Aortoiliac Aneurysmal Disease Research Articles

Frequency and Intensity of Smoking, Duration of Smoking Cessation, and Risk of Early Postoperative Outcomes after High-risk Arterial Reconstructions

Introduction: The relative influence of smoking and smoking duration/intensity in a co-morbid cohort is uncertain. We examined whether smoking status, duration of cessation, and smoking frequency/intensity significantly affected postoperative morbidity and mortality risk. Methods: We collected single institution, retrospective data from consecutive patients undergoing open operative intervention for carotid, aortoiliac, or infrainguinal aneurysmal or occlusive arterial disease. Smoking cessation duration was calculated as the time between smoking cessation and index surgery. The primary outcome was a composite of 30-day mortality and morbidity. Logistic and Cox regressions estimated associations between the primary outcome and smoking status with interaction terms between cessation duration and intensity (pack-years) for former smokers. Results: Between 2010 and 2019, 1,087 patients underwent 1,523 high-risk surgeries. The mean duration of cessation was 19.3 years (standard deviation [SD] = 16.2). Mean pack-year history was 45.2 pack-years (SD=33.7) among former smokers and 54.8 pack-years (SD=38.5) among current smokers (p < 0.001). Smoking status did not independently predict an increased risk of postoperative mortality or morbidity (Odds Ratio [OR]=0.97, p = 0.85). In the former smoker group, neither smoking cessation duration (OR=0.99, p = 0.23) nor pack-years (OR=1.00, p = 0.99) were statistically significant predictors of adverse events (interaction p = 0.08). Long-term survival probabilities were lower among current smokers (Hazard Ratio [HR] = 1.31, p = 0.002) with no significant effect from either pack-years or cessation duration. Conclusion: Among patients undergoing procedures that represent systemic disease, the adverse effects of continued smoking are better appreciated in long-term survival probability reduction that is observed regardless of smoking frequency or intensity.

Identification of Single-Nucleotide Polymorphisms in ZNF469 in a Patient with Aortoiliac Aneurysmal Disease

Thoracic aortic aneurysms and dissections often have inter-related pathologies that are increasingly recognized to have a genetic basis. A patient with a vascular history consisting of a spontaneous aorto-iliac dissection and thoracic aortic aneurysm belonged to a family with a significant self-reported history of aneurysmal disease. Suspecting a genetic component, genetic investigation was undertaken. Three variants of unknown significance were found in the ZNF469 gene, which is responsible for the production of a collagen-related zinc finger protein involved in multiple aspects of the development and regulation of major extracellular matrix components. This is the first report to associate this gene with vasculopathy, and further investigation by our group is underway to understand the role it plays in the development of aneurysmal diseases.

Do Surgical Site Infections in Open Aortoiliac Surgery Differ Between Occlusive and Aneurysmal Arterial Disease?

A retrospective cohort, single-center study was performed from January 2005 to December 2016. Infection developed in significantly more patients who had undergone elective open aortoiliac surgery for occlusive disease (10%; 22 of 213) than for aneurysms (6%; 10 of 301). The incidence of infection-related readmission (7% vs 1%) and reintervention (4% vs 1%) was also significantly greater after surgery for occlusive disease than for aneurysmal disease. Logistic regression showed occlusive disease and chronic renal disease were associated with surgical site infection. Patients with aortoiliac occlusive disease had a greater rate of surgical site infections compared with patients with aortoiliac aneurysmal disease, in part owing to the inherent use of an inguinal incision in patients with occlusive disease.

The Effect of Hypogastric Artery Revascularization on Ischemic Colitis in Endovascular Aneurysm Repair

BackgroundThe objective of the study was to examine the effect of hypogastric revascularization maneuvers on the rate of postoperative ischemic colitis among patients undergoing endovascular aortoiliac aneurysm repair. MethodsUsing the 2011-2018 Endovascular Aneurysm Repair Procedure-Targeted American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, we analyzed patients undergoing elective endovascular infrarenal aortoiliac aneurysm repairs. Using multivariable modeling techniques, a cohort of patients at high risk for postoperative ischemic colitis was identified. The outcomes of this group were then compared using Pearson's chi-square testing in accordance with whether or not they underwent hypogastric revascularization. ResultsOf 4753 patients undergoing endovascular aortoiliac aneurysm repair in the National Surgical Quality Improvement Program cohort, 1161 had concomitant hypogastric revascularization procedures. High-risk predictors of ischemic colitis included chronic obstructive pulmonary disease and concurrent renal artery or external iliac artery stenting. There was not a significant association between pelvic revascularization and postoperative ischemic colitis [1.0% with versus 0.5% without pelvic revascularization; adjusted odds ratio of ischemic colitis with revascularization 2.07 (0.96, 4.46); P = 0.06] after adjustment for patient- and procedure-related factors. In a subgroup analysis of patients with a distal aneurysm extent beyond the common iliac artery, the incidence of ischemic colitis was significantly lower in patients without pelvic revascularization (0.1% versus 1.6%, P = 0.004). ConclusionsOur analysis of patients undergoing elective endovascular repair of infrarenal aortoiliac aneurysmal disease did not find a reduced incidence of postoperative ischemic colitis in patients who received a concomitant pelvic revascularization procedure, suggesting instead that such procedural adjuncts may actually increase risk for this complication.

Anatomic Suitability of Iliac Branched Devices for Chinese Patients with Abdominal-Iliac Aortic Aneurysm

Preserving internal iliac flow is the key to preventing ischemic complications during endovascular aneurysm repair (EVAR). The aim of this study is to determine the morphological features of abdominal aortic aneurysms (AAAs) that have been reported in clinical trials in Chinese patients to identify unique features of iliac branched systems. The data for patients who had common iliac aneurysms suitable for imaging review from 2014 to 2017 at 1 institution in China were reviewed. Three-dimensional workstations were used to measure the centerline diameters and lengths of aortoiliac structures, which were screened for suitability for both Cook iliac branch devices (IBD) and Gore iliac branch endoprosthesis (IBE). A total of 102 lesions of common iliac aneurysms were suitable for imaging review. The anatomic standards for the Gore IBE and Cook IBD were met by 13.7% (14/102) and 9.8% (10/102) of the cases, respectively, and 3 cases were suitable for both devices. The most common cause of not meeting the criteria was the same for both the Cook IBD (78.4%) and Gore IBE (48.03%), which was a limitation of the diameter of the target internal iliac artery. Of the 92 lesions excluded from the Cook IBD trial, 11 (11.9%) were eligible for the Gore IBE trial. Likewise, 7.95% (7/88) of the lesions excluded from the Gore IBE trial would have been eligible for the Cook IBD graft. In a practice that is able to enroll patients in both trials, a total of 20.6% (21/102) of the patients would be eligible for treatment, based on the anatomic criteria. The high incidence of iliac artery involvement in AAAs makes EVAR more complicated. Cook IBD and Gore IBE are only suitable for the treatment of a total of 20.6% Chinese patients based on the anatomic criteria. A limitation in the diameter of the target internal iliac artery is the most common cause of failure to meet the criteria for both devices. Future generations of iliac branch technologies should be designed with diameter accommodations for the hypogastric branch stent to reach a wider group of patients with aortoiliac aneurysmal disease.

Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions

ObjectiveBypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival. MethodsPatients who underwent operations for aortoiliac or infrainguinal aneurysmal or occlusive arterial disease were retrospectively analyzed. The Infection group included those with patent vascular grafts who developed Szilagyi class II or III deep wound infections within 90 days of index reconstruction and had no evidence of anastomotic or arterial bleeding. All patients in the infection group were managed with graft preservation using serial antibiotic bead exchange every 3 to 5 days until wound cultures became negative. This group was compared with a contemporary group of controls who underwent similar interventions but did not develop wound infections postoperatively. The primary outcome was amputation-free survival, defined as survival without major amputation. Secondary outcomes included major amputations and the occurrence of anastomotic pseudoaneurysms necessitating repair. Inverse propensity score weighting was used for risk adjustment between the groups. ResultsOver an 8-year period, we treated 701 patients (infection, 68; controls, 633). Compared with controls, patients in the infection group had a higher body mass index (mean, 28.5 vs 26.3, P = .002) and more prosthetic conduits placed during the index reconstruction. Amputation-free survival for the infection vs the control group was 78 vs 76% at 2 years, 61 vs 66% at 4 years, and 51 vs 57% at 6 years postoperatively (log-rank test, P = .516). Freedom from major amputation for the infection vs the control group was 82 vs 86% at 2 years, 80 vs 82% at 4 years, and 80 vs 76% at 6 years postoperatively (log-rank test, P = .568). In the risk-adjusted model, the presence of treated infection did not affect amputation-free survival (hazard ratio, 0.82; P = .440) or major amputation (hazard ratio, 1.02; P = .949). Anastomotic pseudoaneurysms occurred only in the Infection group (4.4%; P = .001), and were treated with interposition grafts without complications. ConclusionsBypass graft preservation with wound sterilization using serial antibiotic bead exchange is associated with excellent limb salvage and survival rates, similar to those of noninfected wounds. With the use of this preservation strategy, close follow-up for timely detection of anastomotic pseudoaneurysms is recommended.

Does perfusion matter? Preoperative prediction of incisional hernia development.

Incisional hernias complicate 12-15% of general surgery cases with higher rates reported after laparotomy for aortoiliac occlusive disease (10-17%) and aneurysmal disease (17-38%). We hypothesize that inadequate perfusion of the abdominal wall promotes future hernia development. Thirty-eight patients undergoing midline laparotomy or thoracoabdominal approach for aortic disease with at least 2years of follow-up were included in the study. Preoperative imaging was reviewed to assess vessel patency, contributing to the abdominal wall perfusion. Patency of the superior epigastric artery was determined at the T10 level, the inferior epigastric artery at the L4 level, and the deep circumflex iliac artery at the anterior superior iliac spine. Lumbar arteries were considered patent if they were seen branching from the aorta. Clinic notes and hospital medical records were reviewed to evaluate the hernia development post-procedure. Thirteen patients (34%) developed an incisional hernia. Absent flow from bilateral superior epigastric arteries or absent flow from ipsilateral superior and inferior epigastric arteries was found to be predictive of hernia development (P = 0.013, 0.011, respectively). There was no association identified with perfusion from the lumbar or deep circumflex iliac arteries. Absent patency of the abdominal wall vasculature is a novel risk factor for incisional hernia development in the setting of aortic disease. Preoperative assessment of perfusion may convey the risk of hernia development and may be a tool to guide measures such as prophylactic mesh placement to reduce the future risk of incisional hernia.

Hypogastric Preservation Using Retrograde Endovascular Bypass

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.

3:27 PM Abstract No. 154 Iliac bifurcated graft: extending the indications for endograft treatment in aortoiliac aneurysm disease

EVAR spares the internal iliac arteries (IIA), and is a limited therapy when there is IIA aneurysm or no common iliac artery (CIA) landing zone. The iliac bifurcated graft (IBG) allows treatment of CIA and IIA aneurysms with preservation of IIA flow. This reduces the risk of buttock claudication and maintains collateral flow to the colon and spinal cord. We have reviewed and present our experience with IBG. We present a 10-year retrospective study of 53 consecutive patients who underwent aortoiliac EVAR plus unilateral or bilateral IBG insertion. Clinic notes, surgical and radiological procedure notes and imaging, and electronic patient records were reviewed. Patency was assessed by ultrasound and CTA, and statistically analyzed by Kaplan-Meier (KM) curve. 53pts (48M, 5F; mean age 75.3, SD 6.37) underwent aortoiliac EVAR plus 62 IBG device insertions (9 bilateral). Indications were: no EVAR CIA landing zone (40), IIA aneurysm (19), post-EVAR type 1b endoleak (E/L) (1), and to increase flow to IIA (1). Technical success in 49 patients was 59/62 IBG (CIA tortuosity [2], kinked IIA [1]). Serum creatinine increased temporarily following surgery, but no pt. developed renal failure. Fluoroscopy time (mean 66.2 min, range 13-209) and contrast load (mean 177.8 ml, range 40-335) improved with experience. Six patients died within 1 month of surgery (cardiac [2], bowel ischemia [2], pneumonia [1], iatrogenic aortic dissection [1]). At initial F/U by duplex ultrasound and CTA within 1 month in 40 patients (lost to F/U [3], expired [6]), 43 IBG were patent without endoleak (E/L) (type 1b [4], type 3 [3]); all E/L were successfully treated by re-stenting. At last clinical/imaging F/U in 37pts (mean 24.2-month, range 1-107), 39 IBG were patent without E/L (lost to F/U [1], thrombosed IBG branch [1], remote death [2]). All patients were asymptomatic without aneurysm rupture or buttock claudication. IBG patency at 1 and 6 mth by KM curve was 90% and 88% respectively. IBG is a useful adjunct to EVAR allowing preservation of internal iliac artery flow and effectively treats both common and internal iliac artery aneurysms.

Hypogastric Preservation Using Retrograde Endovascular Bypass

Maintenance of pelvic circulation has been connect to reduced risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aorto-iliac aneurysmal disease. We evaluate the mid to late follow up of a cohort of patients treated using one preservation technique, the endovascular external (EIA) to internal (IIA) iliac artery bypass.

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

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.

IP043. Hypogastric Preservation Using Retrograde Endovascular Bypass

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass. All patients undergoing retrograde EIA-IIA endovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle >45°. Procedures were performed using aortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, and annually thereafter with computed tomography CT scan (with selective contrast usage) 1 month postoperatively and annually thereafter. Seventeen patients (mean age, 70 years; 93% male) were treated over the period. Most were treated for primary disease (n = 11), while the remainder underwent secondary interventions following open repair (n = 4) or endovascular 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 (n = 1), Viabahn (n = 13), or Gore Excluder (n = 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71° (range, 51°-102°). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, 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, 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.

Durability of iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms

ObjectiveThis study evaluated and compared the long-term clinical outcomes of endovascular repair of infrarenal aortoiliac aneurysms (EVAR) vs EVAR with preservation of antegrade internal iliac artery (IIA) perfusion using iliac branched devices (EVAR-IBDs). MethodsFrom October 1998 to August 2015, patients with infrarenal aortoiliac aneurysmal (AIA) disease at high risk for conventional open surgery were enrolled in a prospective physician-sponsored investigational device exemption trial. Clinical data of 75 patients treated with EVAR-IBD and 255 with standard EVAR were analyzed. Technical success, perioperative outcomes, mortality, device patency, endoleak rates, and reinterventions during a follow-up of 10 years were analyzed. ResultsThere were 87 IBDs deployed in 75 patients. Technical success rate was 97%. Mortality at 30 days was 1.3%. Freedom from aneurysm-related mortality at 3, 5, and 10 years was 99%. Freedom from a type I or III endoleak at 3, 5, and 10 years was 99%. Freedom from secondary reinterventions at 3, 5, and 10 years was 86%, 81%, and 81%, respectively. Primary patency of the IBDs at 3, 5, and 10 years was 94%, 94%, and 77%, respectively. Twenty-four percent of patients underwent EVAR for concomitant AIA disease (EVAR-AIA), and 78% were managed by staged IIA embolization before EVAR. No statistically significant difference in freedom from aneurysm-related mortality, limb occlusions, or endoleak rates was identified in patients with EVAR-AIA vs EVAR-IBD (P > .05). There were significantly more secondary reinterventions in the EVAR-AIA group compared with the EVAR-IBD group (hazard ratio, 0.476, 95% confidence interval, 0.226-1.001; P = .045). ConclusionsEVAR of infrarenal AIAs with preservation of antegrade flow to the IIA using IBDs is feasible with long-term sustained durability. Serious considerations should be given to the use of IBDs in patients with infrarenal AIAs meeting appropriate anatomic criteria.

Lesson Learned with the Use of Iliac Branch Devices: Single Centre 10 Year Experience in 157 Consecutive Procedures

Absence of an adequate iliac seal rarely represents an absolute contraindication to endovascular abdominal aortic aneurysm repair. Iliac branch devices (IBD) are increasingly used in patients with extensive aorto-iliac aneurysmal disease, but few data are available on the long-term results of these procedures. Between 2006 and 2016, 157 consecutive IBD procedures performed at a single centre were entered into a prospective database. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aortic aneurysms. Long-term results were reported according to the Kaplan-Meier method. During the study period 149 patients were treated with an iliac branched endograft. Isolated IBD was implanted in 17.8% of the cases; technical success rate was 97.5%. Peri-operative procedure failure occurred in seven patients, four during surgery and three within 30 days of the procedure. Presence of ipsilateral hypogastric aneurysm (p=.031; Exp [B]=6.72) and intervention performed during the initial study period (p=.006; Exp [B]=10.40) were predictive of early failure on multivariate analysis. After a mean follow-up of 44.2 months actuarial freedom from IBD related re-intervention was 97.4%, 95.6%, 94.0%, and 91.8% at 1, 3, 5, and 9 years, respectively. Hypogastric artery patency was 94.7%, 92.6%, and 90.4% at 1, 3, and 10 years, respectively. Presence of a hypogastric aneurysm was an independent predictor of target artery occlusion during follow-up on multivariate analysis (p=.007; Exp [B]=5.93). Iliac branched endografting can now be performed with a high technical success rate; long-term freedom from re-intervention is comparable with patients treated with standard aortic endografting. IBD should be considered a first-option treatment in patients with adequate vascular anatomy unsuitable for standard endovascular aortic repair.

Feasibility of three-dimensional magnetic resonance angiography-fluoroscopy image fusion technique in guiding complex endovascular aortic procedures in patients with renal insufficiency

ObjectiveThree-dimensional image fusion of preoperative computed tomography (CT) angiography with fluoroscopy using intraoperative noncontrast cone-beam CT (CBCT) has been shown to improve endovascular procedures by reducing procedure length, radiation dose, and contrast media volume. However, patients with a contraindication to CT angiography (renal insufficiency, iodinated contrast allergy) may not benefit from this image fusion technique. The primary objective of this study was to evaluate the feasibility of magnetic resonance angiography (MRA) and fluoroscopy image fusion using noncontrast CBCT as a guidance tool during complex endovascular aortic procedures, especially in patients with renal insufficiency. MethodsAll endovascular aortic procedures done under MRA image fusion guidance at a single-center were retrospectively reviewed. The patients had moderate to severe renal insufficiency and underwent diagnostic contrast-enhanced magnetic resonance imaging after gadolinium or ferumoxytol injection. Relevant vascular landmarks electronically marked in MRA images were overlaid on real-time two-dimensional fluoroscopy for image guidance, after image fusion with noncontrast intraoperative CBCT. Technical success, time for image registration, procedure time, fluoroscopy time, number of digital subtraction angiography (DSA) acquisitions before stent deployment or vessel catheterization, and renal function before and after the procedure were recorded. The image fusion accuracy was qualitatively evaluated on a binary scale by three physicians after review of image data showing virtual landmarks from MRA on fluoroscopy. ResultsBetween November 2012 and March 2016, 10 patients underwent endovascular procedures for aortoiliac aneurysmal disease or aortic dissection using MRA image fusion guidance. All procedures were technically successful. A paired t-test analysis showed no difference between preimaging and postoperative renal function (P = .6). The mean time required for MRA-CBCT image fusion was 4:09 ± 01:31 min:sec. Total fluoroscopy time was 20.1 ± 6.9 minutes. Five of 10 patients (50%) underwent stent graft deployment without any predeployment DSA acquisition. Three of six vessels (50%) were cannulated under image fusion guidance without any precannulation DSA runs, and the remaining vessels were cannulated after one planning DSA acquisition. Qualitative evaluation showed 14 of 22 virtual landmarks (63.6%) from MRA overlaid on fluoroscopy were completely accurate, without the need for adjustment. Five of eight incorrect virtual landmarks (iliac and visceral arteries) resulted from vessel deformation caused by endovascular devices. ConclusionsFerumoxytol or gadolinium-enhanced MRA imaging and image fusion with fluoroscopy using noncontrast CBCT is feasible and allows patients with renal insufficiency to benefit from optimal guidance during complex endovascular aortic procedures, while preserving their residual renal function.

Percutaneous Endovascular Aortic Repair with Local Anesthesia - One Day Surgery

To evaluate the results of the abdominal aortic aneurism endovascular treatment (EVAR), percutaneously and with local anesthesia, according to the concept of one day surgery. Unicentric, retrospective analysis of patients with aorto-iliac aneurysmal disease, consecutively treated by EVAR with percutaneous access trough the Preclose technique (pEVAR), according to the outpatient criteria, with one overnight stay in the hospital. The technical success, exclusion of the aneurysmal sac, endoleak, re-intervention and mortality were evaluated. Twenty consecutive patients (all male; mean age 74.65 years) were treated by EVAR with percutaneous access and local anesthesia, from which 95% (19) presented with abdominal aortic aneurysm and 5% (1) common iliac aneurysm. All implants were sucessfully performed, with an initial endoleak rate of 10% (2), determined by one type 1a endoleak successfully corrected intra-operatively and one type 2a endoleak diagnosed in the first imaging control, which sealed spontaneously on the second control. Initial technical success for percutaneous closure was 97.5%, with one case reported of femoral pseudo-aneurism, posteriorly treated by percutaneous thrombin injection. Median length of stay was one day [1-10], with a mean follow-up of 11.4 months [1-36]. Both the re-intervention and mortality rate are 0% for the selected period. Our one day surgery model for the outpatient treatment of abdominal aortic aneurysm by the pEVAR technique is innovative, safe and effective, as long as the selection criteria are respected.

Stent Graft Treatment of AAA With Preservation of the Inferior Mesenteric Artery

Coverage of the inferior mesenteric artery is standard in stent graft treatment of an infrarenal abdominal aortic aneurysm (AAA). Complications of colonic ischemia are rare, but risk factors include poor collateral flow from prior colonic surgery or from severe pelvic arterial occlusive disease. Preservation of inferior mesenteric artery (IMA) flow may prevent such complications in patients deemed to be at high risk for intestinal/pelvic ischemic complications. We have performed two unique cases of aortic stent grafting with preservation of IMA flow, comprising one IMA fenestration and one IMA snorkel. Record reviews of these two patients with details on the indications, technical details, and outcomes were recorded. A 53-year-old woman with a recent right hemicolectomy for cecal cancer also an enlarging AAA at 4.5 cm and a right iliac aneurysm of 3.8 cm. Given the recent colonic resection, the need to occlude the right internal iliac artery, and a stenotic left internal iliac artery, her risk for colonic ischemia was thought to be significantly higher than the average. To avoid this, a single fenestration was made with a back table modification of a Zenith graft (Cook Inc, Bloomington, Ind) and a Viabahn stent (W. L. Gore, Flagstaff, Ariz) and was used to fenestrate the IMA. On follow-up, the patient had no complications with no evidence of colonic ischemia and successful treatment of her AAA (Fig 1). The second patient was a 61-year-old man with a history a left iliac stent placed previously for calf claudication who developed severe, progressive hip claudication and impotence. Computed tomography angiography showed 3.5-cm iliac aneurysms and a 3.7-cm distal aortic aneurysm with preocclusive right and totally occluded left internal iliac arteries. There was a 7-mm-diameter inferior mesenteric artery coming off the AAA with severe stenosis at its origin. An Endologix AFX stent graft (Endologix, Irvine, Calif) was used to treat the aortoiliac aneurysmal disease with a long Viabahn snorkel stent placed into the IMA. Both iliac limbs were extended to the externals. Follow-up computed tomography showed complete exclusion of the aortoiliac aneurysms with no endoleak, and the patient had resolution of his hip claudication and impotence (Fig 2). Preservation of IMA flow with modified stent graft techniques is feasible and may reduce complications of colonic and pelvic ischemia in highly selected patients.Fig 1Fenestration technique. CTA, Computed tomography angiography; IMA, inferior mesenteric artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endovascular Aortoiliac Aneurysm Repair: Surgical Progress Through New Treatment Paradigms and Innovative Endograft Design

Effective treatment for patients with an abdominal aortic aneurysm (AAA) began more than 50 years ago through the development of prosthetic grafts, which were used to replace aneurysmal segments of diseased arteries. Open surgical repair of AAAs became the gold standard for treating this disease. In 1999, two device manufacturers received US Food and Drug Administration approval for their endovascular aneurysm repair (EVAR) devices to treat selected patients with AAA. During the next 10 years, multiple other EVAR devices received US Food and Drug Administration approval, and, now, EVAR rivals open surgical repair as the standard for treating aortoiliac aneurysm disease. The purpose of this article is to outline advances in the device technology used for EVAR procedures, identify historical progress of treatment options, recognize complications after EVAR, describe improvements in device design, and specify related nursing implications.

Endovascular repair of aortoiliac aneurysmal disease with the helical iliac bifurcation device and the bifurcated-bifurcated iliac bifurcation device

Iliac branch device (IBD) treatment of common and internal iliac artery (CIA and IIA) aneurysms has been controversial in the context of available embolization techniques or off-label adjunctive procedures. Two devices exist, a straight IBD (S-IBD) and a helical IBD (H-IBD). We report our midterm results with the latter and present outcomes with a third device intended to treat disease in the presence of short CIAs termed the bifurcated-bifurcated IBD (BB-IBD). Data were prospectively collected from IBD-treated patients with infrarenal aortoiliac or thoracoabdominal aortoiliac aneurysms. Preoperative aneurysmal characteristics were collected in accordance with the endovascular reporting standards document, including presence of IIA stenosis, CIA diameters, and the presence of an IIA aneurysm. Technical success was defined as IBD device placement, branch placement, and patency without type I or III endoleak at implantation in addition to 24 hours survival. Follow-up computed tomography scans at 1, 6 (optional), 12 months, and annually thereafter were performed and reinterventions, sac morphology changes, and endoleaks noted. Survival and patency were evaluated with life-table analyses, and differences among anatomic groups were compared with log-rank tests, whereas t-tests and Fisher exact tests were used to compare simple variables. Between 2003 and 2012, 138 IBD devices were placed into 130 patients (98 H-IBD and 40 BB-IBD). Median follow-up was 20.3 months (range, 1-72 months) with 30- day, 12-month, 3- and 5-year survival rates of 99%, 90%, 79%, and 62%, respectively. Technical success was 94%, and branch patency was 94.6% at 30 days and 81.8% at 5 years. Thirty-five percent (35%) of branches were placed into patients with IIA aneurysms (in addition to their proximal disease), 20% into stenotic IIAs, and 46% into iliac systems with narrow (<16 mm) CIAs. Technical success was significantly lower in patients with IIA stenosis (81.5 vs 96.4%; Fisher exact test, P= .015) but not affected by the presence of an IIA aneurysm or narrow CIA. Branch patency was similar in all groups throughout follow-up. No stent fractures or component separations were noted in the IBDs or mating devices throughout the study period. The H-IBD and BB-IBD configurations have high technical success and acceptable long-term patency for the treatment of CIA and IIA aneurysms, including those with challenging anatomy difficult to treat with the straight branch design.

Limitations of Current EVAR Endografts and Potential Solutions for Their Deficiencies

All current endovascular aneurysm repair (EVAR) devices have defined limitations that prevent the endovascular therapist from using them to treat all forms of aortoiliac aneurysm disease. Short, angulated infrarenal aortic neck pathology, occlusive disease in iliac access arteries, need for preservation of important branch vessel arterial flow, endograft migration, and endoleak all represent major impediments for successful EVAR. Need for secondary intervention after EVAR in a significant number of patients has detracted from universal acceptance for this therapy. New devices in manufacturers' pipelines may provide solutions for many of the current EVAR device deficiencies. As these new devices become more complex, meticulous patient follow-up to verify anticipated outcomes and new training paradigms for the future endovascular therapist will be required.