had the abdominal aortic aneurysm, one ruptured and two isolated iliac artery aneurysms. The indications for EVAR were isthmic aneurismal localisation, aged over 80 years and associated comorbidity (cardiac, pulmonary and cerebrovasular diseases, previous thoracotomy or multiple laparotomies associated with abdominal infection, idiopathic thrombocitopaenia). All of these patients had three or more risk factors. The diagnosis was established using duplex ultrasonography, angiography and MSCT. In the case of thoracic aneurysm, a Medtronic-Valiant endovascular stent graft was implanted, while for the abdominal aortic aneurysm Medtronic-Talent endovascular stent grafts with delivery systems were used. In three patients, following EVAR a surgical repair of the femoral artery aneurysm was performed, and in another three patients femoro-femoral cross over bypass followed implantation of aortouniiliac stent graft.

RESULTS

During procedure and follow-up period (mean 1.6 years), there were: one death, one conversion, one endoleak type 1, six patients with endoleak type 2 that disappeared during the follow-up period, one early graft thrombosis. No other complications, including aneurysm expansion, collapse, deformity and migration of the endovascular stent grafts, were registered.

CONCLUSION

According to all medical and economic aspects, we recommend EVAR to treat acute traumatic thoracic aortic aneurysm, as well as in elderly and high-risk patients with abdominal or thoracic aneurysms, when open surgery is related to a significantly higher mortality and morbidity.

EVAR of aortoiliac aneurysms with branched stent-grafts

INTRODUCTION

Branched iliac stent-grafts (bSG) have recently been developed in order to preserve internal iliac artery (IIA) flow in patients with aneurysmal or short common iliac arteries. The aim of this study is to evaluate a single-center experience with bSG for the IIA.

METHODS

Twenty-two male patients (70 (IQR 65-79) years old) underwent EVAR with 23 bSG (1 bilateral repair) between September 2002 and August 2007. Median AAA diameter was 52 (37-60) mm while common iliac diameter on the side of the bSG was 34 (27-41) mm. Two in-house modified Zenith SG and subsequently 21 commercially available bSG (18 Zenith Iliac Side and 3 Helical Branches) were used. Follow-up (FU) included CT at one month and yearly thereafter. Data was prospectively entered in a database.

RESULTS

Primary technical success was 91% (21 bSG). Median FU duration was 20 (8-31) months. One patient (5 %) died after discharge from acute myocardial infarction on day 13. Another patient died 30 months after EVAR of an unrelated cause. The overall bSG patency was 74% due to 6 branch occlusions (2 intraoperative and 4 late). All patients with patent bSG were asymptomatic. Three occlusions were asymptomatic findings on CT, while the other three developed claudication (two patients with contralateral IIA occlusion and one with simultaneous occlusion of the external iliac). One patient (5%) developed an asymptomatic type III endoleak at 1 month and was successfully treated with a bridging SG. Overall, four patients (18%) required reinterventions (1 bilateral stenting of the external iliac arteries, 1 external and 1 internal SG extensions and 1 femoro-femoral cross-over bypass). Nine out of 16 patients (56%) with CT-FU>/=1 year had shrinking aneurysms. There were no postoperative aneurysm expansions.

CONCLUSIONS

EVAR of aortoiliac aneurysms with IIA bSG is a good alternative to occlusion of the IIA in patients with challenging distal anatomy.

Internal Iliac Artery Embolization before Endovascular Repair of Aortoiliac Aneurysms with a Nitinol Vascular Occlusion Plug

PURPOSE

To evaluate the acute and midterm effectiveness of a novel vascular occlusion device for embolization of the internal iliac artery (IIA) before endovascular repair of aortoiliac aneurysms.

MATERIALS AND METHODS

Between March 2005 and April 2006, nine men (mean age, 75 years +/- 5; range, 66-83 y) with aortoiliac aneurysms underwent bifurcated endovascular stent-graft procedures. All these patients were referred specifically for embolization. Pre- and perioperatively, eight patients underwent unilateral embolization and one underwent bilateral embolization of the IIA to prevent type II endoleak. Via a contralateral femoral approach with a 6-F or 8-F sheath, the embolization procedure was performed with an Amplatzer Vascular Plug, a self-expandable cylindrical device consisting of a nitinol-based wire mesh. Technical success, clinical outcome, and complications were evaluated. Follow-up at 3, 6, and 12 months was performed with clinical and radiologic examinations.

RESULTS

IIA embolization was technically successful in all cases and no procedure-related complications occurred. Imaging at discharge and at 3-, 6-, or 12-month follow-up was accomplished in all nine patients. Control computed tomography and magnetic resonance angiography did not reveal retrograde perfusion of the aneurysmal sac, ie, type II endoleak. Three of nine patients (33.3%) reported symptoms of buttock claudication that did not resolve completely. Clinical symptoms such as bowel ischemia or sexual dysfunction were not observed.

CONCLUSIONS

The midterm results of this study suggest that preoperative IIA embolization with a nitinol vascular occlusion plug during endovascular treatment of aortoiliac aneurysms is safe and effective.

Endovascular abdominal aortic aneurysm repair in patients with common iliac artery aneurysms – Initial experience with the Zenith bifurcated iliac side branch device

OBJECTIVE

To present our initial experience with the Zenith bifurcated iliac side branch device that preserves internal iliac artery flow whilst excluding aorto-iliac aneurysms.

METHODS

Between November 2005 and October 2006, data was prospectively collected on 8 patients in whom this device was used; 2 aorto-bi-iliac aneurysms, 3 aorto-uni-iliac aneurysms, 1 solitary common iliac aneurysm, 1 distal type 1 endoleak, and 1 internal iliac aneurysm.

RESULTS

No mortality or major complications resulted from use of this device. The median fluoroscopy time was 53 minutes (range 38 to 105) and a median of 102 g of iodine (range 84 to 130) as contrast were used. One patient required a blood transfusion and only one of the eight side branches occluded. There has been no endoleak related to the device in the median follow-up period of 6 months (1 to 14 months).

CONCLUSION

This device provides an alternative for the management of patients with aorto-iliac aneurysms that is safe and less complex than, previously described, hybrid procedures that preserve internal iliac flow.

Branched Grafting for Aortoiliac Aneurysms

PURPOSE

To evaluate a novel approach to preserve pelvic perfusion during endovascular AAA repair in patients with common iliac aneurysms extending to the iliac bifurcation.

MATERIALS AND METHODS

A multicenter prospective analysis of patients undergoing implantation of a branched endograft designed to perfuse the internal iliac artery was conducted. All patients enrolled were considered high risk for open surgical repair and presented with common iliac artery aneurysms greater than 20mm and anatomy amenable to implant the branched device. Preoperative high resolution spiral CT, and follow-up CT studies in addition to abdominal radiographs were obtained at discharge, 1, 6, 12, and 24 months.

RESULTS

Between 2003 and 2006, 52 patients (53 internal iliacs) were implanted with an investigational device. Mean common iliac aneurysm maximal diameter was 38 mm. The branch graft was combined with a proximal standard bifurcated component (61%), a fenestrated or a visceral branch component (33%), an aortouni-iliac component (2%), and alone in 2 patients (4%, following prior aortobi-iliac repair). Technical success was achieved in 94% of patients. Within the first month, 6 (11%) internal iliac branches occluded. No occlusions were noted after 1 month. The mean follow-up was 14.2 months. Common iliac aneurysm shrinkage was noted in 42% and 81% of patients at 6 and 12 months. There were no rupture, aneurysm related deaths or conversions, but there were 7 deaths during follow-up.

CONCLUSIONS

The placement of endovascular prostheses that maintain antegrade perfusion of one or both internal iliac arteries is feasible, and early results provide evidence for optimism with regard to safety and efficacy.

Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair

BACKGROUND

Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass.

METHODS

A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (> or = 20 mm) and patent hypogastric arteries not amenable to a cuff or "bell bottom" technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass.

RESULTS

Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 +/- 72 minutes; EMBO, 153 +/- 39 minutes; BYPASS, 283 +/- 75 minutes) and estimated blood loss (CTRL, 251 +/- 313 mL; EMBO, 233 +/- 158 mL; BYPASS, 400 +/- 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 +/- 11% (SE) at 36 months by life-table analysis.

CONCLUSIONS

Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.

Access for Endovascular Aneurysm Repair

Despite advancement in stent-graft technology, access-related problems continue to occur during endovascular repair of aortic aneurysms. Various techniques have been adopted to overcome difficult access situations, however. To survey these developments in arterial access, we performed a systematic literature review from 1994 through 2005 to identify relevant articles pertaining to endovascular access techniques and complications. Excessive iliac tortuosity, circumferential vessel wall calcification, significant occlusive disease, and small caliber vessels account for the majority of access problems, most of which are readily apparent with adequate baseline imaging. Even with careful preoperative assessment, however, some access problems may not be foreseen; nonetheless, the majority can be overcome using today's array of ancillary procedures, such as an iliac conduit, a brachiofemoral wire, or arterial reconstruction. Alternatively, other approach routes, such as the common carotid artery or direct aortic access, may be used to facilitate endovascular aneurysm repair.

Concomitant unilateral internal iliac artery embolization and endovascular infrarenal aortic aneurysm repair

INTRODUCTION

Endograft limb extension to the external iliac artery with embolization of an internal iliac artery (IIA) may be necessary in patients with abdominal aortic aneurysms (AAAs) extending to the common iliac artery to prevent endoleak during endovascular aortic aneurysm repair (EVAR). Coil embolization of the IIA can be performed at the same operative setting as EVAR or, alternatively, as a staged procedure. Most interventionalists favor the latter approach to avoid excessive contrast material and prolonged operative time. We investigated the clinical outcome of concomitant vs staged unilateral IIA embolization in the setting of EVAR.

METHODS

Vascular surgeons at our institution treated 24 patients with infrarenal EVAR and unilateral coil embolization of the IIA from October 1, 2000 to June 30, 2005. All patients had normal renal function. The details of the operative procedure and perioperative complications were compared in patients undergoing concomitant vs staged procedures. Follow up was 1 to 40 months (average, 11 months).

RESULTS

Among the 24, 16 underwent concomitant unilateral IIA embolization in the setting of EVAR and eight patients underwent the staged procedure. Average duration of operative time (298 vs 284 minutes), amount of intravenous contrast (215 mL vs 164 mL), and preoperative (1.12 vs 1.26 mg/dL), and postoperative (1.15 v. 1.31 mg/dl) creatinine levels were similar in the concomitant vs staged group, respectively (P > .05 for all factors). More sensitive markers of renal insufficiency such as creatinine clearance were not measured. In the concomitant group, 25% (4/16) of patients reported significant symptoms of buttock claudication ipsilateral to the embolized IIA, which resolved after a mean of 8.8 months (range, 1 to 15 months) vs no cases (0/8) in the staged group (P = .02048). One patient in the staged group developed ischemic colitis, which was treated conservatively. Coil embolizations that were performed as staged procedures were all done on an outpatient basis. All 24 patients were admitted the day of the EVAR and were discharged the next day, except one patient in the concomitant group was discharged the second day after the procedure, and one patient in the staged group was discharged 7 days after the procedure.

CONCLUSION

Despite concern of prolonged operative time and the amount of contrast needed to perform concomitant IIA embolization and EVAR, our results showed that in patients with normal renal function, concomitant unilateral IIA embolization in the setting of EVAR was safe and effective and associated with shorter hospitalization compared with staged procedures. The disadvantage of a concomitant procedure is an increased likelihood of transient buttock claudication, but the small number of patients in this series prohibits definite conclusions about this complication. The concomitant procedure may be preferable for infirm patients with normal renal function who would be greatly inconvenienced by two procedures.

Intraoperative Monitoring of Penile and Buttock Blood Flow During Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

The purpose of this study was to assess the pelvic circulation during endovascular abdominal aortic aneurysm repair (EVAR) with a new monitoring system measuring penile and buttock blood flow.

METHODS

We measured penile brachial pressure index (PBI) during EVAR by pulse-volume-plethysmography (form PWV/ABItrade mark). We also measured bilateral gluteal tissue oxygen metabolism with near-infrared spectroscopy to provide a gluteal tissue oxygenation index (TOI). Twenty-two men who underwent aortouni-iliac stentgraft with crossover bypass for exclusion of abdominal aortic aneurysm were studied. Twelve patients underwent aorto-uni-common iliac artery stentgraft (CIA) and ten underwent aorto-uni-external iliac artery stentgraft (EIA).

RESULTS

In all patients, there was an immediate reduction in PBI during the EVAR procedure. After revascularization of the ipsilateral limb of the stent graft, the recovery of PBI was significantly less in EIA group. After the completion of crossover bypass, PBI in both groups recovered to the baseline values. In both groups there was a bilateral reduction in gluteal TOI during malperfusion of the internal iliac artery. After revascularization of ipsilateral limb of the stent graft, the ipsilateral TOI recovered to the baseline level in CIA patients, but recovery was incomplete in EIA patients. In contrast, contra-lateral TOI remained low in both groups after revascularization of ipsilateral limb of the stent graft. Only after completion of crossover bypass did the contra-lateral TOI recover to baseline level in both groups.

CONCLUSIONS

Both TOI at the buttocks and PBI are a sensitive reflection of pelvic haemodynamics. Penile blood flow and bilateral gluteal blood flow are supplied via different circulations and both should be monitored for full assessment of the pelvic circulation.

Embolization as cause of bowel ischemia after endovascular abdominal aortic aneurysm repair

OBJECTIVE

We investigated the incidence, cause, and outcome of large bowel and small bowel ischemia after endovascular abdominal aortic aneurysm (AAA) repair.

METHODS

Medical records for all patients undergoing endovascular AAA repair from December 1999 to December 2003 were reviewed. The incidence, cause, and outcome of clinically detected postoperative bowel ischemia were analyzed.

RESULTS

Seven hundred two endovascular AAA repairs were performed. In 10 patients (1.4%) acute bowel ischemia developed. Six of these patients sustained concurrent small bowel necrosis, and the remaining 4 had isolated colon ischemia. Seven patients underwent exploratory laparotomy. In 6 of these bowel resection was performed, and in 1 patient the ischemic bowel was unsalvageable. Of the 6 patients with small and large bowel ischemia, 4 had segmental or patchy necrosis, which was separated by normal-appearing intestine, and 1 had extensive ischemia that involved most of the small bowel and the entire colon, with pathologic evidence of microembolization. Three patients had preoperative occlusion of the inferior mesenteric artery. One had unilateral and 1 had bilateral hypogastric artery interruption. Five of the 6 patients with small bowel ischemia had thrombus or atheroma in the proximal aneurysmal necks. All patients with isolated colon ischemia survived. All 6 patients with concurrent small bowel ischemia died.

CONCLUSION

The total incidence of clinically evident bowel ischemia after endovascular AAA repair is similar to that after open surgery. However, small bowel ischemia occurs more commonly in patients with endovascular repair, and is associated with extremely high mortality. The direct pathologic evidence and the patterns of segmental, skipped, or patchy ischemia in most patients imply that microembolization has an important role.

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair

PURPOSE

Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption.

METHODS

From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg).

RESULTS

There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits.

CONCLUSIONS

Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE

Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure.

METHODS

Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality.

RESULTS

Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups.

CONCLUSION

Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.

Iliorenal artery bypass grafting to facilitate endovascular abdominal aortic aneurysm repair

Effective endovascular repair of an infrarenal abdominal aortic aneurysm (AAA) requires adequate proximal and distal landing zones to allow secure endograft attachment. We report a patient with an infrarenal AAA originating 3 mm below the left renal artery with cardiac morbidity that precluded open AAA repair. Left renal artery relocation with retroperitoneal iliorenal bypass grafting was performed to lengthen the proximal landing zone, which facilitated successful endovascular AAA repair. Postoperative surveillance after 3 years showed aneurysm reduction with a patent iliorenal bypass graft. This case underscores the utility of a combined open and endovascular approach in treatment of a challenging aortic aneurysm.