Iliac Limb Research Articles

Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair.

Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea. We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale. The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis. Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

Final results from a postmarket registry of an iliac leg graft with a continuous, spiral nitinol stent

ObjectiveTo evaluate clinical outcomes from a postmarket registry of the Zenith Spiral-Z abdominal aortic aneurysm iliac leg graft with a continuous, spiral nitinol stent that was designed for improved conformability, kink, and migration resistance. MethodsThis prospective, multicenter registry was designed to evaluate physician-reported outcomes of the Spiral-Z leg graft in up to 600 patients who underwent endovascular repair of abdominal aortic or aortoiliac aneurysms at up to 30 investigative sites in the United States and Canada. Study outcomes were focused on iliac limb occlusion, limb-related reintervention, limb-related endoleak, component separation, and device integrity. Short-term data were collected during an interval of 1 to 6 months, with longer term data collected at 12 months. ResultsBetween March 2012 and March 2015, 599 patients (mean age 74 ± 8 years; 87% male; 26% with aortoiliac aneurysm) were treated, with Spiral-Z iliac leg grafts placed in 564 left iliac arteries and 559 right iliac arteries. The mean iliac inner diameters (both left and right) were 9 ± 3 mm; moderate/severe occlusive disease, calcification, and vessel tortuosity were present in 14%, 25%, and 36% and 15%, 25%, and 34% of the left and right iliac arteries, respectively. Iliac artery adjunctive procedures (iliac artery angioplasty and/or stent placement) were performed intraoperatively in 112 patients (19%; bilateral in 52 patients). Mortality within 30 days was 1.7% (10/599); cumulative mortality at 1 year was 6.2% (37/599). There were no aortic ruptures and only one open conversion (0.2%). Limb occlusions occurred in 11 of 599 patients (2%; 3 within 30 days and 8 after 30 days, all unilateral, none had received procedural iliac artery adjuncts at implantation); of these, 7 patients underwent reinterventions. Other limb-related reinterventions were performed on eight patients for nonocclusive kink, compression, or thrombus (six within 30 days and three after 30 days). In total, 13 patients (2%) underwent 15 limb-related reinterventions (7 for occlusions and 8 for nonocclusive causes). In one patient, a distal type I endoleak and device migration (>10 mm) involving a right iliac leg was noted at the 12-month follow-up visit. No other limb-related endoleak, migration, component separation, or stent fracture was reported during a mean follow-up of 11 ± 6 months. ConclusionsThe Spiral-Z leg graft demonstrated excellent patency and required infrequent limb-related reinterventions in routine clinical care in a postmarket registry.

Graft-related complications after open surgery of abdominal aortic aneurysm – An 8-year follow-up study

Introduction: Open surgery repair (OSR) is generally considered as a single definitive procedure and requires minimal postoperative follow-up once immediate survival is established. There are many studies which focus on endovascular aneurysm repair reintervention, only few contemporary studies report graft-related reinterventions after open repair. The present study describes the incidence of graft-related complications following OSR for abdominal aortic aneurysm (AAA) and its management. This study also analyse the factors which can preoperatively predict the occurrence of graft related complications, so that necessary steps can be taken to prevent such complications. Materials and Methods: This is a single-center prospective analysis of 165 patients who underwent elective open repair for AAA over a period of 8 years from January 2008 to December 2016. Demographics, preoperative, perioperative, and postoperative data were recorded in a structured data collection sheet after reviewing patient records and institutional electronic medical records after obtaining clearance from the Institutional Ethics Committee. Results: The overall incidence of graft-related complications in our study was 6.6%. The most common graft-related complication in our study is iliac graft limb occlusion 3.6% followed by graft infection of 1.5% and anastomotic pseudo aneurysm of 1.5%. The graft-related reintervention rate is 5.1% and graft-related mortality is 1.5% in 8-year follow-up. The risk factors for graft-related complications are preoperative uncontrolled DM, aorto-iliac aneurysms, use of bifurcated graft, and postoperative wound infection. Conclusions: This study showed that aggressive control of DM preoperatively and anastomosing distal Y-limb of graft to femoral artery rather than external iliac artery may decrease the complications. The majority of graft-related complications occurred 2 years after surgery. Hence, we suggest that those patients with above risk factors should be put on a short-interval surveillance program.

Fusion Imaging Significantly Reduces Contrast and Radiation Exposure During Standard EVAR

Background: Standard endovascular aortic repair (EVAR) is frequently performed with few data regarding utilization of 2D-3D fusion imaging (FI). Purpose: To evaluate a) feasibility and safety of 2D-3D FI to guide limb deployment during EVAR and b) efficacy of this technique compared to standard use of digital subtraction angiography (DSA) for guidance. Materials and Methods: Iliac limb deployment by guidance of 2D-3D FI (FUSION group, n=22 limbs) during EVAR was compared to (STANDARD group, n=23 limbs). Retrospectively, we analyzed feasibility (success-rate) and safety (patency of hypogastric artery; type Ib/III endoleak) of FI for limb deployment (FUSION group). Total contrast (ml) and median dose area product (mGy*cm2) per group to visualize the iliac bifurcation were compared. Results: In the FUSION group, limb deployment was performed in 19/22 limbs (86.4%) and all hypogastric arteries were patent at the end of the procedure. Median volumes of contrast per bifurcation were 13.0 ml (RANGE 13–13ml) in the STANDARD and 2.2ml (RANGE 0–13ml) in the FUSION group (p=0.002); median dose area products per bifurcation were 11951mGy*cm2 and 2593.1mGy*cm2 (p=0.001), respectively. Conclusion: Fusion imaging for guidance of limb deployment during standard EVAR is safe and feasible in the majority of procedures and can significantly reduce contrast volume and radiation exposure even if compared with optimal preparation by predicting optimal C-arm positions. Therefore, FI should be used whenever possible

Effect of the Terminal Aortic Diameter on the Patency Rate of Iliac Limbs after Endovascular Aortic Repair.

Objective: Endograft limb occlusion (ELO) is a complication of endovascular aneurysm repair (EVAR). In this study, we investigated the mechanism and anatomical features of ELO.Materials and Methods: We retrospectively reviewed 227 consecutive patients with abdominal aortic aneurysm who underwent EVAR between 2007 and 2017. We then analyzed the preoperative risk factors and anatomical features of patients with ELO.Results: A total of nine patients had ELO (4.0%). The diameter of the terminal aorta was significantly smaller in patients with ELO than in patients without ELO (18.0 mm vs. 22.3 mm, p=0.039). We measured the diameter of each limb near the terminal aorta. The smaller limb (SL) was occluded in all patients with occlusion. The difference between the larger limb (LL) and the SL (LL-SL) was significantly larger in patients with ELO than in patients without ELO (4.0 mm vs. 1.7 mm, p<0.001). The following were considered risk factors for ELO: younger age, narrow terminal aorta, severe calcification at the terminal aorta, and use of an Endurant device.Conclusion: ELO occurs when the diameter of one side of the stent graft limb is small compared with the diameter of the other side owing to the narrow terminal aorta and calcification.

Hemodynamic Comparision Between a Classic Bifurcated Endograft and a Customized Model With “Dog-bone”-shaped Limbs

Introduction - The “customized” endovascular concept for treatment of aneurysms with challenging anatomies focuses on the construction of individualized endograft designs to adapt to patient-specific needs. Among these patterns, the endograft design with “dog-bone”-shaped limbs (DB) presents large diameter at the proximal and distal end of the iliac limbs with significant narrowing at the middle segment, offering a solution for aneurysms with extremely narrow bifurcation. Aim of this computational simulation study was to compare the displacement forces between the classic-bifurcated endograft model and a DB model of equal total length. Methods - A 3D model was constructed using appropriate commercially available validated software (ANSYS ICEM, Ansys Inc., Canonsburg, PA, USA). Inlet and outlet diameters were 28mm and 14mm, respectively. The total length of both models was kept constant to 180cm but with shorter main body by 20cm in the DB model. Accordingly, the iliac limbs of the DB model presented a 9mm stenosis over a 30mm-segmental length in the mid-portion of the limbs. The displacement forces were estimated during a cardiac cycle at three segments (main-body, bifurcation and iliac limbs) of both models with Computational Fluid Dynamics analysis. Results - The DB accommodation was associated with higher forces at the main-body (range 3.15-4.9Ν) compared to the classic configuration (1.56-2.34N). On the contrary, the forces at the bifurcation (3.81-5.98N vs. 3.76-5.54N) as well as at the iliac limbs (0.34-0.85N vs. 0.49-0.74N) were comparable for both models (Figure 1). Conclusion - The DB accommodation seems to correlate with higher displacement forces at the main-body of aortic endografts compared to the classic bifurcated design. Consequently, regular imaging follow-up of the DB design deems necessary to delineate its mid- and long-term hemodynamic and clinical performance.

Fluid Pressure Derived Force is the Main Contributor to Iliac Limb Displacement Forces – Shear Force and Redirection of Flow are Negligible

Introduction - Complications after EVAR, including aortic rupture, continue to be a problem also in long term follow-up1. There is still a need for life-long surveillance and late re-interventions raises the question about long term EVAR-durability. Additional iliac stent grafts due to distal endoleak type I are among the more frequent among these late re-interventions2,3,4. There are indications that graft migration at iliac landing zones and graft interconnections are among the most common causes and that wide iliac arteries predispose for these complications5. Flow induced displacement forces have, in an experimental model, been shown to be significant also at distal landing zones in EVAR stent grafts6 and particularly high in grafts with large distal diameters7. These findings indicate that late EVAR failures are linked to flow induced displacement forces and subsequent graft migration. We have therefore conducted a study of fluid structure interaction with the aim to differentiate the magnitude of the different force components and numerically evaluate the forces acting on iliac limb stent grafts in different graft configurations. Methods - The displacement forces in iliac limb stent grafts were numerically evaluated using a finite volume approach for fluid-structure interaction (FSI) with the open source tool FOAM-extend-3.1. The grafts were modelled with homogeneous properties in three configurations; tapered (16 mm proximal diameter, 12 mm distal diameter), non tapered (16-16 mm) and bellbottom (16-27 mm), all at 90° angulation (see 16-27 in figure). Experimentally determined pulsatile conditions were applied for different pressures; 145/80, 170/90, 195/100 mmHg. Results - Stent graft displacement forces increased with higher fluid pressure in all graft configurations. Maximum forces in bellbottom grafts (proximal end 2.3 N, distal end 8.1 N) were particularly high compared to tapered (proximal end 2.5 N, distal end 1.2 N) and non tapered grafts (proximal end 2.5 N, distal end 2.5 N). The effects of shear stress and redirection of flow were together less than 2.8 % of the total forces in all graft configurations, whereas pressure derived forces were the main contributor to the forces acting on the stent graft. The flexibility of the stent graft absorbed up to 15 % of the forces. Conclusion - The forces acting on stent grafts during pulsatile flow are significant and particularly high in the distal end of grafts with large distal diameter. The main contributor to these displacement forces is pressure while the contribution of shear and redirection of flow are negligible. The flexibility of the stent graft tends to absorb a significant part of the forces.

Emergency use of Physician-modified Fenestrated Endograft in a Symptomatic Patient Who was Waiting for a Manufactured Graft to Treat Chronic Post-dissection Thoracoabdominal Aneurysm

Introduction - Fenestrated-branched endovascular repair (F-BEVAR) using custom manufactured devices (CMDs) has been applied to treat post-dissection thoracoabdominal aortic aneurysms (TAAA), but the long wait period for device manufacturing limits its application in patients with symptomatic or contained ruptured aneurysms. Methods - A 59-year-old female patient who was waiting for CMD (Cook Medical, Brisbane, Australia) presented with a symptomatic post-dissection TAAA. The patient had undergone a successful first stage thoracic endovascular repair with creation of a fenestration in the distal aortic septum to perfuse the right kidney, which originated from the false lumen. Repeat computed tomography angiography revealed compression of the true lumen below the level of the fenestration with pressurization of the false lumen (Figure A). The patient was treated emergently using a physician-modified endovascular graft (PMEG) with four fenestrations and preloaded guidewires. The technique of PMEG using low-profile Zenith Alpha™ Thoracic stent graft (Cook Medical, Copenhagen Denmark) is presented with video and illustrations. Results - The thoracic stent-graft was modified onsite under strict sterile technique using the same measurements obtained for the original CMD request. The active fixation bards were removed to facilitate re-sheathing. Four fenestrations were created with ophthalmologic cautery and reinforced using a double layer of nitinol wire (Figure B). Radiopaque markers were added for orientation. Four 0.014-inch preloaded guidewires were added exiting via the top of the delivery system (Figure C). Diameter-reducing sutures were applied and the device was reintroduced into the original 18Fr sheath. Using bilateral femoral and right brachial approach, a long 5Fr sheath was introduced via the brachial approach exiting via the femoral approach. The PMEG was loaded into a through-and-through wire, while the four preloaded guidewires were loaded into a long 5Fr brachial sheath. The device and sheath were advanced into position and deployed in a stepwise fashion allowing sequential catheterization of the celiac axis, superior mesenteric artery and both renal arteries in the compressed true lumen (Figure D). Once all vessels were catheterized, the bifurcated device and iliac limbs were added and flow was restored to the lower extremities. Sequential renal-mesenteric stenting was done. A completion cone beam computed tomography revealed successful aneurysm exclusion. The repair was completed with a total endovascular time of 133 minutes and the patient was dismissed on postoperative day 10. Follow-up CTA showed patent stent-graft with type 2 endoleak. A total of 6 PMEG repairs with low profile Zenith Alpha™ Thoracic stent grafts were performed at our institution between 2016 and 2018, representing 2% of the 280 patients treated by F-BEVAR during this period. All six patients who had PMEGs did not meet inclusion criteria for an ongoing prospective study using CMDs Conclusion - PMEGs remain a valuable option to treat TAAAs, including chronic post-dissection aneurysms, in patients with symptoms or contained rupture who are not ideally suited for off-the-shelf devices. Compared to tighter stainless-steel Z stents, the widely spaced nitinol stents of the Zenith Alpha™ Thoracic endograft offer more space for fenestration placement.

The Efficacy of a Protocol of Iliac Artery and Limb Treatment during EVAR in Minimizing Early and Late Iliac Occlusion

The Efficacy of a Protocol of Iliac Artery and Limb Treatment during EVAR in Minimizing Early and Late Iliac Occlusion

Impact of Common Iliac Artery’s Anatomy on the Risk of Endograft Limb Occlusion after EVAR

Introduction - The aim of the study was to evaluate incidence and outcome of iliac limb occlusion (ILO) in patients undergoing endovascular aneurysm repair (EVAR) and to identify potential predictors in respect of the anatomy of common iliac artery.

Iliac Artery Deformation During Abdominal EVAR has Consequences for Choice of Iliac Limbs, Optimal C-arm Angulation and Image Fusion Guidance.

Iliac Artery Deformation During Abdominal EVAR has Consequences for Choice of Iliac Limbs, Optimal C-arm Angulation and Image Fusion Guidance.

Fenestrated and Branched Endografting After Previous Open Infra-renal Aortic Aneurysm Repair

Introduction - Proximal para-anastomotic aneurysms, or aneurysmal degenerations of the native aorta above a previous infra-renal aortic open repair (P-AAAs), are not rare challenging scenarios. The aim of this study was to report the early and mid-term outcomes following endovascular repair of P-AAAs with fenestrated and branched endografts (FB-EVAR) Methods - From 2006 to 2017, we prospectively collected and retrospectively analyzed pre, intra and postoperative data of patients undergoing FB-EVAR for P-AAAs at two European vascular surgery units. Early outcomes were: technical success (target visceral vessels cannulation and stenting, absence of Type I-III endoleak, iliac limb occlusion and 24-h mortality), spinal cord ischemia (SCI), and 30-day mortality. Mid-term outcomes were: survival, target visceral vessels (TVV) patency, and freedom from re-interventions. Fisher’s exact test, Kaplan Mayer and Log rank were used for the statistical analysis Results - During the study period, 108 patients (M:94%; age:71±4years; ASA 3-4:74%>26%) were enrolled. The previous aortic OR was a tubular aorto-aortic 63(58%), a bifurcated aorto bi-iliac 37(34%) or an aorto bi-femoral 8(8%) bypass. The OR was performed 10±2years prior to the FB-EVAR. A previous TEVAR had also been performed in 7 patients (6%). The aortic lesions at the time of FB-EVAR was a type I-III 69(64%) or type IV 39(36%) thoracoabdominal aneurysm according to the Crawford’s classification. The mean aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were perfused by endograft fenestrations (63;58%), branches (26;24%) or both fenestrations and branches (19;18%). Tubular, tri-modular or aorto-monoiliac implants were planned in 68 (63%), 38 (35%) and 2 (2%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass and iliac branch devices were planned adjunctive procedures in 41 (38%), 5 (5%) and 3 (3%) cases, respectively. Technical success was 93%. Technical failures included 5 TVV-loss (celiac trunk:1; renal arteries:4) and 3 deaths within 24 hours (cardiac aetiology). Post-operative SCI was diagnosed in 7 patients (7%), including 4 (4%) permanent. Type I-III TAAAs (p .04) and endograft incorporating both fenestrations and branches (p .04) were associated with SCI. Cardiac and pulmonary morbidity was 9% and 10%, respectively. Post-operative renal failure (GFR reduction >30% of baseline) was diagnosed in 22 patients (20%). Bowel ischemia was depicted in 3 (3%) patients. The 30-day mortality was 4%. Preoperative chronic renal failure (p .03), post-operative cardiac morbidity (p .04), and bowel ischemia (p .003) were associated with 30-day mortality. The mean follow-up was 38±18 months. Survival at 1, 3 and 5 years was 82%, 64% and 54%, respectively. There was no late aneurysm-related mortality. Survival during follow-up was significantly impacted by pre-operative chronic renal failure (p .005), post-operative cardiac morbidity (p .04), and SCI (p .04). Target visceral patency at 1, 3 and 5 years was 93%, 91% and 91%, respectively. New onset of hemodialysis was required in 4 patients (4%). Aneurysm enlargement (>5mm) was detected in 6 (5.5%) cases. Freedom from re-interventions at 1, 3 and 5 years was 89%, 77% and 74%, respectively Conclusion - Endovascular treatment of aortic aneurysmal evolution above a prior open AAA repair with FB-EVAR is safe and effective. If those promising results are confirmed during late follow-up, FB-EVAR should be considered as a therapeutic option, especially in high-risk patients

Outcomes of endovascular repair of abdominal aortic aneurysms in narrow aortic bifurcations using the ultra-low profile “INCRAFT” device: A retrospective multicenter study

ObjectiveAlthough the long-term results of endovascular aortic repair (EVAR) with low-profile devices in patients with hostile iliac anatomies have been published, there are no reported results specifically for narrow aortic bifurcations (NAB). This study investigated the outcomes of EVAR with the INCRAFT device in NAB (<16 mm). MethodsThis multicenter retrospective study involved five vascular surgery centers. From November 2014 until June 2018, 127 patients were treated with the INCRAFT device. The patient population was divided into two groups based on aortic bifurcation diameter. They were designated as the (1) standard aortic bifurcation (SAB) group (>16 mm) and the (2) the NAB group (<16 mm). Primary end points were the differences between the two groups in terms of technical success, survival at 30 days, iliac limb patency, and reinterventions. ResultsThe SAB group included 96 patients and the NAB group included 31 patients. The mean aortic bifurcation diameter was 25.5 mm in the SAB group and 13.2 mm in the NAB group. It is noteworthy that, in the NAB group, 21.8% of patients had aortic bifurcations with focal calcific lesions (less than one-third of the circumferential length of the bifurcation) and 48.3% showed extensive calcifications (two-thirds of the circumferential length of the bifurcation), for 29.9% of the patients in the NAB group the aortic bifurcation had a circumferential highly calcific lesion (complete occlusion of the circumferential length of the bifurcation). Technical success was 98.9% in the SAB group and 96.7% in the NAB group (P = .1). The need for iliac component stenting was not significantly different between the groups (SAB 2.0% vs NAB 3.2%; P = .07). The 1-year survival was 97.9% and 96.7% in the SAB and NAB groups, respectively, with no aneurysm-related mortality. The mean follow-up was 18.4 months and 15.3 months in the SAB and NAB groups, respectively. The iliac primary patency was 98.9 % in the SAB group and 96.8% in the NAB group (P = .088), and the primary assisted patency was 100% in both groups. ConclusionsEVAR with INCRAFT in NABs showed acceptable results. In this multicenter study, the results were comparable in terms of technical success and iliac patency rate between patients with SABs and NABs.

TAA 6. Staging Procedures, Cerebrospinal Fluid Drainage, Selective Neuromonitoring, and Use of Conduits During Complex Endovascular Aortic Repair in Patients With High Risk of Spinal Cord Injury

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and thoracoabdominal aortic aneurysm (TAAA) repair is a devastating complication. Outcomes improved significantly after 2015, when we revised our spinal cord protection strategy. This study describes a single experience of SCI prevention in patients who have had endovascular repair. A prospectively maintained database of patients having repair using standard, branched/fenestrated stent grafts at a single university center was reviewed. We optimized the implantation procedure, including the early restoration of pelvic and lower limb perfusion by precannulated devices and temporal conduits. The left subclavian artery was routinely revascularized before coverage. Procedures for extent thoracic and II and III TAAAs were staged. The aim was also to maintain controlled perfusion to the sac before complete exclusion. In cases of TEVAR, the first step was subclavian revascularization, then endograft deployment, and the next step was proximal occlusion of the left subclavian artery with a plug. For the TAAA, strategies used for staging included placement of the thoracic component; branch/fenestration device deployment, maintaining perfusion to the sac by delayed completion of either one of the stent graft side branches, perfusion branches, or contralateral iliac limb extension; and complete exclusion after side branch occlusion test and motor and somatosensory evoked potential monitoring (Fig). The current policy was to place a spinal drain; the mean arterial pressure is raised to >90 to 100 mm Hg, and the hemoglobin level is maintained at 10 g/dL. Twenty-nine patients (median age, 73 years; 24 male patients; 20 TEVARs and 9 branched/fenestrated endovascular aneurysm repairs) underwent endovascular repair. No death or neurologic symptoms or signs related to SCI were registered at 30 days. Temporary iliofemoral conduits were used in 16 limbs in 14 patients. One patient had a ≥75% decrease in motor and somatosensory evoked potential amplitude, and the complete exclusion of the sac was delayed for 2 more weeks. No patients developed late SCI or mortality. This series illustrates the importance of a dedicated institutional protocol aimed at ensuring the intraoperative maneuvers to avoid perioperative paraplegia. This study aimed to demonstrate the possible protective effects of ischemic preconditioning on the preservation of spinal cord function after segmental and sequential artery occlusion.

AAA 19. Midterm Results of Parallel Grafts in Patients With Pararenal and Type IV Thoracoabdominal Aortic Aneurysms Unsuitable for Fenestrated or Branched Endografts

The objective of this study was to evaluate the midterm outcomes of parallel grafts (PGs) in patients presenting with pararenal or type IV thoracoabdominal aortic aneurysms unsuitable for off-the-shelf or custom-made fenestrated or branched endografts. Between February 2011 and July 2019, there were 41 consecutive patients presenting with pararenal or type IV thoracoabdominal aortic aneurysms who were treated by implantation of PGs. Reasons for use of PGs were the following: patients judged unfit for open surgery; urgent or emergent procedures in which off-the-shelf graft was not applicable; and elective patients refused for manufacture of custom device because of anatomy. Different commercially available endografts and covered balloon or self-expandable stents were used. Outcomes included intraoperative technical success and early (30-day) and midterm all-cause mortality and morbidity as well as freedom from reintervention, endoleaks, and occlusions of PGs. Technical success was defined as a procedure completed as intended, without secondary interventions within 30 days. Forty-one patients were included (mean age, 76.3 ± 7.1 years; 34 male). Mean aortic aneurysm diameter was 67.2 ± 18.6 mm. Twenty-three patients were treated electively; the remaining patients were treated in emergency. Previous infrarenal aneurysm repair was reported in 11 patients (26.8%). Ninety-two target aortic branches (TABs) were treated (2.2/patient). Technical success was obtained in all patients. At 30 days, mortality was 7.4%, accounting for three emergently treated patients (two aortic infections and one rupture), and TAB occlusion rate was 2.1% (2/92). One patient required an additional embolization procedure because of a persistent gutter endoleak. At a mean follow-up of 29 ± 7 (2-96) months, freedom from mortality was 89.5%; four more patients died (one new infection, one aneurysm rupture, and two myocardial infarctions). Rate of TAB new occlusion was 1.1% (1/92). Reintervention was performed in four patients, in three for endoleaks and in one for iliac limb occlusion. During the entire study period, cumulative TAB occlusion rate was 3.2%, all renal branches. Aneurysm sac shrinkage was observed in 59.5% of patients, with a mean aneurysm diameter reduction 3.8 ± 2.1 mm. The technique of PGs seems to represent a reasonable option in patients at high risk for open surgery who are not able to be treated by fenestrated or branched endografts. Despite high clinical and anatomic risk of treated patients, TAB patency remains high at midterm follow-up.

Evolving Management of Distal Anastomotic Technical Issues During Open Aortic Aneurysm Repair

Thrombosis of the iliac anastomosis is an important complication of open aortic aneurysm repair. We evaluated our evolving management of this complication to an endovascular approach and compared it with open revision to the common femoral artery. Consecutive patients undergoing open aortic aneurysm repair from January 2009 through November 2016 at our institution were reviewed. Patients who developed iliac limb flow issues or thrombosis intraoperatively or within 48hrs postoperatively were identified. Patients were grouped by management strategies of either 1) an endovascular approach including iliac angiography, thrombectomy if needed, and stenting or 2) open surgical revision of the iliac anastomosis with or without bypass to the common femoral artery. Demographics, comorbidities, operative variables, and outcomes were retrospectively analyzed between groups. Primary patency and mortality were assessed by Kaplan-Meier estimates. There were 711 patients who underwent aortoiliac aneurysm repair during the study period. 43/711 patients (6.0%) developed early perioperative iliac limb flow issues including thrombosis. Twenty-nine patients (31 limbs) were managed by an endovascular approach, and 14 patients (15 limbs) were managed by open surgical revision. The mean age of the cohort was 69years, and 27 patients (62.8%) were male. Preoperative creatinine and diabetes frequency were higher in patients managed by an endovascular approach, although no other differences existed between preoperative comorbidities. Thrombosis or limb flow issues presented intraoperatively more commonly in the open surgical group and in the first 24hrs postoperatively in the endovascular group. All patients had complete restoration of outflow as a result of the rescue procedure. Transfusion requirements and crystalloid replacement were significantly higher in the open surgical group. Length of stay, perioperative complications, and mortality were similar between groups. Overall, 21/31 limbs in the endovascular group and 9/15 limbs in the open surgical group had postoperative imaging, with mean follow-up of 35.0 and 55.6months, respectively. Only one patient in the cohort lost patency: an iliofemoral jump graft that presented with late infection after postoperative wound infection, requiring staged extra-anatomic bypass and explant at 12months. Three-year primary patency was 100% for the endovascular group and 85.7% for the surgical group by Kaplan-Meier method (P=0.32). Endovascular management became our institution's primary salvage approach during the study. Whereas 8/15 limbs (53.3%) were managed by an endovascular approach from 2009-2011, 23/31 (74%) were managed by iliac stenting from 2012-2016. Endovascular management of iliac limb flow issues or thrombosis after open aneurysm repair is potentially a viable alternative to open surgical revision in the early postoperative period.

Five-year results of endovascular abdominal aortic aneurysm repair with the Ovation abdominal stent graft

ObjectiveEndovascular abdominal aortic aneurysm repair (EVAR) has been rigorously compared with open repair for the treatment of abdominal aortic aneurysms in randomized trials and observational studies, but a comparison of individual devices is lacking, and single-device registries and trials are limited by small sample size. Here we report a descriptive analysis of the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, pooled results of multiple studies evaluating the midterm results of EVAR with the Ovation Abdominal Stent Graft Platform. MethodsThis is a retrospective analysis of the ENCORE database, a cohort of patients undergoing EVAR with the Ovation platform composed of pooled, prospectively collected data from 1296 patients from five clinical trials and the prospectively maintained European Union Post-Market Registry. The primary outcomes were 5-year rates of type IA and type I or III endoleak. Secondary outcomes included were 30-day mortality, 30-day major adverse event, technical success (successful deployment of the aortic body and iliac limbs), as well as 5-year survival, and freedom from aneurysm-related mortality, type II endoleak, device-related intervention, aneurysm rupture, sac expansion, and conversion to open repair. ResultsA total of 1296 patients were included in the analysis. The average age was 73 ± 8 years and 81% of patients were male. Fifty percent of patients had complex aortic anatomy, (neck length <10 mm, neck diameter >28 mm, neck angle >60°, reverse neck taper >10%, distal common iliac artery diameter <10 mm, or external iliac artery diameter <6 mm). Technical success was 99.7%. Thirty-day mortality was 0.3%, 30-day rate of major adverse event was 1.6%, and polymer leak rate was 0.2%. Freedom from type IA endoleak at 1, 3, and 5 years was 97.6%, 97.1%, and 95.8%, respectively; type I or III endoleak at 1, 3, and 5 years was 96.9%, 95.7%, and 94.0%, respectively. Freedom from device-related reintervention at 1, 3, and 5 years was 96.2%, 94.4%, and 92.4% and primary freedom from sac expansion was 97.0% at 1 year, 90.3% at 3 years, and 84.9% at 5 years. Freedom from all-cause mortality and aneurysm-related mortality at 5 years were 78.9% and 99.3%, respectively. ConclusionsThis analysis of the ENCORE database demonstrates that EVAR with the Ovation platform has favorable midterm durability evidenced by successful aneurysm exclusion and 5-year freedom from aneurysm-related mortality.

Tailor-made iliac branched device for preserving the internal iliac artery in patients with common iliac artery aneurysm.

Endovascular repair with stent-graft is a treatment option for patient with common iliac artery aneurysm (CIAA). However, the preservation of the internal iliac artery (IIA) is a concern. The commercially available iliac branched device (IBD) requires a common iliac length of at least 5 cm, which is usually too long for Asian people. Here, we report our medium-term results of using tailor-made IBD for patients with short common iliac artery (CIA) with and without abdominal aortic aneurysm (AAA). A selected iliac limb of the AAA stent-graft was unloaded from the delivery system. A 6-mm fenestration hole was made at the length of the CIA from the proximal end. The edge of the hole was reinforced with the soft and radiopaque tip of a 0.014´´ wire. Then, the iliac limb was reloaded into the introduced sheath as the tailor-made IBD. It was inserted from the selected side of the femoral artery and deployed. The ipsilateral IIA was cannulated through the fenestration hole. Then, a balloon-expandable or self-expandable covered stent with an appropriate size was deployed as the bridging stent-graft. Between March 2013 and March 2017, a total of 10 patients received the tailor-made IBDs. One patient died of systemic thromboembolism 2 days after the operation. The bridging stent-grafts remained patent in all patients, except one occluded at 1 year after operation. A tailor-made IBD is an easy-to-apply, alternative option for preserving the IIA perfusion in short CIAA patients with and without AAA.

45. Large vessel vasculitis associated with common iliac artery aneurysm and limb ischaemia

IntroductionAn 81-year-old gentleman with no prior medical history presented with a 5-month history of gradual onset malaise and reduced appetite. Weight loss of 2 stone was noted. Mild intermittent headache was present. After 3 months, he developed intermittent claudication of the right leg. A diagnosis of giant cell arteritis (GCA) was made. Disease was corticosteroid resistant, on the basis of clinical findings, biochemistry and imaging. Tocilizumab was commenced. Imaging also revealed dissection of the proximal right common iliac artery. The intermittent claudication progressed to acute limb ischaemia, which responded well to conservative treatment with heparin.Case descriptionHeadache was unilateral, intermittent and lasted a few minutes only, although it was described as severe. There were no visual symptoms, no scalp tenderness and no jaw or tongue claudication. His mobility was severely impacted by intermittent claudication. He was previously playing 3 rounds of golf per week but exercise tolerance reduced to fifty metres. There were no specific risk factors for atherosclerotic disease. He was a retired head teacher and had never smoked. Alcohol intake was 3 units per week. He was not taking any medication.The predominant features in the history were systemic upset and weight loss and the initial focus was on ruling out malignancy. Extensive investigations were performed by the general practitioner (GP). Erythrocyte sedimentation rate (ESR) was 80 and C-reactive protein (CRP) 74. A full blood count and serum biochemistry were otherwise unremarkable. Immunoglobulins were normal with no paraprotein detected. Thyroid stimulating hormone (TSH) was within the normal range. Prostate specific antigen (PSA) was raised at 17.8 but urology investigations revealed no evidence of malignancy.Computed tomography (CT) of the thorax, abdomen and pelvis showed non-specific inflammation of jejunum & mesenteric fat. Subsequent magnetic resonance imaging (MRI) of the small bowel showed resolution of these changes but noted a chronic focal area of dissection at the proximal right common iliac artery.The GP commenced prednisolone 40mg daily, increased after twelve days to 60mg daily due to partial response. Review in rheumatology clinic two weeks later noted ongoing intermittent claudication. Headache had resolved and weight stabilised. The right temporal artery was difficult to palpate and the right ulnar pulse was absent. Temporal artery ultrasound scan (TA USS) in clinic demonstrated bilateral ongoing active inflammation. Three pulses of 500mg intravenous methylprednisolone were arranged.DiscussionWhilst ESR had initially improved to 10 and CRP to < 3, they subsequently increased to 53 and 45 respectively. Subsequent positron emission tomography with computed tomography (PET-CT) showed diffuse metabolic activity in thoracic aorta, bilateral subclavian, axillary and femoral arteries.On the basis of bloods, ongoing claudicant symptoms and strongly positive TA-USS and PET-CT, the disease was felt to meet criteria for steroid non-responsiveness. As per NICE guidelines, permission was sought and granted from the local tertiary centre to commence tocilizumab. The patient was noted to have diverticulosis on the basis of imaging but had never been symptomatic. After appropriate patient counselling on the risks of gastrointestinal perforation, a decision was made to proceed with treatment.The finding of dissection at the proximal right common iliac artery prompted urgent referral to the vascular surgery team. However, whilst awaiting review, the patient developed acute limb ischaemia with pallor, weakness and pain of the right leg. He was admitted and managed conservatively with intravenous heparin, followed by subcutaneous heparin and clopidogrel. He responded well to medical therapy and remains under vascular follow up. Notably, the aneurysm was retrospectively noted on CT scan imaging, confirming that it predated corticosteroid treatment.Key learning pointsWhilst aneurysm formation is a recognised complication of giant cell arteritis, they are typically aortic and involvement of lower limb arteries is rareThere is no consensus opinion on optimal surveillance of extra-aortic aneurysms in GCA; decisions should be made on a case by case basisTocilizumab is an effective treatment for refractory GCA. The current NICE guideline on its usage is based on the GiACTA study findingsConflicts of interestThe authors have declared no conflicts of interest.

Early Experience with the Octopus Endovascular Strategy in the Management of Thoracoabdominal Aneurysms

The Octopus endovascular strategy involves placement of multiple, stacked bifurcated grafts in the thoracic segment of a thoracoabdominal aneurysm (TAAA) to facilitate deployment of multiple parallel covered stents for visceral perfusion. This study aimed to review early outcomes of the Octopus TAAA repair strategy at a tertiary, high-volume referral center. All patients who underwent this Octopus procedure from 2015 to 2018 were reviewed from a prospectively collected single-institution registry. Demographics, comorbidities, and aneurysm anatomy including side and extent, perioperative data including blood loss, length of procedure length of stay, morbidity, and mortality up to 3years after the procedure were elevated. A total of 21 patients (48% female, age 72.9years) underwent the Octopus procedure over the study period. Mean TAAA diameter was 6.7cm, with 14% dissection related and 86% degenerative TAAA. All patients had been turned down for open repair and 3 (14%) were performed urgently of which 2 were ruptures. TAAA extent was 9% type 2, 62% type 3, and 29% type 4. A mean of 3.04 branches were revascularized per patient, with the superior mesenteric artery (SMA) (90%) perfused through its own limb, and both renals usually reconstructed in parallel graft fashion (left 90%, right 85.7%) with the distal abdominal extension through one of the limbs. Mean operative time was 8hr, fluoroscopy time 164min, contrast 182mL, and blood loss 807mL. We staged the thoracic and juxtavisceral portions of the cases in 24% of patients. 90% of cases were able to be completed with exclusion of the TAAA and all planned visceral branches cannulated. Perioperative complications included paraplegia (19%) (13.3% permanent, 26.6% temporary), acute kidney injury (24%), prolonged ventilation (19%), myocardial infarction (4.9%), and ischemic bowel (4.8%). Median follow-up was 13.5months (range 1-26months). At latest follow-up, type I endoleak rate was 9.5%, with all being treated with proximal cuffs. Other second interventions included restenting of a right renal, angioplasty of an iliac limb kink, and type 2 endoleak coiling. Primary patency of visceral branches was 93.8% at latest follow-up (celiac 100%, SMA 94.7%, right renal 88.9%, left renal 94.8%). In-hospital all-cause mortality rate was 14.2%, with 30-day survival being 90.5%, 6-month survivalwas 88.3%, one-year survival 71.4%, and 3-year survival was 52.1%. The Octopus procedure is a high-risk option for urgent or emergent endovascular TAAA repair with off-the-shelf devices in patients who are not candidates for open repair.