Outcomes of endovascular aneurysm repair with selective internal iliac artery coverage without coil embolization

Abstract

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) that also involve the common iliac artery (CIA) typically is accomplished by endograft limb extension into the external iliac artery (EIA). In order to prevent endoleak, the internal iliac artery (IIA) is usually embolized, or alternatively a branched limb is deployed. However, IIA embolization is associated with longer operative time and increased use of contrast and radiation. It has been our practice not to routinely coil embolize the IIA. The purpose of this study was to present the midterm outcomes of this approach. Between April 1997 and June 2010, 137 patients (130 men; mean age, 70.9 years; range, 45-92 years) underwent EVAR of their AAA and had IIA coverage without coil embolization in 112 patients (no embolization [NE] group) and after coil embolization in 25 patients (coil embolization [CE] group). Anatomic indications for coverage of the IIA without coil embolization included presence of adequate sealing in the distal 5 mm of the CIA, or sealing ring at the origin of the CIA, or IIA diameter <5 mm. Preoperative mean AAA size was 60 ± 14 mm, and mean CIA diameter was 38 ± 13 mm. Postoperative computed tomography (CT) scanning was performed at 1, 6, and 12 months, and yearly thereafter. Thirty-day mortality was 0.7% (1 of 137 patients). A patient presented with gluteal skin necrosis (0.7%). The incidence of postoperative buttock claudication was not different between the two groups (NE: 15 of 112 patients; CE: 3 of 25 patients; P = .852). Procedure and fluoroscopy time, contrast use, and hospital stay were significantly reduced in the NE group. Patients were followed up for 33 ± 30 months. During follow-up, 44 patients died (32.1%) and in 3 of them (2.2%), death was AAA-related. There was no difference in cumulative survival between the two groups at 1, 2, 3, and 4 years, respectively. Secondary interventions were performed in 20 of 137 patients (14.5%), including three conversions for proximal endoleak. There was no difference between the two groups in the incidence of secondary interventions (NE: 18 of 112 patients; CE: two of 25 patients; P = .301) and freedom from reintervention at 1, 2, 3, and 4 years, respectively. Ten patients (8.9%) from the NE group presented a type II endoleak during follow-up. Seven of them were associated with the covered IIA; none required reintervention. Stent graft coverage of the IIA without coil embolization is a safe, simple, and effective maneuver for the treatment of aortoiliac aneurysms, with a low incidence of postoperative complications and reinterventions and acceptable immediate and midterm results.