IP089. Options for Preservation of Pelvic Circulation During Endovascular Aortic Aneurysm Repair

Abstract

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of aortoiliac aneurysmal disease. We evaluated the use of four techniques for preservation of flow to hypogastric arteries. All patients undergoing endovascular aneurysm repair requiring extension into the external iliac artery (and therefore management of the hypogastric artery) at a single institution were reviewed from 2006 to 2016. Choice of preservation vs embolization and preservation technique was at surgeon discretion. Four techniques were used in the series: external-to-internal iliac artery endovascular bypass (EIA-IIA), iliac branch endograft (IBD), kissing iliac stents extended from the gate of a bifurcated endograft (parallel grafts), and double bifurcated main-body graft use. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively and annually thereafter for patients who required cross-femoral bypass (with the EIA-IIA bypass). For the remainder of patients, surveillance computed tomography scan (with selective contrast usage) was done 1 month postoperatively and annually thereafter. Thirty-two patients (mean age, 70 years; 97% male) were treated, preserving 36 hypogastric arteries. Most were treated for primary disease (n = 20), and the remainder was secondary interventions following open repair (n = 4) or endovascular repair (n = 8). Thirty patients had bilateral common iliac aneurysms, one had bilateral hypogastric aneurysms, and the remaining 18 had unilateral common iliac aneurysms. There was no preference for laterality (right, n = 20; left, n = 16). Proximal extension requiring snorkel/fenestration was present in seven patients. Seventeen aneurysms were treated with EIA-IIA bypass, 2 by IBD, 4 with double-bifurcated endografts, and 13 with parallel grafts. Technical success was 100%, with mean operative time 182 minutes and 71 mL contrast usage (range, 30-275 mL). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 22 months, there were no aortic-related mortalities, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, buttock claudication, and paralysis was zero in the series. While it is not yet clear which patients warrant preservation vs embolization, multiple techniques exist for preservation of pelvic circulation during endovascular repair. All four techniques presented appear to offer acceptable success and patency rates, and the optimal technique for each patient is largely a factor of preoperative selection based on anatomy and surgeon experience.