Iliac Branch Graft Research Articles

An observational assessment of aortic deformation during infrarenal and complex endovascular aortic aneurysm repair

ObjectiveReal-time aortic deformation during endovascular aortic aneurysm repair (EVAR) has not been reported. Successful EVAR relies on predicting intraoperative aortic-endograft deformation from preoperative imaging. Correct prediction is essential, because malalignment of endografts decreases patient survival. We describe intraoperative aortic deformation during infrarenal EVAR and complex fenestrated/branched EVAR (F/BEVAR), relating deformation to preoperative anatomy and follow-up outcomes. MethodsA multicenter, retrospective cohort of aortic aneurysm patients undergoing operation between January 2019 and February 2021, substratified by repair, infrarenal EVAR (n = 50), F/BEVAR (n = 80), and iliac branch graft with F/B/EVAR (IBG + F/B/EVAR; n = 27), were compared using software-based nonrigid two- and three-dimensional aortic deformational intraoperative assessment (CYDAR). Preoperative computed tomography reconstructions of aortic and iliac tortuosities were assessed against intraoperative deformation, the primary outcome, and related to perioperative and follow-up adverse outcomes. ResultsAll treatment groups had low preoperative visceral aortic tortuosity; the EVAR group had higher iliac tortuosity (1.43 ± 0.05; P = .018). Intraoperative aortic visceral deformation was consistently cranial and anterior; IBG + F/B/EVAR patients had the largest magnitude deformation (superior mesenteric artery, EVAR 5.1 ± 0.9 mm; F/BEVAR 4.4 ± 0.4 mm; IBG 8.3 ± 1.2 mm; P = .004). Celiac artery, superior mesenteric artery, and bilateral renal artery deformations were correlated (R = 0.923-0.983). Iliac deformation was variable in magnitude and direction. Preoperative tortuosity was not correlated with the magnitude of intraoperative deformation nor was deformation magnitude related to endograft instability during follow-up, including endoleak development, reinterventions, or visceral vessel complications. ConclusionsThe aorta deforms consistently during EVAR at the visceral aortic segment but unpredictably at the iliac bifurcation. Aortoiliac deformation is unrelated to adverse perioperative outcomes, branch instability, or reinterventions during short-term follow-up.

A cross-sectional study on the anatomic feasibility of iliac side branch grafts in a real-world setting

ObjectiveThe aim of this cross-sectional, single-center study was to analyze the feasibility of different commercially available iliac branch devices in Europe in a cohort of patients with aorto-iliac aneurysms. MethodsAll patients with aorto-iliac or iliac aneurysms that required iliac aneurysm repair, between 2017 and 2021, were included. Morphologic data was analyzed using computed tomography angiograms. The main outcome was the feasibility of each endoprosthesis (Cook ZBIS, Gore Iliac Branch Endoprosthesis [IBE], and JOTEC E-Iliac) according to the manufacturer’s instructions for use. Secondary outcomes were feasibility in all three devices, in any device, and with adjunctive procedures (liberal criteria). Additionally, a comparative analysis of all three grafts was performed to analyze differences in feasibility. ResultsOverall, 119 iliac aneurysms in 101 patients were included. The mean age was 71 ± 11 years, and 91.6% were male. Feasibility was 52.9% for Cook ZBIS, 33.6% for Gore IBE, and 26.9% for the JOTEC E-Iliac device. A total of 65.5% of patients were feasible with at least one device, whereas only 10.1% complied with all three devices. The main reasons for lack of feasibility were a short common iliac artery length (Cook ZBIS), a narrow common iliac artery diameter (Gore IBE), and a >50° angulation between the external and internal iliac arteries (JOTEC E-Iliac). There was a significant difference between the feasibility of the three devices (P < .001). Cook ZBIS was the graft with the higher feasibility, with 3.3 and 4.4 higher odds when compared with Gore IBE and JOTEC E-Iliac devices, respectively. There was no significant difference between the Gore IBE and the JOTEC E-Iliac. By using liberal criteria, the overall feasibility increased to 95.8%. ConclusionsWe found that only 65.5% of patients were feasible with one of the available devices according to the manufacturer’s instructions for use. The Cook ZBIS was the device with the overall highest feasibility. Extending the use of these devices with adjunctive measures and a more liberal approach increased feasibility to 95.8%.

Transgluteal Coil Embolization of Internal Iliac Artery Aneurysm

Inflow occlusion of internal iliac artery aneurysm without occlusion of the outflow vessels can lead to continued aneurysm expansion and possible rupture because of retrograde flow. Surgical exploration could be challenging, with significant morbidity. Percutaneous options for embolization are also limited owing to lack of antegrade access into the aneurysm sac. We describe a percutaneous transgluteal approach to the internal iliac artery aneurysm for coil embolization. An 80-year-old man underwent endovascular repair of right iliac artery aneurysm. The patient also had an internal iliac artery aneurysm that could not be repaired with an iliac branch graft for technical reasons. After repair, the patient continued to show evidence of endoleak into the internal iliac artery aneurysm because of continued blood flow. Antegrade arterial access into the aneurysm was unsuccessful. The decision was made to perform transgluteal coil embolization of internal iliac artery aneurysm. The patient was placed on the angiography table in lateral position with left side down. We prepared the right buttock with the right knee bent to facilitate ultrasound-guided access into inferior gluteal artery. We accessed the right inferior gluteal artery using ultrasound guidance. Micropuncture wire dilator and sheath were then placed. After that, we were able to place a 035 angled Glidewire (Terumo Interventional Systems, Somerset, NJ) into the artery to obtain secure access. Subsequently we placed a 0.38 glide catheter into the artery. A microcatheter was then telescoped through the glide catheter into the aneurysm cavity. We were able to cannulate the branches coming off the internal iliac artery aneurysm and to coil embolize arterial branches going into the aneurysm. The aneurysm cavity itself was then packed with coils as well. Inferior gluteal artery leading to the internal iliac artery aneurysm was also coil embolized to stop any flow from going into the aneurysm. The procedure was completed without any complications. Follow-up scan showed no evidence of endoleak. The aneurysm size has remained stable subsequently after follow-up in 1 year. Coil embolization of the internal iliac artery by a percutaneous, transgluteal approach is effective and safe when standard antegrade transarterial access is not an option.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair. From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n=21) or bilateral common iliac artery aneurysms (n=20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year. A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention. IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts: Institutional Experience

The objective of this study was to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair. From October 2009 to November 2014, 31 consecutive patients (all men), mean age of 73.1 years (range, 51-89), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 15) and bilateral common iliac artery involvement (n = 16) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year. A total of 32 IBGs were deployed in 31 patients successfully. At 1-month and annual follow-up, 100% of grafts implanted were patent. The mean hospitalization duration was 4 days (range, 1-40), with one death at 30 days due to acute renal failure. Ten type II endoleaks and one type Ib endoleak occurred, with one reintervention performed for the type Ib endoleak and the balance being treated conservatively. Five patients had complications. Nineteen patients complained of claudication, with seven cases being resolved. After IBG deployment, 61% of patients were claudication free. IBG placement has excellent short-term outcomes and potential to limit buttock claudication.

Internal Iliac Aneurysm Repair Outcomes Using a Modification of the Iliac Branch Graft

Iliac branch grafts (IBGs) are a validated option for the treatment of aorto-iliac aneurysms preserving internal iliac artery (IIA) flow. IIA aneurysm (IIAA) is a relative contraindication to IBG placement. The goal of this study was to review experience in managing aorto-iliac aneurysms with concomitant IIAAs with extension of the IIA branch stent graft into the superior gluteal artery (SGA). This retrospective study between May 2009 and November 2014 includes consecutive patients who underwent placement of an IBG (Cook, Bloomington, IN, USA) with extension of the internal iliac component of the branch stent graft into the SGA because of aneurysmal IIA (>15 mm). The stent grafts used were Viabahn (Gore, Karlsruhe, Germany), Fluency (Bard, Flagstaff, AZ, USA), or iCast (Atrium, Hudson, NH, USA) proximally. Imaging follow up was with computed tomography angiography (CTA) within 30 days of device insertion and then annually. The procedure was performed on 15 patients with a mean age of 76.8 years (SD 6.1 years). Twenty IIAAs were treated with a mean IIA and common iliac artery (CIA) diameter of 33 mm (SD 13 mm) and 35 mm (SD 11 mm) respectively. Technical success rate was 100%. One patient who underwent simultaneous IBG and three vessel fenestrated endovascular aneurysm repair died of mesenteric ischemia 2 days after the procedure. Mean imaging follow up with CTA was 18.3 months (SD 15.1 months). Primary patency of the SGA stent grafts was 100%. There was one case of type II endoleak. All patients were free from buttock claudication at follow up (mean: 19.7 months). Two patients who had IIA embolization contralateral to the IBG placement suffered from unilateral lower limb monoparesis. Extension of the internal iliac component of IBGs into the SGA for distal seal is feasible and safe in the endovascular treatment of aorto-iliac aneurysms with concomitant IIAs. Long-term results are needed to further validate this technique.

Implantation of an Iliac Branch Device After EVAR via a Femoral Approach Using a Steerable Sheath

Purpose: To describe a contralateral femoral approach for iliac branch device implantation using a steerable sheath in the setting of an existing bifurcated stent-graft. Technique: The method is demonstrated in an 80-year-old man who developed a 4-cm iliac aneurysm 3 years after implantation of an Endurant bifurcated stent-graft. Both femoral arteries were cannulated after surgical cutdown. The steerable sheath was advanced from the contralateral side over the neobifurcation of the bifurcated stent-graft. A 0.014-inch Roadrunner wire was used as a through-and-through wire to stabilize the curve of the sheath and to get proper push. The bridging stent-graft for the iliac branch was advanced over this sheath to seal the iliac aneurysm. During the entire procedure, the sheath was stable over the neobifurcation without pulling it down. Conclusion: The contralateral femoral approach for iliac branch graft implantation is feasible in cases with an extant bifurcated stent-graft using a steerable sheath and a through-and-through wire.

Early outcomes of iliac branch grafts in the endovascular repair of abdominal aortic aneurysms with concomitant bilateral common iliac artery aneurysms at a Japanese institution.

Endovascular aneurysm repair (EVAR) is used to treat abdominal aortic aneurysms (AAAs) with bilateral common iliac artery aneurysms (CIAAs), and an interruption of the bilateral internal iliac arteries (IIAs) is often needed, which may cause postoperative ischemic complications. An iliac branch device (IBD) has thus been introduced as an endovascular technique to preserve the IIA flow. This study aimed to evaluate the technical feasibility and short-term results of using an IBD when treating AAA with bilateral CIAAs in a Japanese institution, where IBD use has still not been approved by the government. EVAR was performed using an IBD in six patients at high risk for open repair of an AAA with bilateral CIAAs. Advanta V12 stent grafts were successfully placed in the IIA, bridging between the IIA and the IBD side branch from the contralateral iliac artery. Subsequently, EVAR was performed as usual. The technical success rate was 100%. At the most recent follow-up (mean follow-up period, 14.2months), all IBDs were patent. No patients complained of buttock claudication or ischemic colitis. The implantation of an IBD during EVAR is technically feasible in Japanese AAA patients with bilateral CIAAs, and may be a viable method to avoid pelvic ischemic complications, such as intractable buttock claudication.

9:12 AM Abstract No. 21 - Preservation of the superior gluteal artery in patients with internal iliac artery aneurysm using iliac bifurcated device and viabahn stent grafts, a single institution experience

Purpose To evaluate the feasibility and efficacy of extension of iliac branch graft (IBG) into the superior gluteal artery in endovascular repair of complex aortoiliac aneurysms Materials and Methods From May 2009 to December 2012, 7 men (mean age 76 years, range 69-85 y) were treated with IBG with stent graft extension into the superior gluteal artery. Indications were abdominal aneurysm with internal iliac artery aneurysm (n=5), repair of type III endoleak in a patient initially managed with EVAR and IBG alone (n=1), and expanding internal iliac aneurysm in a patient treated with a surgical aortobifemoral graft (n=1). Post-operative endoleak and patency rates were determined by CT (n=7) within 4 weeks of placement, with clinical follow-up for symptoms of pelvic ischemia. Average follow-up was 3.5 months (range 1 month - 15 months). Results Technical success, as defined by successful extension into the superior gluteal artery with no intraprocedural endoleak, was 100% (7/7). There were no cases of post-procedural endoleak. All stent-implanted internal iliac aneurysms remain stable in size, with no aneurysm rupture or death recorded. All superior gluteal artery stent grafts remain patent on follow-up CT angiography. None of the patients have new symptoms of pelvic ischemia. Conclusion Preservation of the superior gluteal artery is technically feasible with excellent short-term results in treatment of patients with aortoiliac aneurysms. This technique presents an opportunity for preservation of pelvic perfusion in patients with complex anatomy not amenable to conventional IBG placement in the internal iliac artery.

Endovascular Treatment of Abdominal Aortic Aneurysms Involving Iliac Bifurcation: Role of Iliac Branch Graft Device in Prevention of Buttock Claudication

The aim of this study was to describe our early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair at our institution and to evaluate the technical feasibility, short-term patency rate, and potential clinical benefits, with special focus on prevention of buttock claudication. From March 2009 to November 2010, 9 consecutive patients (all men), mean age 71.1 years (range 62-80 years), underwent IBG implantation at our institution. Indications were abdominal aortic aneurysm (AAA) with common iliac artery (CIA) involvement (n = 7), bilateral CIA aneurysm (n = 1), and AAA with bilateral CIA and unilateral IIA involvement (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography (CT) within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 14.7 (range 9-29) months. Technical success rate, as defined by successful implantation of the iliac branch graft (IBG) with no intraprocedural type I or type III endoleak, was 100%. The mean hospitalization duration was 4 days (range 3-6 days), with 0% mortality at 30 days. There were 3 cases of type II endoleak detected perioperatively, which were treated conservatively. Two endoleaks sealed spontaneously on the 1-month CT scan and 1 persists without aneurysm sac expansion. All stent-implanted aortic and iliac aneurysms remained stable in size during follow-up, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up and all patients were asymptomatic. Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of abdominal aortic aneurysms involving the iliac bifurcation. This technique can efficiently prevent buttock claudication.

Radiology of advanced EVAR techniques in complex abdominal aortic aneurysms

Advanced Endovascular Aortic Repair (EVAR) refers to devices and techniques used for endografting of aortic aneurysms that are considered anatomically unsuitable for conventional EVAR. Customised devices and modified use of conventional EVAR devices now overcome challenging landing zones. Fenestrated and branch devices, together with chimney and periscope techniques can be used to overcome proximal landing zone challenges, while iliac branch grafts and sandwich techniques have been used to address challenging distal iliac landing issues. Due to the novelty of these techniques, life-long surveillance is crucial, with CT Aortography (CTA) being the key investigation. Currently, the body of literature surrounding the imaging aspects of these techniques is scarce. The purpose of this imaging review is to illustrate the appearance of advanced EVAR in both routine surveillance and complicated cases, using conventional and novel CTA techniques. Key Points • This review updates readers about advanced endovascular repair of abdominal aortic aneurysms • It illustrates the common CT appearances following advanced EVAR • Novel CTA techniques in troubleshooting problems unique to advanced EVAR are described.

Iliac Branch Graft in the Treatment of Complex Aortoiliac Aneurysms: Early Results from a North American Institution

Purpose To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair. Materials and Methods From July 2007 to August 2009 (25 months), 14 patients (13 men, one woman) with a mean age of 70.1 years (range, 59.3–80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n = 11), juxtarenal aortic aneurysm with CIA involvement (n = 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6–35 mo). Results Technical success rate, as defined by successful implantation of IBG with no intraprocedural type I or type III endoleak, was 86% (12 of 14). A total of 14 IBGs were successfully deployed in 12 patients. Two cases of technical failure were related to excessive iliac tortuosity. The mean hospitalization duration was 6.5 days (range, 3–14 d), with zero mortality at 30 days. There were two cases of type II endoleak treated conservatively and a single case of IBG-related type III endoleak that required repeat intervention. The rest of the stent-implanted aortic and iliac aneurysms remained stable in size, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up. None of the patients who received IBGs had new symptoms of pelvic ischemia. Conclusions Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of aortoiliac aneurysms.

Endovascular Bilateral Evolutive Common Iliac Artery Aneurysm Repair Using a Zenith Branch Graft Through a Combined Femoro-Brachial Approach in a Patient with Previous EVAR

Introduction To report treatment of bilateral evolutive iliac artery aneurysms three years after EVAR. Report Three years following uncomplicated Zenith AAA stent-graft placement, the patient presented with aneurysmal common iliac arteries. Through a combined femoro-brachial approach, both iliac artery aneurysms were excluded, and a Zenith branch graft was placed to preserve the left hypogastric artery. The procedure was technically successful and free from complication. One year post-procedure, the Zenith branch graft remains stable. Discussion A combined femoro-brachial approach, with iliac branch graft placement, offered a solution to a challenging scenario.

Morphological Suitability of Patients With Aortoiliac Aneurysms for Endovascular Preservation of the Internal Iliac Artery Using Commercially Available Iliac Branch Graft Devices

To quantify the proportion of patients with morphology suitable for the use of a commercially available iliac branch graft device (IBD), which offers an endovascular alternative to avoid the morbidity of internal iliac artery (IIA) embolization during endovascular aneurysm repair (EVAR) of aortoiliac aneurysms. A retrospective single-center study was conducted of 51 patients (44 men; mean age 75+/-7 years) undergoing IIA embolization (36 unilateral, 15 bilateral) prior to EVAR between June 2005 and August 2009. Three-dimensional volume-rendered reconstructions of computed tomographic angiography (CTA) scans were compared to criteria published by experienced surgeons and to manufacturer's instructions for use (IFU). Morphological suitability for IBD was graded with a score reflecting 15 variables (morphological score) extracted from the IFU and publications from experienced endovascular centers. The higher the score, the more adverse morphological features were encountered. In the 51 patients, 66 target IIAs were studied. Of these, 25 (38%) target IIAs with a mean morphological score 4.44+/-1.96 were compliant with the manufacturer's IFU. Nineteen (29%) target IIA were compliant with experienced surgeons' criteria, with a mean morphological score of 4.2+/-2.0. The most common adverse feature was an aneurysmal IIA. In a population of patients with aortoiliac aneurysms, morphological applicability of a commercially available IBD was low, with the majority of patients possessing at least 1 adverse anatomical feature. A validated morphological scoring system derived from registry-type data is needed, with quantification of outcomes in IBD deployment that extends the IFU.

Endovascular Aneurysm Repair with Preservation of the Internal Iliac Artery Using the Iliac Branch Graft Device

Endovascular Aneurysm Repair with Preservation of the Internal Iliac Artery Using the Iliac Branch Graft Device

Abstract No. 210: Use of iliac branch grafts in the treatment of aorto-iliac aneurysms, a single institution experience

Abstract No. 210: Use of iliac branch grafts in the treatment of aorto-iliac aneurysms, a single institution experience