Image-based assessment of aortoiliac aneurysm anatomical characteristics in patients from the global iliac branch study

OBJECTIVE

Endovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes.

METHODS

Pre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation.

RESULTS

Left total iliac artery length was shorter than right (6.7 mm, P = .0019); right common iliac artery less tortuous (P = .0145). Males exhibited greater tortuosity in the left total iliac artery (P = .0475) and larger diameter in left internal iliac artery's landing zone (P = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females.

CONCLUSION

This study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.

An open approach to a ruptured common iliac artery aneurysm with resultant ilio-iliac arteriovenous fistula

OBJECTIVE

Presentations of a spontaneous ilio-iliac arteriovenous fistula are considered a rare occurrence and warrant urgent intervention. They are usually a result following trauma, previous surgery or uncommonly from a ruptured aneurysm.

METHOD

We describe a case of a patient presenting with general malaise who examined to have a pulsatile abdominal mass with an associated bruit. He was found to have an ilio-iliac arteriovenous fistula secondary to a ruptured iliac aneurysm that was treated successfully with open surgical repair.

RESULT

The patient was brought forward for open surgical repair due to haemodynamic instability as well as likely predicted difficulties with endovascular repair. Intra-operatively, his sigmoid colon was adherent to the aneurysm prompting the need for a Hartmann's procedure to allow for better visualisation of the aneurysm. A combination of external digital compression and Prolene suture was used to close the arteriovenous fistula.

CONCLUSION

Open surgical repair of an ilio-iliac arteriovenous fistula secondary to a ruptured iliac aneurysm appears to be safe and feasible approach. The advancement of medical technology does open up the possibility of an endovascular approach; however, in a small subset of patients, open repair would appear to be better.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry

PURPOSE

To evaluate the clinical utility of the Gore Excluder iliac branch endoprosthesis (IBE) for Japanese patients with aortoiliac aneurysms.

MATERIALS AND METHODS

This was a multicenter retrospective cohort study (J-Preserve Registry). Patients undergoing endovascular aortic repair using the Gore Excluder IBE for aortoiliac aneurysms between August 2017 and June 2020 were enrolled. Data pertaining to the baseline and anatomical characteristics, technical details, and clinical outcomes were collected from each institution. The primary endpoints were technical success, IBE-related complications, and reinterventions. Secondary endpoints were mortality, aneurysm size change, and reintervention during follow-up. Technical success was defined as accurate deployment of the IBE without type Ib, Ic, or III endoleaks on the IBE sides on completion angiography. A change in aneurysm size of 5 mm or more was taken to be a significant change.

RESULTS

We included 141 patients with 151 IBE implantations. Sixty-five IBE implantations (43.0%) had at least one instruction for use violation. Twenty-two patients (15.6%) required internal iliac artery (IIA) embolization for external iliac artery extension on the contralateral side. Of 151 IBE implantations, 19 exhibited IIA branch landing zones due to IIA aneurysms. Mean maximum and proximal common iliac artery (CIA) diameters were 32.9±9.9 mm and 20.5±6.9 mm, respectively. The mean CIA length was 59.1±17.1 mm. The IIA landing diameter and length were 9.0±2.3 mm and 33.8±14.6 mm. The overall technical success rate was 96.7%. There were no significant differences in IBE-related complications (2.3% vs 5.3%, p=0.86) or IBE-related reinterventions (1.5% vs 5.3%, p=0.33) between the IIA trunk and IIA branch landing groups. The mean follow-up period was 635±341 days. The all-cause mortality rate was 5.0%. There were no aneurysm-related deaths or ruptures during the follow-up. Most patients (95.7%) had sac stability or shrinkage.

CONCLUSION

The Gore Excluder IBE was safe and effective for Japanese patients in the midterm. Extending the IIA device into the distal branches of the IIA was acceptable, which may permit extending indications for endovascular aortic aneurysm repair of aortoiliac aneurysms to more complex lesions.

CLINICAL IMPACT

This study suggests clinical benefits of the Gore Excluder IBE for Japanese patients, despite 43% of the IBE implantations having at least one IFU violation.

Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

Cryopreserved Arterial Allografts Versus Rifampin-Soaked Dacron for the Treatment of Infected Aortic and Iliac Aneurysms

BACKGROUND

Infected aortic and iliac artery aneurysms are challenging to treat. Cryopreserved arterial allografts (CAAs) or rifampin-soaked Dacron (RSD) are standard options for in situ reconstruction. Our aim was to compare the safety and effectiveness of CAA versus RSD for these complex pathologies.

METHODS

This is a retrospective review of infected iliac, abdominal, and thoracoabdominal aortic aneurysms treated with either CAAs or RSD between 2002 and 2022 at our institution. The diagnosis was confirmed by intraoperative, radiologic, or microbiological evidence of aortic infection. Perioperative events, 30-day and long-term mortality, reinfection, and reintervention were analyzed.

RESULTS

Thirty patients (17 CAA, 13 RSD) with a mean age of 61 and 68 years, respectively, were identified. The infected aneurysm was most commonly suprarenal or infrarenal. Culture-negative infections were present in 47% of the CAA group and 54% in the RSD group. Early major morbidity was 57% and 54% for the CAA and RSD, respectively. Thirty-day mortality was similar between groups (18% vs. 23% CAA vs. RSD, P ≥ 0.99). Median follow-up was longer in the RSD group (14.5 months vs. 13 months). Overall survival at 1 and 5 years was 80.8% and 64.8% in the CAA group and 69.2% and 57.7% in the RSD group. Reinterventions only occurred with CAA repairs and indications included graft occlusion (2), multiple pseudoaneurysms and reinfection (1), and hemorrhagic shock caused by graft rupture (1). Freedom from reintervention at 1 and 3 years was 87.5% and 79.5% (CAA group) versus 100% and 100% (RSD, P = 0.06). Freedom from reinfection at 1 year was 100% in both groups, while at 3 years it was 90.9% for the CAA group and 100% for the RSD group (P = 0.39).

CONCLUSIONS

Infected aortic and iliac aneurysms have high early morbidity and mortality. CAA and RSD had similar outcomes in our series; CAA trended toward higher reintervention rates. Both remain viable options for complex scenarios but require close surveillance.

Outcomes and Economic Impact of Hypogastric Artery Management During Elective Endovascular Aortic Repair for Aorto-Iliac Aneurysms

BACKGROUND

To analyze clinical outcomes and perform a macro-costing evaluation of endovascular aortic repair (EVAR) for aorto-iliac aneurysms.

METHODS

This is a retrospective, financially unsupported, physician-initiated observational cohort study. Patients with iliac artery involvement treated with EVAR between January 1st, 2014 and December 31st, 2021 were identified. Inclusion criteria were intact aneurysm, elective EVAR with at least 1 hypogastric artery (HA) treatment, use of bifurcated endograft (EG), and at least 6 months of follow-up. Primary outcomes of interest were overall survival, freedom from aneurysm-related mortality (ARM), freedom from EVAR-related reintervention, and overall EVAR(procedure)-related costs.

RESULTS

We studied 122 (9.1%) patients: 119 (97.5%) were male and 3 (2.5%) females. Median age of patients was 76 years (range, 68.75-81). Overall, 107 (87.7%) patients had both HAs preserved according to following strategy: 45 (36.9%) with flared limbs, 13 (10.6%) with bilateral branched device, and 49 (40.2%) with a combination of flared limb on 1 side and branched device on the contralateral side. Bilateral overstenting was performed in 15 (12.3%) patients. Estimated overall survival was not different between groups of EVAR (Log-rank, P = 0.561). There was only 1 (0.8%) ARM ascertained during the follow-up. Estimated freedom from EVAR-related reintervention was not different among groups (Log-rank, P = 0.464). During the follow-up, 9 (7.4%) patients developed buttock claudication (Society for Vascular Surgery (SVS) grade 1, n = 4, SVS grade 2, n = 5), more frequently in HA overstenting (hazard ratio (HR): 3.6; 95% confidence intervals (CIs): 0.96-13.5, P = 0.058). When all cots were included, branched EVAR still carried the highest burden (P = 0.001) in comparison with the mixed subgroup, the overstenting subgroup, and the flared limbs subgroup.

CONCLUSIONS

Early mortality and pelvic ischemic syndromes rate were acceptably low in all techniques. Hypogastric artery preservation showed lower complication rate in comparison with HA overstenting which, however, appears to be safe an effective for option with similar overall costs for patients who are not candidates for HA preservation based on aortic anatomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report

INTRODUCTION

Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients.

PATIENT CONCERNS

A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup.

DIAGNOSES

Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length.

INTERVENTIONS

After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD.

OUTCOMES

The stent grafts were patent without endoleak at the 6-month follow-up.

LESSONS

In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Embolization of Large Internal Iliac Artery Pseudoaneurysm through a Retrograde Trans-Superior Gluteal Arterial Access

The presence of osteal stenosis/occlusion or osteal exclusion by prior interventions poses a challenge to selective catheterization of the internal iliac artery. We describe a case where a retrograde access through the superior gluteal artery (SGA) was used to successfully treat an internal iliac artery pseudoaneurysm (PSA) in a patient when an antegrade catheterization was not feasible due to internal iliac osteal exclusion by an endograft.

Natural history and growth rates of isolated common iliac artery aneurysms

OBJECTIVE

The natural history of isolated common iliac artery aneurysms (CIAAs) has not been well-studied. The optimal size threshold for elective repair of isolated CIAAs is also not well-defined. We sought to determine the natural history and growth rates of isolated CIAAs to justify a surveillance protocol and size for elective repair.

METHODS

Isolated CIAAs (>2 cm) identified from January 1, 2008, through February 29, 2020, at a single center were reviewed. Patient demographics, comorbidities, and details of CIAA operative repairs were retrospectively collected. All available duplex ultrasound and computed tomography scans were reviewed from time of CIAA identification through June 2020.

RESULTS

There were 244 isolated CIAAs found in 167 patients. The cohort was 94% male with an average age of 68.1 ± 8.8 years at the time of CIAA detection. CIAAs were identified with ultrasound examination 69% of the time with a mean CIAA diameter of 2.3 cm. Operative repair of a CIAA was performed in 11.4% of the cohort at an average diameter of 3.30 ± 1.02 cm. The majority of these repairs were performed via an endovascular approach (73.7%; n = 14). There were no symptomatic or ruptured isolated CIAAs. Concurrent aortic growth that led to an abdominal aortic aneurysm with diameter of at least 3 cm occurred in 10.6% (n = 26) of isolated CIAAs. The average length of time from CIAA diagnosis to repair was 65.7 ± 47.1 months. The overall CIAA growth rate was 0.4 mm/y. A subgroup analysis based on CIAA size demonstrated a growth rate of 0.2 mm/y fore CIAAs 2.00 to 2.49 cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 1.3 mm/y for CIAAs 3.0 cm or larger. There were two CIAAs greater than 3.0 cm with extreme growth, which significantly impacted the CIAA growth rate on sensitivity analysis. After excluding those two CIAAs from the model, the overall CIAA growth rate was 0.3 mm/y. The subgroup analysis then demonstrated a growth rate of 0.2 mm/y for CIAAs 2.00 to 2.49cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 0.5 mm/y for CIAAs 3 cm or larger.

CONCLUSIONS

Isolated CIAAs are typically slow growing aneurysms that expectedly grow faster as they enlarge. Given the rare occurrence of rapid isolated CIAA growth, we recommend surveillance at 3 years for 2.00 to 2.49 cm isolated CIAAs, 2 years for 2.50 to 2.99 cm isolated CIAAs, and yearly for isolated CIAAs greater than 3.0 cm. The lack of symptomatic or ruptured isolated CIAAs in this study supports delaying elective repair until an isolated CIAA diameter reaches at least 3.5 cm. These recommendations should be considered for isolated CIAA practice guidelines.

Ruptured Abdominal Aortic Aneurysm Complicated with Occlusion of Bilateral Common Iliac Arteries

We report a case of ruptured abdominal aortic aneurysm complicated with occlusion of bilateral common iliac arteries. A 68-year-old man complained of sudden onset of lower abdominal and back pain. A contrast-enhanced computed tomography showed ruptured abdominal aortic aneurysm of about 80 mm in diameter and a giant retroperitoneal hematoma, as well as occlusion of both common iliac arteries. We performed Y-grafting, concomitant with thrombectomy of both iliac arteries from inside the aneurysm. Postoperative course was uneventful without ischemic findings of the legs and the patient was discharged on the 17^th postoperative day.

Isolated common iliac artery aneurysm with specific anatomical considerations

INTRODUCTION

Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general population involving typically the common iliac artery in 70-90%.

CASE-REPORT

This is the clinical case of an 88 years-old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass.

DISCUSSION

Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

ISOLATED COMMON ILIAC ARTERY ANEURYSM WITH SPECIFIC ANATOMICAL CONSIDERATIONS

INTRODUCTION

Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general popula- tion involving typically the common iliac artery in 70-90%. Literature describes that bilateral common IAA may be present in approximately 50% of the affected patients.

CASE-REPORT

The authors present an 88 years old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an Aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass.

DISCUSSION

Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

Endovascular repair of an ilio-iliac arteriovenous fistula following rupture of common iliac artery aneurysm with an aortic extension cuff in common iliac vein: A case report

RATIONALE

Common iliac artery aneurysm (CIAA) is complicated by ilio-iliac arteriovenous fistulas (IIAVF), which is rare but fatal and require prompt diagnosis and appropriate treatment. As open repair is associated with high morbidity and mortality, endovascular therapy is considered appropriate for treating an IIAVF.

PATIENT CONCERNS

A 76-year-old male patient who developed an IIAVF as a complication of ruptured CIAA, requiring immediate surgical repair presented to the hospital with hemodynamic instability.

DIAGNOSIS

Computed tomography angiography and conventional angiography revealed an IIAVF.

INTERVENTION

Endovascular therapy was selected to reduce the risk of morbidity and mortality. As the angiogram after the first endovascular aneurysm repair with stent-grafting showed contrast medium filling in the aneurysm sac, right common iliac vein, and the inferior vena cava, an aortic extension cuff was inserted into the right common iliac vein to close the orifice on the venous side.

OUTCOMES

The right lower leg edema and discomfort were resolved immediately after the procedure, with the vital signs remaining stable. Computed tomography performed 6 months postoperatively showed patent stent-grafts of the artery and vein, with no evidence of IIAVF and endoleak.

LESSONS

IIAVF following CIAA rupture can be repaired successfully by stenting of the common iliac vein with an aortic extension cuff. For successful endovascular repair, the vein side of the fistula tract should be excluded with a stent-graft to block the backflow into the aneurysm sac.

Epithelioid Angiosarcoma after EVAR. A Case Report

INTRODUCTION

Endovascular aneurysm repair (EVAR) has become a standard in the treatment of aneurysms. However, complications still occur. Endoleaks are the most common. Graft infection diagnosis might be challenging. Even uncommon, we describe a case of epithelioid angiosarcoma after EVAR.

CASE REPORT

A 64-year-old male came to our emergency department with left lumbar and left thigh flexion pain, increasing since a month. Four years before, he had been treated for a left common iliac artery aneurysm extending to the aortic bifurcation by EVAR with a bifurcated unibody aortic (AFX Endologix) endograft. The year before the admission, he was treated twice by percutaneous angioplasty for a symptomatic mural thrombus of the left endograft limb. On admission, CT angiogram showed a recurrence of the aneurysm associated with elevated lab inflammatory markers. FDG-PET-CT showed an abnormal tracer uptake in the endograft limbs and in the left inguinal area. White blood cell scintigraphy did not show any sign of endograft infection. CT angiogram performed 2 months later showed an additional increase of the infrarenal aortic and left common iliac aneurysms. We removed the endograft. Histological analysis showed an epithelioid angiosarcoma. Patient died a few weeks later during chemotherapy.

CONCLUSION

For patients that have undergone EVAR and have subsequently developed morphological changes of the aortic wall and aneurysmal sac, an aortic tumor should be considered. Imaging diagnosis was challenging for this rare case of epithelioid angiosarcoma.

SURGICAL TREATMENT OF A SPONTANEOUS RUPTURE OF A MYCOTIC ANEURYSM

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. Even though surgical approach carries a relative risk of perioperative morbidity, it is a feasible and durable solution for extreme situations like the one here described.

Late Open Repair of a Massive Common Iliac Artery Aneurysm after Endovascular Failure

Giant Common Iliac Artery Aneurysms (CIAA) are an uncommon pathology that may present as a late complication after endovascular aortic repair secondary to aneurysmal degeneration with endoleak. We present an unusual case of a patient presenting 9 years after index endovascular CIAA exclusion with a painless abdominal mass found to be a 20+ cm CIAA secondary to type II endoleak from a recanalized coil embolized hypogastric artery. The patient underwent open aneurysmorrhaphy with ligation of the hypogastric artery.

Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms

INTRODUCTION

Isolated iliac artery aneurysms (IAA), accounting for 2-7 percent of all abdominal aneurysms, are nowadays often treated with the use of iliac branched endografts. Although outside of the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an EVAR device, for the treatment of isolated IAA. In this study we aim to describe the outcomes of the use of the Gore IBE device, without support of an infrarenal EVAR device, for the exclusion of isolated IAA.

DESIGN

This study is an international multicenter retrospective cohort analysis.

METHOD

All patients that were treated with a solitary IBE for IAA exclusion from 11-01-2013 up to 31-12-2018 were retrospectively reviewed. The primary outcome was technical success. Secondary outcomes included mortality, intraoperative and postoperative complications, and re-interventions.

RESULTS

In total 18 European and American centers participated, including 51 patients in which 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. There was no 30-day mortality and a 98.1% patency of both the internal and external iliac artery was found at 24-months follow-up. At 24-months follow-up, 81.5% of patients were free of complications and 90% were free of a secondary intervention.

CONCLUSION

Treatment with a solitary IBE is a safe and, at midterm, effective treatment strategy in selected patients with a solitary IAA.

Hematuria in a 3-month-old filly with an internal umbilical abscess and internal iliac artery aneurysm

A 3-month-old foal with a history of acute hematuria was evaluated. Hydronephrosis and hydroureter were visualized upon renal ultrasonography of the left kidney. Cystoscopy identified a blood clot occluding the left ureter. Computed tomography (CT) revealed a large retroperitoneal abscess at the level of the aortic bifurcation and a left internal iliac aneurysm. Due to the severity of the lesions and the poor prognosis, the filly was euthanized and the clinical findings were confirmed by post-mortem examination. This report emphasizes the value of obtaining a precise diagnosis via CT in order to avoid unviable treatment approaches when confronted with this unusual secondary complication of omphaloarteritis. Key clinical message: Umbilical complications are routinely diagnosed in equine neonatal medicine, and commonly lead to septicemia, physitis, and septic arthritis; severe internal umbilical abscessation, and subsequent vascular and urinary disorders are uncommon sequelae.

Cross-over Deployment of a Tapered Stent Graft to Repair a Ruptured Isolated Internal Iliac Aneurysm

We report the case of a 72-year-old man who presented with a left ruptured internal iliac aneurysm (IIA). A percutaneous cross-over approach was used to coil-embolize the 3 distal branches of the IIA. A tapered endograft limb was then delivered via the right common femoral artery using a femorofemoral through-and-through cross-over approach. The widest part of the graft was deployed in the common iliac artery and the smallest in the external iliac artery. This percutaneous endovascular technique opens up new perspectives in emergency care for ruptured internal iliac artery aneurysms.

[Endoprosthetic repair of iliac artery aneurysm with a branch of the Anaconda stent graft]

An iliac artery aneurysm is characterized by arterial lumen dilatation which is more than 1.5 times greater than the normal diameter of the artery. In clinical practice, this pathology is rarely encountered, being associated with arterial hypertension and smoking, and more often observed in men. Its natural course inevitably leads to aneurysmal rupture. Treatment is only operative. Is admissible to use both open and endovascular techniques, with preference given to endovascular interventions using special linear endografts. Presented herein are two clinical case reports concerning endoprosthetic repair of an iliac artery aneurysm with a branch of the bifurcated stent graft Terumo Aortic Anaconda. The operative interventions had no complications in either peri- or postoperative periods. Our experience shows that endoprosthetic repair of an isolated aneurysm of the common iliac artery with a branch of the bifurcated stent graft Terumo Aortic Anaconda combines safety and efficacy and may be used by a wide range of vascular and roentgenoendovascular surgeons.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES

This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients.

METHODS

This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping.

RESULTS

From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter.

CONCLUSIONS

The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Coexistence of isolated internal iliac artery aneurysm with uterine cervical carcinoma

Isolated internal iliac artery aneurysms are rarely described in the available literature. The paper presents a case of a 70-year-old female with idiopathic thrombocytopenia, squamous cell cervical carcinoma, and saccular aneurysm of the left internal iliac artery, detected in magnetic resonance. The review of aneurysm of the common, external and internal iliac arteries is added.

Progressing left-side sciatica revealing a common iliac artery mycotic aneurysm in an elderly patient: A CARE-compliant case report

RATIONALE

Sciatica is usually caused by lumbar spine disease; the incidence of sciatica from extra-spinal causes is noted to be only about 0.09%.

PATIENT CONCERNS

We report a case of a 92-year-old man who came to the neurologist outpatient department due to left buttock pain and numbness that radiated to the left lower leg in the recent 6 months and progressed rapidly over 10 days.

DIAGNOSIS

We arranged magnetic resonance imaging for lumbar nerve lesion. Magnetic resonance imaging showed a common iliac artery mycotic aneurysm, at about 6.3 cm in diameter, which compressed the psoas muscle, nerve plexus, and vein.

INTERVENTIONS

We used a left-side iliac bifurcation stent graft of 12 mm in diameter for aneurysm repair. An internal iliac artery with a stent graft of 10 mm x 5 cm. An abdomen aortic aneurysm stent was inserted, 1 cm beneath the right renal artery from the right side femoral artery.

OUTCOMES

After endovascular repair and 4 weeks of antibiotic treatment, he could walk again, and no sciatica was noted. We repeated computed tomography 5 months after the operation and noted that the size of the iliac artery aneurysm decreased without stent graft migration or extravasation. Our patient recovered from sciatic and left leg weakness; above all, he could walk again.

LESSONS

We suggest practitioners check for common iliac artery aneurysms in the diagnosis of symptoms mimicking spinal cord origin sciatica, especially in elder patients.

Iliac Arteries Dissection with a Rapid Dilatation as Debut of Fibromuscular Dysplasia

We report a case of a 38-year-old male diagnosed with fibromuscular dysplasia (FMD) and a dissection of both common iliac arteries without aortic involvement. It was revealed after an inguinal hematoma and a pelvic pain, which are not the typical FMD presentation. Surgical treatment was performed after a rapid iliac growth in the first month control computed tomography angiography. Although the clinical course of this entity is relatively benign, rupture of the common iliac artery has also been described.

Treatment Results of Endovascular Aneurysm Repair Using the Parallel Stent-Graft Double D Technique for Distal Saccular Abdominal Aortic Aneurysms and Common Iliac Aneurysms

BACKGROUND

Endovascular aneurysm repair (EVAR) using a bifurcated stent graft may involve technical challenges when aortic disease (aneurysm or dissection) consists of a length <70 mm between the inferior renal artery and aortic bifurcation or narrow aortic bifurcation that is common in asymmetric distal abdominal aortic aneurysms (AAAs) or iliac artery aneurysms (IAAs). We use EVAR with the double D technique (DDT-EVAR) for such cases, which involves straight type of stent grafts with same diameter in left and right that are deployed parallel to an aortic cuff that has been previously placed. In addition, DDT-EVAR can preserve the inferior mesenteric artery (IMA) for IAA.

METHODS

DDT-EVAR was performed for 21 of 910 (2%) cases from April 2007 to April 2019 at our institution. The median patient age was 74 years (range, 52-85). Nineteen patients (90%) were men. Six patients (all saccular; 1 rupture) had AAAs, 12 had IAAs, and 3 had chronic type B aortic dissociation (TBAD) for re-entry closure. AAA and IAA had diameters of 45 mm (range, 34-71) and 34 mm (range, 25-58), respectively. An aortic cuff was used for 19 (90%) cases. Endurant II (Medtronic, Santa Rosa, CA) was used for 12 cases. The Excluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) was used for 7 cases. Endurant II was used for 20 cases, and the VBX (W.L. Gore & Associates, Inc) was used for 1 case as stent-graft limbs.

RESULTS

The procedural success rate was 100%. The median operative time was 146 min (range, 88-324). IMA planned for preservation was successful for all 12 cases. Type I and type III endoleaks were not observed. With TBAD, flow to the false lumen decreased or disappeared, and no complications during the hospital stay were associated with the procedure. For 2 patients whose procedure involved Endurant II stent-graft limb, limb occlusions were observed postoperatively, and reintervention was required. No other patients required additional treatment at a median follow-up of 18 months (range, 4-50).

CONCLUSIONS

DDT-EVAR is a safe and straightforward technique for the treatment of distal AAA, common iliac artery aneurysm, and TBAD. It may help preserve the IMA and internal iliac artery, even when it is impossible to preserve them with a bifurcated stent graft.

The Triple Wire Technique for Delivery of Endovascular Components in Difficult Anatomy

We describe a novel endovascular technique in which three 0.014″ guidewires are placed in parallel through a 0.035″ lumen catheter, in order to create a stiff platform to allow for delivery of 0.035″ profile devices through challenging anatomy. Three illustrative cases are presented: a difficult aortic bifurcation during lower extremity intervention, a tortuous internal iliac artery during placement of an iliac branch device, and salvage of a renal artery after inadvertent coverage during proximal cuff deployment for type 1a endoleak. We also quantify the relative stiffness of the triple 0.014″ wire configuration, using several well-known 0.035″ wires for comparison. The "triple wire technique" is an effective method for tracking endovascular devices through difficult tortuous anatomy, and can be used in a variety of clinical settings. The technique is especially useful when a traditional, stiff 0.035″ wire will not track without "kicking out." Each 0.014″ wire is reasonably soft and traverses the tortuous vessel easily, but when the 3 wires are used together as a rail it provides a stiff enough platform for delivery.

[Common iliac artery aneurysm urological manifestations]

BACKGROUND

An iliac artery aneurysm is a permanent and focal dilation of the artery that measures more than 50% of the normal diameter of the vessel. Isolated iliac artery aneurysms are infrequent, mostly as an association with an abdominal aortic aneurysm. The objective of this article is mainly to focus on urological symptoms as the manifestations of iliac artery aneurysm, to propitiate an early diagnosis.

CLINICAL CASE

In this article, we present a clinical case of a patient with generalized weakness, an episode of lipothymia and pain in the renal fossa, finding three aneurysms in the computed tomography, located in the right common iliac artery, the left internal iliac artery and the left external iliac artery. Later, the patient presents urological complications, after an obstruction of the right ureter, and therefore, a right hydronephrosis and loss of renal parenchyma function. Given this, urgent surgery is performed with satisfactory results.

CONCLUSIONS

The diagnosis of an iliac aneurism represents a challenge since most patients are asymptomatic. As main manifestation, urinary compression symptoms represented a fundamental part of diagnostic suspicion, which coincides with other similar cases reported in the literature.

Prevalence of abdominal aortic aneurysm and associated lower extremity artery aneurysm in men hospitalized for suspected or known cardiopulmonary disease

BACKGROUND

AAA is a disease affecting predominantly male patients ≥65 years and its dreaded complications such as rupture led to population-based screening programs as preventive measure. Nonetheless, the supposed prevalence may have been overestimated, so that targeted screening of high risk populations may be more effective. This study was performed to evaluate the prevalence of abdominal aortic aneurysm (AAA) of an inpatient high-risk cohort and to estimate the co-prevalence of lower extremity arterial aneurysms.

METHODS

Participants: 566 male inpatients, ≥ 65 years of age, hospitalized for suspected or known cardiopulmonary disease. Primary and secondary outcome measures: Maximal infrarenal aortic diameters using abdominal ultrasound (leading edge to leading edge method). Upon detection of an AAA (diameter ≥ 30 mm), the lower extremity arteries were examined with regard to associated aneurysms.

RESULTS

In 40 of 566 patients (7.1%) AAAs were detectable. Fourteen patients (2.5%) had a first diagnosis of AAA, none of which was large (> 55 mm), the remaining 26 patients were either already diagnosed (14 patients, 2.5%) or previously repaired (12 patients, 2.1%). The three most common main diagnoses at discharge were acute coronary syndrome (43.3%), congestive heart failure (32.2%), and chronic obstructive pulmonary disease (12%). The cohort showed a distinct cardiovascular risk profile comprising arterial hypertension (82.9%), diabetes mellitus (44.4%), and a history of smoking (57.6%). In multivariate analysis, three-vessel coronary artery disease (Odds ratio (OR): 4.5, 95% confidence interval (CI): 2.3-8.9, p <  0.0001) and history of smoking (OR: 3.7, CI: 1.6-8.6, p <  0.01) were positively associated with AAA, while diabetes mellitus (OR: 0.5, CI: 0.2-0.9, p = 0.0295) showed a negative association with AAA. Among the subjects with AAA, we found two large iliac and two large popliteal aneurysms.

CONCLUSION

Ultrasound screening in male inpatients, hospitalized for suspected or known cardiopulmonary disease, revealed a high AAA prevalence in comparison to the present epidemiological screening programs. There was a moderate proportion of newly-screen detected AAA and additional screening of the lower extremity arteries yielded some associated aneurysms with indication for possible intervention.

Comparison of Perioperative Outcomes of Patients with Iliac Aneurysms Treated by Open Surgery or Endovascular Repair with Iliac Branch Endoprosthesis

BACKGROUND

Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE.

METHODS

The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions.

RESULTS

Sixty-seven patients (96% male) were treated with OS (n = 25, mean age 68 ± 8 years) or IBE (n = 42, mean age 73 ± 8 years; P = 0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P = 0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5 ± 3.4 vs. 1.7 ± 1.4 days for IBE, P < 0.0001 and ICU LOS 3.3 ± 2.1 vs. 0.1 ± 0.4 days, P < 0.0001). Estimated blood loss was higher for patients undergoing OS (4,732 ± 2,540 mL) compared to patients treated with IBE (263 ± 451 mL, P < 0.0001), resulting in higher RBC transfusion requirements (1.5 ± 2.4 vs. 0.2 ± 0.8 units, P = 0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P = 0.09).

CONCLUSIONS

Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.

Urinary retention revealing a large common iliac artery aneurysm

Isolated aneurysms of the common iliac artery are rare, affecting less than 0.01% of the general adult population. Most of these aneurysms are asymptomatic and are discovered as an incidental finding. We describe an elderly patient presented with a urinary retention, which the investigations had led to the diagnosis of a large left common iliac artery aneurysm.

Giant External Iliac Artery Aneurysm

Isolated external iliac artery aneurysms are a very rare occurrence. We present the case of a patient with a very large symptomatic isolated external iliac artery aneurysm found incidentally on imaging for other reasons. Due to his compressive symptoms, he underwent uncomplicated open repair of his aneurysm. We also discuss the etiology and management options for this rare entity.

Selection of Stents by Calculation of Arterial Cross-sectional Area in Modified Sandwich Technique for Complex Aortoiliac Arterial Lesions

BACKGROUND

We prospectively evaluated the modified sandwich technique for treatment of complex aortoiliac arterial lesions using commercial stent grafts selected according to the arterial cross-sectional area. The primary outcomes were technical feasibility and mid-term follow-up results.

METHODS

We prospectively enrolled 13 patients (mean age 63.85 ± 6.12 years) with aortoiliac arterial lesions (5 infrarenal abdominal aortic dissections, 1 lower abdominal aortic occlusion, 5 iliac artery aneurysms, 1 external iliac arterial pseudoaneurysm, and 1 type IB endoleak following endovascular aneurysm repair) for endovascular repair with the modified sandwich technique. All lesions were complex and unsuitable for routine endovascular treatment. The bifurcated stent-graft diameters were determined by calculating the arterial cross-sectional area. Success and complication rates were recorded. Patients were followed for 20.69 ± 6.51 (range 6-31) months and stent patency determined by contrast-enhanced ultrasound and computed tomography 1, 3, and 6 months post-operatively and every 12 months thereafter.

RESULTS

The initial technical success rate was 100%, and no surgical complications occurred. The primary patency of the stent grafts was 100% during follow-up. Post-procedural type I "gutter" endoleaks occurred in 4 patients (30.8%) after 1 month. At 3 months, the endoleaks in 3 of the 4 patients had disappeared without treatment, and the remaining endoleak resolved after coil embolization.

CONCLUSIONS

The sandwich technique is a safe and effective therapy for complex aortoiliac arterial lesions. Stent-graft sizes based on the arterial cross-sectional area can ensure technical success and reduce the rate of "gutter" endoleaks.

Endovascular treatment of iatrogenic arteriovenous fistula of the iliac vessel

BACKGROUND

Iatrogenic vascular injuries, due to the particular nature of such pathology, are associated with high morbidity and mortality in the postoperative period.

OBJECTIVES

The objective of this study was to present a case of non-classic approach to the therapy of iatrogenic arteriovenous fistula.

MATERIAL AND METHODS

We present a case of a 17-year old female patient admitted to the Department of Vascular, General and Oncologic Surgery (Copernicus Memorial Hospital, Łódź, Poland) due to an iatrogenic injury to the common iliac vein and artery, following neurosurgical intervention on the spine. Two weeks prior to admission, the patient underwent surgery in the Neurosurgery Clinic for herniated nucleus pulposus and lumbar spine scoliosis. The imaging diagnostic revealed the presence of a pseudoaneurysm of the right common iliac artery and arteriovenous fistula between the right common iliac vessels. The patient was qualified for endovascular treatment. Two self-expanding covered stents were successfully deployed. The clinical and radiological outcome of the procedure was good. The postoperative period was uneventful. The patient was discharged home on the 3rd postoperative day.

RESULTS

The control examinations (directly after the procedure and 6, 12, 24 and 32 months thereafter) revealed full patency of the iliac vessels, as well as no recurrence of arteriovenous fistula, nor a pseudoaneurysm of the right common iliac artery. No symptoms of either chronic limb ischaemia or venous insufficiency were observed.

CONCLUSIONS

Iatrogenic vessel injury, being a complication of neurosurgical and orthopedic surgeries, may be overlooked and remain undetected both in intraand postoperative period. Modern imaging techniques allow for an adequate diagnosis of the injury and planning the treatment of arteriovenous fistula. The endovascular procedures are the method of choice in patients with arteriovenous fistulas of iliac vessels, alternative to open surgery.

Endovascular treatment of primary mycotic aortic aneurysms: a 7-year single-center experience

Objective This study was performed to assess the efficacy and outcome of endovascular aneurysm repair (EVAR) for treatment of primary mycotic aortic aneurysms (PMAAs). Methods Fourteen consecutive patients who presented with PMAA from April 2010 to July 2017 were retrospectively reviewed. Preoperative, intraoperative, and postoperative clinical data were recorded, and late infection-related complications and long-term survival were assessed. Results The aneurysms were located in the abdominal aorta in 10 patients and in the left common iliac artery in 4 patients. Positive microbial cultures were found in 12 patients, including Salmonella species in 11 and Streptococcus in 1. The remaining two patients had negative culture results. Ten patients received preoperative antibiotics before elective EVAR for 7 ± 9 days after admission. Four patients who underwent emergent EVAR due to ruptured aneurysms were given their first dose of antibiotics before EVAR. Three patients underwent surgical drainage, and six underwent percutaneous drainage within 30 days after EVAR. No death occurred within 30 days of the initial procedure. The mean follow-up was 34.8 (range, 3-84 months). One patient underwent re-intervention to resolve obstruction of the iliac/femoral artery 5 months postoperatively. Relapse of infection occurred in six patients (42.8%) during follow-up; infection-related death occurred in three of these patients. The other patients recovered with either conversion to open radical surgery or medical therapy. The actuarial 7-year survival after EVAR was 75.7%. Conclusions EVAR and aggressive antibiotic therapy might be suitable for PMAAs. Favorable results may be typical for infection caused by Salmonella.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parallel placement of Excluder legs for treatment of type IIIb endoleaks caused by fabric tear after endovascular aneurysm repair

A total of 576 patients underwent endovascular aneurysm repair using main body devices for treatment of abdominal aortic aneurysms or iliac artery aneurysms. During follow-up, type IIIb endoleaks caused by fabric tear occurred in six patients (1.0% [6/576]). The device used was Zenith (Cook Medical, Bloomington, Ind) in five cases and Talent (Medtronic, Santa Rosa, Calif) in one case. All endoleaks were close to the flow divider of the main body devices. The distance between the lower renal artery and the top end of the contralateral leg was 53 ± 14 mm. Bell-bottom-shaped Excluder (W. L. Gore & Associates, Flagstaff, Ariz) legs were placed parallel from the top of the main body device through both legs to treat these endoleaks. In two patients, coil embolization was required to treat gutter endoleaks. Postoperative computed tomography showed the obliteration of type IIIb endoleaks in all patients. Our technique may be an acceptable method for treatment of type IIIb endoleaks, especially when they occur near the flow divider.