Hypogastric Preservation Using Retrograde Endovascular Bypass

Abstract

Maintenance of pelvic circulation has been connected to reduced risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluate the mid-to-late follow-up of a cohort of patients treated using 1 preservation technique, the endovascular external iliac artery (EIA) to internal iliac artery (IIA) bypass. All patients undergoing elective retrograde EIA-IIA endovascular bypass at a single institution were retrospectively reviewed over a 10-year period from 2006 to 2016. Anatomic inclusion criteria were single or bilateral common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle greater than 45°. Procedures were performed using aortouni-iliac (AUI) endografts extended to 1 EIA (with endovascular occlusion of the ipsilateral hypogastric artery), cross-femoral artery bypass, and retrograde placement of 1 of 3 types of covered stent grafts into the contralateral IIA. In the case of patients with prior open repair, AUI placement was not required. Follow-up surveillance included duplex ultrasound 1 and 6months postoperatively and annually thereafter, with computed tomography scan (with selective contrast usage) 1month postoperatively and annually thereafter. Seventeen patients (mean age 70years, 93% male) were treated over the period studied. Most were treated for primary disease (N=11) while the remainder was secondary interventions following open repair (N=4) or endovascular aneurysm repair (N=2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac N=8, left iliac N=9). Retrograde bypasses were performed using Fluency stent graft (N=1), Viabahn stent graft (N=13), or Gore Excluder limbs (N=3). Additional hypogastric embolization with AUI extension to the EIA (for bilateral common iliac aneurysms) was required in 6 patients. Proximal extension requiring snorkel/fenestration was present in 5 patients. Technical success was 100% with mean operative time was 168min (range 50-300min), and 71cc contrast usage (range 30-115cc). Mean preoperative iliac artery aneurysm size was 4.0cm with iliac bifurcation angle 71° (range 51-102°). Median length of stay was 3days (range 1-13). Over mean follow-up of 29.8months, there were no aorta-related mortalities, 1 EIA-IIA bypass occlusion (asymptomatic), and 1 reintervention (for type II endoleak not attributed to the EIA-IIA bypass). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series. Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.