Exclusion Of Internal Iliac Artery Research Articles

Failure to preserve the internal iliac artery during abdominal aortic aneurysm repair is associated with mortality and ischemic complications

ObjectiveOpen or endovascular repair of abdominal aortic aneurysms (AAAs) can involve sacrifice of the internal iliac artery (IIA). In the present study, we investigated the effect of IIA exclusion on ischemic complications and overall mortality. MethodsThe data from 326 patients who had undergone elective open surgical or endovascular treatment of a nonruptured AAA from January 2010 to December 2019 in a tertiary hospital were retrospectively reviewed. Ischemic complications included buttock claudication, spinal ischemia (including paraparesis), ischemic colitis, lower limb paresthesia, and skin necrosis. Their duration and mortality during the study period were investigated. ResultsNearly 50% of patients (148; 45.4%) had undergone endovascular aortic aneurysm repair and 178 (54.6%) had undergone open surgery. The median patient age was 78 years (range, 31-94 years). The median follow-up period was 1140 days (range, 0-4757 days). Of the 326 patients, 50 (15.3%) had died during follow-up. The bilateral IIAs were preserved in 187 patients (57.4%), a single IIA in 86 patients (26.4%), and no IIA in 53 patients (16.3%). Ischemic complications occurred in 57 patients (17.5%). Multivariable analysis revealed failure to preserve the bilateral IIAs (hazard ratio [HR], 8.65; 95% confidence interval [CI], 4.31-17.36; P < .01), management of the IIA (HR, 3.05, 95% CI, 2.17-4.28; P < .01), and hyperlipidemia (HR, 2.09; 95% CI, 1.04-4.17; P = .04) affected the occurrence of ischemic complications. Furthermore, univariable analysis revealed that patients had experienced more ischemic complications when a single IIA (HR, 6.97; 95% CI, 3.74-13.02; P < .01) or none of the IIAs had been preserved (HR, 8.88; 95% CI, 4.12-19.16; P < .01) than when both IIAs were preserved. Moreover, multivariable analysis revealed that stage 5 chronic kidney disease (HR, 2.7; 95% CI, 1.09-6.14; P = .03), age >75 years (HR, 2.48; 95% CI, 1.12-5.49; P = .03), cerebrovascular accident (HR, 1.95; 95% CI, 1.00-3.78; P = .05), and failure to preserve the bilateral IIAs (HR, 1.91; 95% CI, 1.02-3.46; P = .04) were associated with higher mortality after AAA repair. ConclusionsIIA exclusion is a risk factor for ischemic complications and overall mortality. Thus, preservation of the IIA as much as possible during AAA repair is recommended.

Contemporary Management of Large Common Iliac Arteries During Endovascular Aortic Aneurysm Repair

Advances in endovascular technology allow management of large common iliac arteries (CIAs) during endovascular aneurysm repair (EVAR). Large CIAs can be managed by flared iliac stents (FLARED), by exclusion of internal iliac artery and stenting into external iliac artery (EIA), or with an iliac branch device (IBD). This study compares use and outcomes of these different approaches for management of large CIAs during EVAR using a large national database.

A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair.

Objectives To collect specific literature on type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm, reporting data on diagnosis, treatment, and follow-up results. Methods Publications about type Ib endoleak after aorto-iliac endografting for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science, and Scopus. Considered studies were in English and published until 3 November 2016. Research methods and reporting were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were: (1) reporting on abdominal aortic or iliac aneurysm as primary diagnosis; (2) reporting on distal endoleak after aorto-iliac endografting. Patient data, data on endovascular treatment, endoleak, reintervention, and follow-up were collected by two independent authors. Results Included studies were 11 (five original articles, six case reports), corresponding to 29 patients and 30 type Ib endoleak. Excluding missing data (2/30, 6.7%), type Ib endoleak was treated intra-operatively, within six months and after six months in six cases (21.4%), eight cases (28.6%), and fourteen cases (50%), respectively. Treatment of type Ib endoleak was endovascular in 27 cases (90%) (7 embolizations + extender cuffs, 10 extender cuffs, 8 embolizations without extender cuff, 1 Palmaz stenting and 1 iliac branched endograft), hybrid in 1 case (3.3%) and surgical in 2 cases (6.6%). Buttock claudication occurred in two cases (6.7%). One-month mortality was 3.4% (2/29) without events due to type Ib endoleak. In 14 cases (46.7%), median follow-up was six months (interquartile range: 2.75-14; range: 0.75-53). Type Ib endoleak persisted or reappeared in three cases (10%), all after endovascular treatment. Two of these (2/3, 66.7%) needed endovascular reintervention. No death during follow-up was reported. Conclusions Few specific data are available in literature about type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm. About 50% of type Ib endoleak occurred after six months from the endovascular abdominal aneurysm repair procedure. Treatment is mainly endovascular and distal endograft extension is the main and effective treatment. Buttock claudication is the most frequent complication in case of exclusion of internal iliac artery. Persistent type Ib endoleak is possible, and adjunctive endovascular procedures are necessary.

Endovascular Aneurysm Repair Treatment of Aortoiliac Aneurysms: Can Iliac Branched Devices Prevent Gluteal Claudication?

PurposeTo compare the risk of gluteal claudication after endovascular aneurysm repair (EVAR) of aortoiliac aneurysms by interventional exclusion of the internal iliac artery (IIA) with plugs or coils versus a branch iliac device to maintain pelvic blood supply and to identify risk factors for postoperative gluteal claudication. Materials and MethodsA retrospective analysis of a prospectively collected data set included patients with aortoiliac aneurysms treated with EVAR from January 2007 to December 2013 at a tertiary referral vascular unit. Descriptive and procedural data were obtained from a database of prospectively enrolled patients. Medical records of 112 consecutive patients treated with EVAR were scrutinized for graft-related adverse events and pelvic ischemia. The occurrence of gluteal claudication was determined from medical records. ResultsIliac occlusion was performed in 115 limbs, and a branch iliac device was placed in 25 limbs. Gluteal claudication developed in 38% of limbs treated with IIA exclusion but in none of the limbs treated with branch iliac devices (P < .001). Procedure time, fluoroscopy time, and use of iodine contrast material did not differ between the two groups. The incidence of gluteal claudication was higher when coils rather than plugs were used for embolization of the IIA before EVAR (P = .002). ConclusionsThe findings suggest that the use of a branch iliac device significantly reduces the risk of gluteal claudication after EVAR of aortoiliac aneurysm.

Evolution from open surgical to endovascular treatment of ureteral-iliac artery fistula

To review the indications and results of open surgical and endovascular treatment for ureteral-iliac artery fistula (UIAF). We reviewed the clinical data of 20 consecutive patients treated for 21 UIAFs between 1996 and 2010. Since 2004, iliac artery stent grafts were the primary treatment except for complex fistulas with enteric contamination or abscess. Endpoints were early morbidity and mortality, patient survival, vessel or graft patency, freedom from vascular or stent graft/graft infection, and freedom from recurrent bleeding. There were 20 patients, 15 females, and five males, with mean age of 63 ±13 years. Predisposing factors for UIAF were prior tumor resection in 18 patients, radiation in 15, ureteral stents in 15, ileal conduits in four, and ileofemoral grafts in three. All patients presented with hematuria, which was massive in 10. Treatment included iliac stent grafts in 11 patients/12 fistulas (55%), with internal iliac artery (IAA) exclusion in nine, femoral crossover graft with IAA exclusion in five, direct arterial repair in three, and ureteral exclusion with percutaneous nephrostomy and no arterial repair in one. There were no early deaths. Five of eight patients treated by open surgical repair developed complications, which included enterocutaneous fistula in three and superficial wound infection in two. Four patients (36%) treated by iliac stent grafts had complications, including pneumonia, non-ST segment elevation myocardial infarction, buttock claudication, and early stent occlusion in one each. After a median follow-up of 26 months, no one had recurrent massive hematuria, but minor bleeding was reported in three. Patient survival at 5 years was 42% compared with 93% for the general population (P < .001). Freedom from any recurrent bleeding at 3 years was 76%. In the stent graft group, primary and secondary patency rates and freedom from stent graft infection at 3 years were 81%, 92%, and 100%. UIAF is a rare complication associated with prior tumor resection, radiation, and indwelling ureteral stents. In select patients without enteric communication or abscess, iliac artery stent grafts are safe and effective treatment, and carry a low risk of recurrent massive hematuria or stent graft infection on early follow-up. Direct surgical repair carries a high risk of enterocutaneous fistula.

Endovascular Preservation of Full Pelvic Circulation with External Iliac-to-internal Iliac Artery “Cross-stenting” in Patients with Aorto-iliac Aneurysms

Common iliac artery (CIA) aneurysms that extend into the iliac bifurcation and internal iliac artery (IIA) usually require exclusion of the IIA, exposing pelvic ischemic complication risks. This case report presents an endovascular technique of "cross-stenting" in a short proximal landing zone with complete exclusion of the CIA aneurysm using a covered stent graft with a longer uncovered stent extending into one branch of the IIAs, maintaining full pelvic circulation. External iliac artery to IIA cross-stenting with an additional uncovered stent warrants further investigation, because it seems to extend graft stent placement indications, increase stability, and help avoid IIA exclusion.

A Word of Caution Before Killing Hypogastric Arteries

The clinical investigation performed by Bratby et al. [1] regarding internal iliac artery (IIA) embolization prior to endovascular aneurysm repair (EVAR) is very important because it highlights the relatively safe feasibility of EVAR in such borderline iliac anatomies. In a similar study we conducted [2] including 33 unilateral and 8 bilateral IIA embolizations, we found similar results, with five cases of buttock/hip claudication (12.2%) and no case of bowel or spinal cord ischemia. While buttock claudication is the most frequent complication [1, 2], bowel and spinal cord ischemia are the major complications of IIA embolization. Bowel ischemia has been considered a multifactorial problem in open surgery, considering embolism, long-term hypoperfusion, mesentery stretch, traction or compression due to self-retraining retractor, bowel reperfusion syndrome, and collateral circulation. While most of these situations are not present during EVAR, collateral arterial circulation is a common risk factor. Yano et al. [3] reported high rates of bowel ischemia with hypogastric exclusion after EVAR, attributed to stenosis or occlusion of the ipsilateral femoral artery. Collateral arterial vasculature seems to play an important role in bowel ischemia after EVAR [4]. Even if there is no angiographic evidence that could forecast bowel ischemia, before proceeding to bilateral IIA exclusion, patients’ collateral arterial circulation should be studied, aiming for the preoperative identification of celiac artery or superior mesenteric artery stenosis or obstruction and patency of external iliac artery and common femoral artery collaterals. Furthermore, operators should be particular accurate regarding the preservation of these circumflex collaterals during surgical preparation of the femoral arteries. Regarding spinal cord ischemia prevention when planning IIA exclusion, particular attention should be paid to the patient’s medical history. Thoracic aortic procedures, endovascular or surgical with sacrifice of intercostal arteries, and subclavian artery stenosis or occlusion are important factors that could increase the risk of spinal cord injury. In conclusion, I believe that when bilateral IIA exclusion is considered as an operative strategy prior to EVAR, preoperative imaging workup should focus also on the status of the patient’s collateral circulation.