IP003. Midterm Results of Internal Iliac Artery Preservation Using the Sandwich Technique During Endovascular Aneurysm Repair

Abstract

Patients undergoing endovascular repair (EVAR) of aortoiliac or iliac artery aneurysm may require sacrifice of one or both internal iliac arteries. Until FDA approved commercial grafts are available, internal iliac artery (IIA) preservation has been accomplished using the “sandwich” technique (ST) or surgeon modified grafts, but limited information is available regarding their results. After obtaining IRB approval, we identified patients undergoing IIA preservation with the ST during EVAR at our institution. The patients have been followed up prospectively since being identified to record patency rates and vascular symptoms or events. Twenty-four procedures (22 men, 2 women) were performed from 2011 to 2015 to treat iliac artery aneurysms. The mean age was 74 years. Fourteen of these were done with concomitant EVAR using different endografts (Gore, 11; Endologix, 2; Cook, 1). Five were done to extend a previous EVAR that had developed a type Ib endoleak, 2 for an isolated external iliac artery aneurysm, 3 for an anastomotic aneurysm from a previous aortobiiliac graft, and 2 were for isolated iliac aneurysm repair. There were 25 sandwich grafts (unilateral in 19, bilateral in 6). Contralateral embolization was performed in 5 cases. Percutaneous femoral access was possible in 19, contralateral embolization was necessary in 5, and brachial delivery was needed in 18. Immediate technical success was 100%, average values for operative time was 210 minutes, estimated blood loss was 381 mL, fluoroscopy time was 45 minutes, contrast volume was 145 mL, and length of stay was 2.2 days. Mean follow-up time was 19 months (1-47). There were nine type III endoleaks observed on completion angiography, eight resolved on follow-up CTA, and one required endoprosthetic extension. Six patients have stable type II endoleaks. Two patients were lost to follow-up but of the remaining, 96% of the external iliac limbs were patent and 96% of internal iliac limbs were patent. No patient had buttock claudication or bowel ischemia. Endovascular IIA preservation is feasible with currently available devices using this technique. Immediate success rates are high and patency rates are excellent at intermediate followup. Intraoperative type III endoleaks are not uncommon but usually resolve postoperatively. This procedure is recommended for preservation of the IIA during endovascular treatment of aortoiliac and iliac artery aneurysms when anatomy requires internal iliac artery salvage.