Editor's Choice - Long Term Outcomes of the Advanta V12 Covered Bridging Stent for Fenestrated and Branched Endovascular Aneurysm Repair in 1 675 Target Vessels

OBJECTIVE

To report outcomes of the Advanta V12 as a covered bridging stent in fenestrated and branched endovascular aneurysm repair (F/BEVAR).

METHODS

Patients treated with F/BEVAR and followed in a single centre receiving the Advanta V12 as a covered bridging stent between January 2010 and May 2020 were included.

RESULTS

A total of 636 patients (543 men) were analysed. A total of 1 675 target vessels (TVs) were bridged with the Advanta V12. Estimated TV patency at one, five, and eight years was 99.1% ± 0.2%, 96.9% ± 0.5% and 96.2% ± 0.7%, respectively. Estimated patency at eight years was 98.1% ± 0.5% for fenestrations and 87.3% ± 2.9% for branches (p < .001). Estimated patency of renal arteries was statistically significantly lower for those targeted with branches compared with fenestrations (p = .001). Multivariable analysis showed that targeting a TV with a branch compared with a fenestration was the only independent risk factor for occlusion during follow up (hazard ratio 6.41, 95% CI 3.4 - 11.9; p < .001). Estimated freedom from endoleak at one, five, and eight years was 99.4% ± 0.2%, 96.4% ± 0.6%, and 95.4% ± 0.8%, respectively. Estimated freedom from target vessel instability (TVI) at one, five, and eight years was 98.5% ± 0.3%, 93.0% ± 0.8%, and 91.3% ± 1%, respectively. Estimated freedom from TVI at eight years was 93.2% ± 0.9% for fenestrations and 82.7% ± 3.5% for branches (p < .001). Estimated freedom from TVI was statistically significantly lower for renal arteries targeted with branches compared with those targeted with fenestrations (p < .001) CONCLUSION: The Advanta V12 shows excellent technical success rates as a covered bridging stent in F/ΒEVAR. Late outcomes remain good with low rates of TV occlusion, endoleak, and re-intervention. Renal arteries targeted with branches demonstrated a higher risk of occlusion and instability compared with those targeted with fenestrations.

Editor's Choice - Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms

OBJECTIVE

The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre.

METHODS

Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed.

RESULTS

A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088).

CONCLUSION

Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions

OBJECTIVES

To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures.

METHODS

Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared.

RESULTS

No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02).

CONCLUSIONS

There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

Outcomes of Advanta V12 Covered Stents After Fenestrated Endovascular Aneurysm Repair

Purpose:

Fenestrated endovascular aneurysm repair (FEVAR) is a well-established endovascular treatment option for pararenal abdominal aortic aneurysms in which balloon-expandable covered stents (BECS) are used to bridge the fenestration to the target vessels. This study presents midterm clinical outcomes and patency rates of the Advanta V12 BECS used as a bridging stent.

Methods:

All patients treated with FEVAR with at least 1 Advanta V12 BECS were included from 2 large-volume vascular centers between January 2012 and December 2015. Primary endpoints were freedom from all-cause reintervention, and freedom from BECS-associated complications and reintervention. BECS-associated complications included significant stenosis, occlusion, type 3 endoleak, or stent fracture. Secondary endpoints included all-cause mortality in-hospital and during follow-up.

Results:

This retrospective study included 194 FEVAR patients with a mean age of 72.2±8.0 years. A total of 457 visceral arteries were stented with an Advanta V12 BECS. Median (interquartile range) follow-up time was 24.6 (1.6, 49.9) months. The FEVAR procedure was technically successful in 93% of the patients. Five patients (3%) died in-hospital. Patient survival was 77% (95% CI 69% to 84%) at 3 years. Freedom from all-cause reintervention was 70% (95% CI 61% to 78%) at 3 years, and 33% of all-cause reinterventions were BECS associated. Complications were seen in 24 of 457 Advanta V12 BECSs: type 3 endoleak in 8 BECSs, significant stenosis in 4 BECSs, occlusion in 6 BECSs, and stent fractures in 3 BECSs. A combination of complications occurred in 3 BECSs: type 3 endoleak and stenosis, stent fracture and stenosis, and stent fracture and occlusion. The freedom from BECS-associated complications for Advanta V12 BECSs was 98% (95% CI 96% to 99%) at 1 year and 92% (95% CI 88% to 95%) at 3 years. The freedom from BECS-associated reinterventions was 98% (95% CI 95% to 100%) at 1 year and 94% (95% CI 91% to 97%) at 3 years.

Conclusion:

The Advanta V12 BECS used as bridging stent in FEVAR showed low complication and reintervention rates at 3 years. A substantial number of FEVAR patients required a reintervention, but most were not BECS related.

Single Center Experience with Endovascular Repair of Acute Thoracoabdominal Aortic Aneurysms

PURPOSE

To investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA).

MATERIALS AND METHODS

Data from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan-Meier analysis.

RESULTS

A total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%.

CONCLUSION

Endovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

The Relationship Between Operative Volume and Peri-operative Mortality After Non-elective Aortic Aneurysm Repair in Australia

OBJECTIVE

Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown.

METHODS

The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR).

RESULTS

Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67).

CONCLUSION

There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.

Increasing Role of Fenestrated and Branched Endoluminal Techniques in the Thoracoabdominal Segment Including Supra- and Pararenal AAA

Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

OBJECTIVES

Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients.

METHODS

This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017 at two vascular institutions experienced in endovascular techniques.

RESULTS

A total of 71 consecutive patients (56 male, mean age 63.8 ± 10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7 ± 4.5%, 80.7 ± 5.1%, and 70.0 ± 6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7 ± 5.3%, 63.0 ± 6.9%, and 52.6 ± 8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n = 4; superior mesenteric artery n = 2; coeliac artery n = 2). Mean aneurysm sac regression during follow up was 9.2 ± 8.8 mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up.

CONCLUSION

F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised.

A Systematic Review of Proximal Neck Dilatation After Endovascular Repair for Abdominal Aortic Aneurysm

Purpose: To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR). Methods: A review of the English-language medical literature from 1991 to 2015 was conducted using MEDLINE and EMBASE to identify studies reporting AND after EVAR. Studies considered for inclusion and full-text review fulfilled the following criteria: (1) reported AND after EVAR, (2) included at least 5 patients, and (3) provided data on AND quantification. The search identified 26 articles published between 1998 and 2015 that encompassed 9721 patients (median age 71.8 years; 9439 men). Results: AND occurred in 24.6% of patients (95% CI 18.6% to 31.8%) over a period ranging from 15 months to 9 years after EVAR. No significant dilatation of the suprarenal part of the aorta was reported by most studies. The incidence of combined clinical events (endoleak type I, migration, reintervention during follow-up) was higher in the AND group (26%) when compared with 2% in the group without AND (OR 28.7, 95% CI 5.43 to 151.67, p<0.001). Conclusion: AND affects a considerable proportion of EVAR patients and was related to worse clinical outcome, as indicated by increased rates of type I endoleak, migration, and reinterventions. Future studies should focus on a better understanding of the pathophysiology, predictors, and risk factors of AND, which could identify patients who may warrant a different EVAR strategy and/or a closer post-EVAR surveillance strategy.

Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms

AIM

The aim was to conduct a systematic review of the literature investigating outcomes after interruption or preservation of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR).

METHODS

A systematic review was undertaken using the MEDLINE and EMBASE databases to identify studies reporting IIA management during EVAR. The search identified 57 articles: 30 reported on IIA interruption (1468 patients) and 27 on IIA preservation (816 patients).

RESULTS

The pooled 30 day buttock claudication (BC) rate was 29.2% (95% CI 24.2-34.7). Patients undergoing bilateral IIA interruption had a higher incidence of BC than patients with unilateral IIA interruption (36.5% vs. 27.2%, OR 1.7, 95% CI 1.11-2.6, p = .01). During a median follow up of 17 months, the pooled rate of persistent BC was 20.5% (95% CI 15.7-26.2). Of the patients, 93.9% underwent an endovascular revascularization procedure for IIA preservation. Most patients (87.6%) had an iliac branched device, and technical success was 96.2%. Within 30 days of EVAR, 4.3% of internal iliac branches occluded. During a median follow up of 15 months, the pooled occlusion rate at the site of IIA revascularization was 8.8% (95% CI 6.8-11.3). In patients treated with an iliac-branched device, 5.2% of internal iliac branches and 1.7% of external iliac arteries occluded. The pooled BC rate on the side of the IIA revascularization during follow up was 4.1% (95% CI 2.9-5.9). Pooled rates of late device related endoleak type I or III and secondary procedures on the side of the previous IIA revascularization were 4.6% (95% CI 3.2-6.5) and 7.8% (95% CI 5.7-10.7) respectively.

CONCLUSION

Unilateral or bilateral IIA occlusion during EVAR seems to carry a substantial risk of significant ischemic complications in nearly one quarter of patients. Bilateral IIA occlusion was related to a significantly higher rate of BC. IIA preservation techniques represent a significant improvement in the treatment of aorto-iliac aneurysms and have been associated with high technical success and low morbidity.

Thoracic Stent Grafts with a Distal Fenestration for the Celiac Axis

Descending thoracic aneurysms can be treated with a stent graft provided that there is sufficient proximal and distal aortic neck length above the celiac axis. One of the options for the treatment of thoracic aneurysms with a too short distal neck is described in this report. For this purpose, a stent graft was constructed with a scallop for the celiac axis. Three cases are presented, and the technical details are described.

Emergency Endovascular Stent Grafting for Thoracic Aortic Pathology

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease.

From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm ( n = 13), pseudoaneurysm ( n = 6), aortic rupture ( n = 5), type B dissection ( n = 5), aortobronchial or aortoesophageal fistula ( n = 4), and intramural hematoma ( n = 1).

The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures.

The mean follow-up was 31 ± 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections.

Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft.

Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.

Quality of life from a randomized trial of open and endovascular repair for abdominal aortic aneurysm

Background

Long-term survival is similar after open or endovascular repair of abdominal aortic aneurysm. Few data exist on the effect of either procedure on long-term health-related quality of life (HRQoL) and health status.

Methods

Patients enrolled in a multicentre randomized clinical trial (DREAM trial; 2000–2003) in Europe of open repair versus endovascular repair (EVAR) of abdominal aortic aneurysm were asked to complete questionnaires on health status and HRQoL. HRQoL scores were assessed at baseline and at 13 time points thereafter, using generic tools, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) and EuroQol 5D (EQ-5D™). Physical (PCS) and mental component summary scores were also calculated. Follow-up was 5 years.

Results

Some 332 of 351 patients enrolled in the trial returned questionnaires. More than 70 per cent of questionnaires were returned at each time point. Both surgical interventions had a short-term negative effect on HRQoL and health status. This was less severe in the EVAR group than in the open repair group. In the longer term the physical domains of SF-36® favoured open repair: mean difference in PCS score between open repair and EVAR −1·98 (95 per cent c.i. −3·56 to −0·41). EQ-5D™ descriptive and EQ-5D™ visual analogue scale scores for open repair were also superior to those for EVAR after the initial 6-week interval: mean difference −0·06 (−0·10 to −0·02) and −4·09 (−6·91 to −1·27) respectively.

Conclusion

In this study EVAR appeared to be associated with less severe disruption to HRQoL and health status in the short term. However, during longer-term follow-up to 5 years, patients receiving open repair appeared to have improved quality of life and health status.

Treatment algorithms for patients with (sub)acute type B aortic dissections

Aortic dissection is the most common acute aortic syndrome and constitutes a potentially catastrophic cardiovascular condition. Traditionally, complicated acute type B dissection has been considered an indication for surgical treatment, whereas patients with uncomplicated dissection have been treated medically. In recent years, there has been a clear paradigm shift towards endovascular treatment of complicated type B dissection. This is founded in numerous reviews and meta-analyses demonstrating a lower perioperative mortality and morbidity for TEVAR in comparison to open surgical repair. In uncomplicated patients, treatment options are still a matter of debate. Best medical therapy shows acceptable early results with respect to in-hospital mortality and morbidity but fails to address the issue of late aortic expansion and aortic-related adverse events in a significant number of patients. There is increasing evidence that early TEVAR promotes false lumen thrombosis, induces remodeling of the aortic wall and should be considered preventively in selected patients with suitable anatomy. This report gives an overview of current literature on treatment options and optimal time of intervention, and finally proposes a treatment algorithm for acute type B aortic dissection.

Retrograde Target Vessel Catheterization as a Salvage Procedure in Fenestrated/Branched Endografting

Purpose: To present retrograde target vessel catheterization as a bailout technique in fenestrated and branched endografting (F/B-EVAR). Methods: Between November 2003 and November 2014, 11 (1.6%) of 671 consecutive patients with juxtarenal, suprarenal, and thoracoabdominal aortic aneurysms required retrograde target vessel access as a bailout measure during F/B-EVAR due to failure of an antegrade approach. The target vessels involved the left renal artery (LRA) in 6 patients, the celiac artery (CA) in 3 patients, the right renal artery (RRA) in 1 patient, and both renal arteries in 1 patient. Results: The target vessels were successfully catheterized and secured with stent-grafts in 10 patients; a single case was unsuccessful because the fenestration was in the wrong position and blocked against the arterial wall. One (9.1%) patient died within 30 days. Major perioperative complications occurred in 6 patients, including 3 with renal function deterioration, 2 with access-site wound dehiscence, and a case of pneumonia. Median hospital stay was 20 days (range 7–60) and median intensive care unit stay was 2.5 days (range 0–9). Over a mean 26-month follow-up (range 1–60), one unrelated death occurred. Reintervention was required in 1 patient due to progression of an aneurysm of the right iliac artery. Conclusion: Retrograde target vessel access in F/B-EVAR is a feasible bailout procedure when antegrade cannulation fails. Secondary technical success is high, but the procedure is associated with higher perioperative morbidity and longer hospital stay.

Editor's Choice - Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients

OBJECTIVE

To present a 10 year experience with endovascular thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent grafts.

MATERIALS AND METHODS

Consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004-December 2013. Data were collected prospectively.

RESULTS

166 patients (125 male, 41 female, mean age 68.8 ± 7.6 years) were treated. The mean TAAA diameter was 71 ± 9.3 mm. Types of TAAA were: type I, n = 12 (7.2%), type II, n = 50 (30.1%), type III, n = 53 (31.9%), type IV, n = 41 (24.8%), and type V, n = 10 (6%). Fifteen (9%) patients had an acute TAAA (11 contained rupture, 4 symptomatic). One hundred and eight (65%) patients were refused for open surgery earlier. Seventy eight (47%) patients had previously undergone one or more open/endovascular aortic procedures. Technical success was 95% (157/166). Thirty day operative mortality was 7.8% (13/166), with an in hospital mortality of 9% (15/166). Peri-operative spinal cord ischemia (SCI) was observed in 15 patients (9%), including permanent paraplegia in two (1.2%). Mean follow up was 29.2 ± 21 months. During follow up 40 patients died, two of them probably from aneurysm related cause. Re-intervention, mostly by endovascular means, was needed in 40 (24%) patients. Estimated survival at 1, 2, and 5 years was 83% ± 3%, 78% ± 3.5%, and 66.6% ± 6.1%, respectively. Estimated target vessel stent patency at 1, 2, and 5 years was 98% ± 0.6%, 97% ± 0.8%, and 94.2% ± 1.5%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 88.3% ± 2.7%, and 78.4% ± 4.5%, respectively.

CONCLUSIONS

Endovascular repair of TAAA with fenestrated and branched stent grafts in high volume centers appears safe and effective in the mid-term in a high risk patient cohort. A considerable reintervention rate should be acknowledged, however.

Fenestrated and branched stent-grafting after previous open or endovascular aortic surgery

AIM

Aim of the study was to review our experience with fenestrated and branched stent-grafts to treat juxtarenal (JAA) and thoracoabdominal (TAAA) aortic aneurysms after previous open or endovascular aortic surgery.

METHODS

A prospectively maintained database including all consecutive patients with JAA or TAAA treated with fenestrated/branched stent-grafts after previous open or endovascular aortic surgery within the period March 2002-November 2013 was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity and late procedure-related events with regard to survival, target vessel patency, and re-intervention.

RESULTS

A total of 122 patients (110 male, 12 female; mean age mean age 70±9.5 years) were treated. Median time interval from previous aortic surgery to current fenestrated/branched stent-grafting was 80 months (range 3-261 months). Seventy-seven (63.1%) patients had previous open infrarenal aortic surgery, 33 (27%) had previous endovascular abdominal aortic aneurysm repair (EVAR), nine (7.4%) had previous open thoracic aortic surgery, and three (2.5%) had previous endovascular thoracic aortic repair (TEVAR). Indication for current treatment was a JAA in 65 (53.3%) patients and a TAAA in 57 (46.7%) patients. Technical success was achieved in 115 (94.3%) patients. Seven patients were considered as technical failure (open conversion; N.=1, target vessel loss; N.=6). Operative target vessel perfusion success rate with endovascular means was 98.5% (391/397). Intraoperative technical difficulties due to pre-existing stent-graft/surgical graft were encountered in 28 (23%) patients (access, N.=12; target vessel catheterisation, N.=16). Thirty-day operative mortality was 4.1% (5/122), with zero mortality in 65 JAA, and 8.8% (5/57) in TAAA, respectively. Cause of death was multiple organ failure (N.=3), acute gastrointestinal bleeding (N.=1), and subdural hematoma (N.=1). Major complications occurred in 20 (16.4%) patients. Median hospital stay was 7 days (range 3-50 days), and mean ICU stay 1.5±3.2 days. Mean follow-up was 22.5±21 months. All-cause late mortality was encountered in 23 patients, including one aneurysm-related mortality. Estimated survival was 91.2±3%, 83.3±4.2% and 81.1±4.6% at one, two and three years, respectively. During follow-up, eight target vessels occluded. Estimated target vessel patency was 97.2±1.1%, and 96.3±1.2% at one and three years, respectively. Reintervention during follow-up was required in 13 (10.6%) cases accounting for an estimated freedom from reintervention of 91.6±3.1%, and 82.1±5.4% at one and three years, respectively.

CONCLUSION

Fenestrated and branched stent-grafting represents a feasible option for the repair of JAA and TAAA after prior endovascular or open aortic surgery. Despite increased technical difficulties it is associated with high technical success rate and is advantageous in terms of mortality and morbidity compared to redo open aortic surgery.

A modified technique for Gore Excluder limb deployment in difficult iliac anatomy during endovascular abdominal aortic aneurysm repair

Complex iliac anatomy including extreme tortuosity constitutes a relative contraindication for endovascular abdominal aortic aneurysm repair with additional risk of limb-graft occlusion. The Gore Excluder limb-graft is a flexible stent-graft, which adapts easily to iliac tortuosity. Nevertheless, the presence of the stiff guide wire does not always allow for an ideal apposition of the stent graft to the angulated common iliac artery vessel wall. We describe herein a modified technique for Gore Excluder limb-graft deployment with partial removal of the stiff wire in cases with difficult tortuous or narrow iliac arteries during endovascular abdominal aortic aneurysm repair.

Current status of Hemobahn/Viabahn endografts for treatment of popliteal aneurysms

The aim of the present study was to review the literature reporting the use of the Hemobahn/Viabahn endograft (W. L. Gore and Assoc Inc., Flagstaff, AZ, USA) for endovascular treatment of popliteal artery aneurysms (PAA). A PubMed database search was performed looking for studies reporting endovascular treatment of PAA with the Hemobahn/Viabahn endograft within the period January 2000-December 2012. All relevant studies were independently assessed and all references were examined for potentially missed relevant reports. Studies were included if they reported experience with five patients or more. Eight studies with 222 patients (mean age 72.4 years, 92.3% male) and 251 PAA (mean diameter 2.9 mm, 14.3% symptomatic) were included. Thirteen cases (5.2%) were treated on an urgent basis, including three cases of ruptured PAA and 10 cases of acute limb ischemia. Initial technical success was 99.2%. The mean number of implanted endografts/PAA was 1.8 (range 1-4). Thirty-day mortality was 1 (0.4%) patient. Perioperative complications occurred in 1.6%, consisting of three access site hematomas and one acute endograft thrombosis. Cumulative mean follow-up duration was 36.9 months. During this period, a total of 46 endograft failures (42 occlusions, 4 stenoses) were observed within a mean postoperative time interval of 10.8 months. Cumulative primary and secondary patency rates were 85.6% and 93.4% at one year, and 78.5% and 90.4% at 2 years, respectively. Limb salvage rate during follow-up was 99.2%. Endoleak was noticed in 15 (6%) cases and endograft migration in 13 (5.2%) cases. Endograft fracture was reported in 14 (5.6%) cases, resulting in occlusion in six patients, and in type III and IV endoleaks in two patients. Secondary intervention during follow-up was required in 47 (18.7%) cases, including 32 reinterventions for endograft occlusion, four for endograft stenosis, and 11 for endoleak repair. Endovascular PAA repair with the Hemobahn/Viabahn endograft is feasible and safe yielding excellent initial technical success rates, minimum perioperative mortality and morbidity, and mid-term patency and limb salvage rates comparable to open surgery. These results suggest that a significant proportion of patients might benefit from endovascular PAA repair.

Early outcome of endovascular aneurysm repair in challenging aortic neck morphology based on experience from the GREAT C3 registry

AIM

The aim of this paper was to evaluate early outcome of the GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System in subjects with aortic neck anatomy outside IFU.

METHODS

Individual patient data prospectively collected over a 2 year period from the Global Registry for Endovascular Aortic Treatment (GREAT). For each subject a minimum data set was collected containing demographic, pre/intra- and postoperative variables. Main outcome measures were successful exclusion of the AAA and occurrence of any major endoleak at 1 month. In this study, outside IFU was defined as aortic neck length less than 15 mm and/or aortic neck angle greater than 60 degrees.

RESULTS

A total of 400 subjects, (86.6% male, mean age 73.9 years). Primary pathology was AAA in 94.2% with 98.2% undergoing EVAR as a primary procedure. Sixty-eight subjects underwent EVAR outside IFU (neck length <15 mm N.=32, neck angle >60˙N.=47 and neck length <15 mm and angle >60° N.=11). The graft was successfully deployed within 5 mm of its intended location in 63 (94%) cases utilising a total of 33 repositioning episodes. Eight aortic cuffs were used, 5 to treat a type 1 endoleak. At 30 days we recorded 2 type 2 endoleaks both successfully treated and 1 type 1b also successfully treated. There were 2 deaths, one in each group.

CONCLUSION

GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System allows re-positioning to be performed safely in cases outside IFU. Repositioning is an effective operative manoeuvre and facilitates EVAR in challenging anatomy. Longer follow-up is required to evaluate the durability of these results at 30 days.

Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results

The chimney technique in endovascular aortic aneurysm repair (Ch-EVAR) involves placement of a stent or stent-graft parallel to the main aortic stent-graft to extend the proximal or distal sealing zone while maintaining side branch patency. Ch-EVAR can facilitate endovascular repair of juxtarenal and aortic arch pathology using available standard aortic stent-grafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR both in acute and elective cases with good early results. This review discusses indications, technique, and the current available clinical data on Ch-EVAR.

The role of mandatory lifelong annual surveillance after thoracic endovascular repair

Thoracic endovascular aortic repair (TEVAR) has become an attractive and well-accepted option for the management of the various thoracic aortic pathologies that vascular surgeons are confronted with. As in the abdominal aorta, current management trends include the treatment of younger patients with longer life expectancies, raising the issue of postoperative surveillance. There are several relevant differences between these anatomic areas when it comes to surveillance, including the relative inaccessibility of the thoracic aorta to ultrasound interrogation and the increased variability of thoracic aortic pathologies and post-TEVAR complications. In addition, concerns regarding radiation-induced carcinogenesis and contrast-induced nephropathy reduce the enthusiasm of many surgeons for regular computed tomography surveillance. Most agree that surveillance is important after TEVAR, but the method, duration, and frequency of that surveillance is much less clear and is the topic of this debate.

Endovascular strategies for infrarenal aneurysms with short necks

The aim of this paper was to review the current options for endovascular treatment of abdominal aortic aneurysms (AAAs) with short infrarenal neck. Studies reporting endovascular treatment of AAAs with short proximal neck were reviewed. Fenestrated endovascular aneurysm repair (F-EVAR) is most frequently reported for the treatment of patients with short neck AAA, with high technical success rates (≥ 99%), low operative mortality (≤ 3.5%) and excellent mid- and long-term results in terms of target vessel patency (≥ 97%). Chimney-EVAR (Ch-EVAR) is far less reported, but also presents with high technical success rates (>97%), varying operative mortality rates (0-12.5%), and excellent short- and mid-term target vessel patency (≥ 96%). Ch-EVAR, however, seems to be associated with high postoperative stroke up to 6.3%, and increased proximal type I endoleak (5-31%). Standard EVAR performed outside manufacturers' instructions for use (IFU) is also documented in the treatment of short proximal neck AAA, but is associated with increased operative mortality and morbidity, type I endoleak, and migration, compared to standard EVAR in AAA with longer proximal neck length. F-EVAR currently represents the most validated and reliable endovascular option for the treatment of short-neck AAA. Ch-EVAR is feasible, but lacks long-term data. Its use seems only favored in acute high surgical risk patients, in elective cases complicated with unintentional renal artery coverage or in anatomies unsuitable for F-EVAR. Standard EVAR in short neck AAA is associated with poorer outcomes and should not be recommended as first choice.

Iliac branched device implantation in tortuous iliac anatomy after previous open ruptured aortic aneurysm repair

The aim of this paper was to present iliac branched device (IBD) implantation in a fit 67-year-old man with tortuous iliac anatomy after previous emergent open abdominal aortic aneurysm (AAA) repair. The patient underwent open treatment for a ruptured abdominal aortic aneurysm in another hospital. The procedure was complicated by extreme blood loss which prevented concommitant treatment of two large iliac aneurysms. Later, the patient underwent stent-grafting of a right common iliac artery aneurysm (CIAA) with coil embolization of the internal iliac artery (IIA). He was then refferred to our institute for treatment of the left CIAA with preservation of the left IIA. An IBD was used to this purpose. The introduction system was inserted over a through-and-through wire, and the bridging stent-graft via a left axillary approach. An Excluder leg was used to mate the IBD with the surgical graft limb. Additional self-expanding stents were needed to keep the limbs of the surgical graft open. One year later the patient is doing well, without buttock claudication, and the aneurysm is well excluded. With challenging anatomy, endovascular repair with an IBD may require additional technical tricks but also back-up materials to achieve success.

Is it time to eliminate CT after EVAR as routine follow-up?

Growing concerns regarding radiation exposure, contrast induced nephropathy and increasing costs lead us to reconsider the necessity of CTA for all EVAR patients. The purpose of this study is to compare the results of different follow-up imaging modalities with the aim of finding a rationale to the optimal follow-up imaging protocol. We reviewed recent literature regarding post EVAR imaging modalities and compared it to our experience with different follow-up protocols. Modalities compared were CTA, DUS, CEUS, and plain abdominal X-ray with regard to detection of complications, cost, overall impact to the patient, and on decision making regarding reintervention. CTA is related to increased follow-up costs and a much higher exposure to radiation compared to other modalities. The cumulative radiation dose can have a significant impact on the attributable lifetime cancer risk of patients. Renal function deterioration during post EVAR follow-up is higher compared to open repair. Plain abdominal X-ray is the best manageable modality and a well established tool in documenting migration kinking and stent fracture. Plain X-Ray cannot be used as a standalone imaging modality since it doesn't allow direct detection of endoleaks. As far as detection of endoleaks is concerned recent meta-analyses show a sensitivity of 66-77% for DUS and 81-98% for CEUS, respectively. Most endoleaks missed by DUS and CEUS are type II endoleaks with no need for reintervention. Our data in a cohort of 62 patients do show a sensitivity of 66.7% for DUS, and do correlate with current literature. No endoleaks requiring reintervention were missed. A follow-up protocol comprising of DUS/CEUS and plain abdominal X-ray gives a wide range of information covering EVAR related risks and is associated with less radiation exposure, avoidance of renal function deterioration due to repeated contrast agent application and an important decrease in the cost of EVAR follow-up. CTA should be reserved for cases of inconclusive ultrasound, signs of complications and unfavourable anatomy.

Effectiveness of treatment for octogenarians with acute abdominal aortic aneurysm

OBJECTIVE

To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA).

METHODS

This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ± 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair.

RESULTS

Mean follow-up was 33 ± 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ± 20 days for patients younger than 80 and 13 ± 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ± 6.8 months versus 64.5 ± 3.0 months in those younger than 80.

CONCLUSIONS

For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory short- and long-term outcome, with no difference with regard to disease- or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deny patients surgery.

Fenestrated stent-grafting after previous endovascular abdominal aortic aneurysm repair

AIM

The aim of this study was to present their experience and highlight the technical difficulties associated with the use of fenestrated stent-grafts to treat juxta and pararenal abdominal aortic aneurysms (AAA) in patients having undergone a previous infrarenal endovascular aneurysm repair (EVAR).

METHODS

A prospectively held database maintained at the University Medical Center of Groningen including 162 patients who have undergone branched and fenestrated stent-grafting for AAA, was queried for patients treated with this technology after previous EVAR. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality and morbidity were evaluated.

RESULTS

A total of 9 patients underwent repair with a fenestrated endograft after previous EVAR. All patients had aneurysmal degeneration of the juxta- and pararenal aorta not suitable to standard endovascular techniques. We encountered various intraoperative complications including iliac and renal artery access problems, intraoperative previous graft migration, and dislocation of previous graft limb. In one patient, immediate conversion was needed because a twisted graft limb prevented retrieval of the top cap of the fenestrated graft. The remaining eight patients were successfully treated by endovascular means. For these patients, target vessel success rate was 100% (20/20) and mean hospital stay 6.0 days (range 3-12 days). Thirty-day and one-year mortality were 0%. Mean follow up was 31 months (range 1-76 months). No aneurysm related death occurred during follow-up.

CONCLUSION

Fenestrated endovascular stent-grafts can be used to repair juxta- and pararenal AAA after previous EVAR. However, several technical challenges have to be overcome due to the presence of a previous stent-graft.

Long-term outcome of open or endovascular repair of abdominal aortic aneurysm

BACKGROUND

For patients with large abdominal aortic aneurysms, randomized trials have shown an initial overall survival benefit for elective endovascular repair over conventional open repair. This survival difference, however, was no longer significant in the second year after the procedure. Information regarding the comparative outcome more than 2 years after surgery is important for clinical decision making.

METHODS

We conducted a long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention. Survival was calculated with the use of Kaplan-Meier methods on an intention-to-treat basis.

RESULTS

We randomly assigned 178 patients to undergo open repair and 173 to undergo endovascular repair. Six years after randomization, the cumulative survival rates were 69.9% for open repair and 68.9% for endovascular repair (difference, 1.0 percentage point; 95% confidence interval [CI], -8.8 to 10.8; P=0.97). The cumulative rates of freedom from secondary interventions were 81.9% for open repair and 70.4% for endovascular repair (difference, 11.5 percentage points; 95% CI, 2.0 to 21.0; P=0.03).

CONCLUSIONS

Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair. (ClinicalTrials.gov number, NCT00421330.)

Thoraco-abdominal aortic aneurysm branched repair

Open thoraco-abdominal aortic aneurysm repair is a demanding procedure with high impact on the patient and the operating team. Results from expert centres show mortality rates between 3-21%, with extensive morbidity including renal failure and paraplegia. Endovascular repair of abdominal aortic aneurysms initially required an undilated portion of the aorta below the renal arteries to safely fixate the stent-graft. More complex abdominal artic aneurysms (i.e., short-necked, juxta- and suprarenal aneurysms) were later successfully treated with fenestrated grafts. The development of branched grafts opened the way to treat thoraco-abdominal aneurysms endovascularly. In this review, a comprehensive overview of technical aspects and results of the available literature is given. Mortality rates are below 10%, with spinal cord ischemia reported between 2.7% and 20%. Target vessel branch patency invariably has been reported between 95% and 100%, with first mid-term results demonstrating evidence for durability. Most series included high-risk patients, who were denied open repair. Nevertheless, risks associated with endovascular repair of thoraco-abdominal aneurysm should be acknowledged. Technique-specific complications including perforation of small vessels due to multiple catheterization resulting in retroperitoneal hematoma, and compartment syndrome of the lower limbs should be mentioned. Technical evolution of branched grafts is ongoing. Tapering down the main graft to allow for room for the branches has resulted in easier catheterization of target vessels and insertion of bridging stent-grafts. For the same reason, the branches for celiac artery and superior mesenteric artery are deliberately off-set in position. To stabilise the usually long devices, additional spiral wires have been added, to facilitate deployment in the correct orientation. Endovascular repair of thoraco-abdominal aneurysms will continue to evolve and gradually take over from open repair, in view of the much lower physical impact on the patient.

The intracranial aneurysm susceptibility genes HSPG2 and CSPG2 are not associated with abdominal aortic aneurysm

BACKGROUND

A genetic variant on chromosome 9p21 associates with abdominal aortic aneurysm (AAA) and intracranial aneurysm (IA), indicating that despite the differences in pathology there are shared genetic risk factors. We investigated whether the IA susceptibility genes heparan sulfate proteoglycan 2 (HSPG2) and chondroitin sulfate proteoglycan 2 (CSPG2) associate with AAA as well.

METHODS

Using tag single nucleotide polymorphisms (SNPs), all common variants were analyzed in a Dutch AAA case-control population in a 2-stage genotyping approach. In stage 1, 12 tag SNPs in HSPG2 and 22 tag SNPs in CSPG2 were genotyped in 376 patients and 648 controls. Genotyping of significantly associated SNPs was replicated in a second independent cohort of 360 cases and 376 controls.

RESULTS

In stage 1, no HSPG2 SNPs and 1 CSPG2 SNP associated with AAA (rs2652106, P = .019). Association of this SNP was not replicated (P = .342).

CONCLUSIONS

Our findings demonstrate that, in contrast to IA, HSPG2 and CSPG2 do not associate with AAA.

Results of endovascular abdominal aortic aneurysm repair with selective use of the Gore Excluder

AIM

To evaluate single center results with selective use of the Gore Excluder stent-graft for elective abdominal aortic aneurysm repair.

METHODS

Retrospective analysis of a prospective data base. Primary endpoints were technical success, all-cause and aneurysm-related mortality and aneurysm rupture. Secondary endpoints were late complications including migration, endoleak, aneurysm growth, limb occlusion, and re-intervention.

RESULTS

The Gore Excluder stent-graft was used in 92 elective cases, mainly in cases with difficult iliac anatomy. There were 81 (88%) male patients. Mean age was 70.4+/-7.5 (range, 53-87). Primary assisted technical success rate was 98.9% (91/92 patients). Thirty-day mortality was 0%. Median follow-up was 35.7 months (range, 2-99). Overall survival was 95.2+/-2.4% at 1 year, 89.2+/-3.7% at 2 years, 83.9+/-4.5% at 3 years and 70.2+/-6.8% at 5 years. During follow-up there were 3 (3.3%) Type I endoleaks and 20 (21.7%) Type II endoleaks. Proximal migration of more than 5 mm without endoleak occurred in two patients. In total 13 re-interventions were performed in 12 (13%) patients. No graft limb occlusion occurred. No aneurysm ruptured during follow-up.

CONCLUSIONS

Selective use of the Gore Excluder demonstrates excellent short- and long-term results. Despite being used in challenging iliac anatomy no graft limbs occluded.

The role of branched endografts in preserving internal iliac arteries

AIM

The aim of this study was to report our treatment algorithm and early results with the use of an iliac branched device (IBD) to preserve the internal iliac artery (IIA) in the treatment of aortoiliac and solitary common iliac artery (CIA) aneurysms.

METHODS

From September 2004 on, all patients with aorto-iliac aneurysms with a suitable proximal neck or CIA aneurysms were evaluated. Selection for treatment with an IBD was done based on activity level of the patient and anatomical criteria of the aneurysm. Absolute exclusion criteria included aneurysmal IIA, severe atherosclerosis of the IIA, and small residual CIA lumen. Patients who were at risk of losing one out of two patent IIA were only considered for IBD if they were physically active. Follow-up was performed with computed tomography scanning at six weeks and one year, and thereafter yearly.

RESULTS

Fifty-nine patients (39 aorto-iliac, 20 CIA) were evaluated for treatment with an IBD. Seven patients were not considered for IBD for low activity level. Twenty-five patients were not suitable because of adverse anatomy. In total, 27 patients (20 aorto-iliac, 7 CIA) were treated with 30 IBDs. Technical success was achieved in 96.3% of patients. There was no 30-day mortality. Mean follow-up period was 16+/-14 months. In three patients the IIA side branch occluded, resulting in buttock claudication in only one patient. No external iliac artery occlusion or device component disconnection was observed.

CONCLUSIONS

An IBD provides a totally endovascular option to preserve the IIA in selected aortoiliac and isolated CIA aneurysms. Anatomical application rate for the use of an IBD was 52.5% in our series. Further studies are needed to determine the indications for use of this device.

External-to-internal iliac artery endografting for the exclusion of iliac artery aneurysms: an alternative technique for preservation of pelvic flow?

PURPOSE

The purpose of this study was to describe an alternative endovascular procedure to exclude iliac artery aneurysms, preserving perfusion to the internal iliac artery.

CASES

Two patients, considered unfit for open repair, underwent endovascular repair of iliac artery aneurysms. One of these occurred after previous placement of a bifurcated prosthesis. In both cases the aneurysms were excluded using a nitinol stent covered with expanded polytetrafluoroethylene from the external to the internal iliac artery. Using this technique, the internal iliac arteries were perfused in a retrograde manner. Both interventions were technically successful. The external-to-internal endograft remained patent after 6 and 16 months, respectively.

CONCLUSION

Endovascular placement of a stent-graft from the external iliac artery into the internal iliac artery may offer an alternative and minimal invasive alternative for the management of common and internal iliac artery aneurysms. With the use of this technique, pelvic perfusion is preserved. Further studies are warranted to appraise the advantages and risk of this approach for iliac artery aneurysms.