Internal Iliac Artery Patency Research Articles

Up and over staged endoconduit technique for endovascular aortic aneurysm repair

Adverse iliofemoral anatomy can preclude complex endovascular aortic aneurysm repair. This study aims to describe the “up-and-over” staged endoconduit technique to improve access and avoid vascular injury before complex endovascular aneurysm repair. A staged procedure for complex endovascular aortic aneurysm repair is performed using an endoconduit (W.L. Gore & Associates). After obtaining contralateral femoral access, the extension of iliofemoral disease is assessed using angiography. The endoconduit is advanced “up and over” the aortic bifurcation and delivered percutaneously into the common femoral artery to treat a diseased access site and maintain intact the ipsilateral femoral access for future stent graft deployment. Internal iliac artery patency is maintained when feasible. During complex aneurysm repair, the endoconduit is accessed directly under ultrasound guidance using sequential dilation to avoid vascular injury. PerClose sutures (Abbott Vascular) are used to close the endoconduit femoral access site. This study found that staged “up and over” endoconduit creation is a useful technique before complex endovascular aneurysm repair in patients with adverse iliofemoral anatomy. Avoiding accessing the main femoral access site during the first stage prevents vascular or access site injuries and allows for both iliac and femoral disease to be addressed.

Long-term outcomes of staged iliofemoral endoconduits prior to complex endovascular aortic aneurysm repair

ObjectiveAdverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (ECs) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral ECs prior to complex EVAR. MethodsBetween 2012 and 2023, 59 patients (44% male; median age, 75 ± 6 years) underwent ECs before complex EVAR using self-expanding covered stents (Viabahn). For common femoral artery (CFA) disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency. ResultsUnilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac, external iliac, and CFA were 7 mm (interquartile range [IQR], 6-8 mm), 6 mm (IQR, 5-7 mm), and 6 mm (IQR, 6-7 mm), respectively. Internal iliac artery was inadvertently excluded in 10 patients (17%). Six patients (10%) had an intraoperative vascular injury during the EC procedure, and six patients (10%) had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. In 23 patients (39%), 22 Fr OD devices were used; 20 Fr were used in 22 patients (37%), and 18 Fr in 14 patients (24%). Technical success for accessing EC was 89%. There was no difference in major adverse events at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82%, respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six secondary interventions (10%) were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up. ConclusionsECs improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the EC directly under ultrasound guidance and using sequential dilation to avoid EC disruption.

Internal Iliac Artery Patency as a Predictor of Above-Knee Amputation Stump Healing

PurposeThe primary aim of this study is to assess role of internal iliac patency in predicting outcome of AKA stump healing. The secondary objectives were assess accuracy of Wound, Ischemia, and foot Infection (WIfI) classification system in predicting AKA stump healing and association of delayed mortality. Materials and MethodThis is a retrospective study performed in Vascular Surgery Unit, in a tertiary hospital, on patients who underwent above-knee amputations over one year, from July 2021 until June 2022. Patient demographic data, WIfI scoring, outcome of above-knee amputations and patency of profunda femoris and internal iliac artery were collected. To minimize confounding, a single vascular surgeon performed all CT imaging reviews and arterial measurements. Approval for this study was obtained from the National Research Registry NMRR ID-23-01865-KQ4 (IIR). ResultNinety patients underwent AKA over one year, from July 2021 until June 2022. Occluded internal iliac artery in the presence of patent profunda femoris did not affect the wound healing of AKA stump. There was significant association between WIfI scoring with mortality. Patients with WIfI scoring 3 to 4 was observed to have higher mortality rate compared to patients with normal healing 47 (72.0%) vs 4 (80.0%); p= 0.021. ConclusionIn this study, the internal iliac artery patency shows no statistically significant effect on AKA stump healing; however, the small number of patients is a study drawback. This study also demonstrates that the WIfI score can be a prognostic factor for mortality in patients undergoing above-knee amputation.

Branched endovascular iliac artery repair using the Zenith® Branch Endovascular Iliac Bifurcation graft: outcomes and reinterventions in our retrospective cohort.

The aim of this retrospective cohort study was to analyze the outcomes and the need for reinterventions following branched iliac artery repair using the Zenith® Branch Endovascular Iliac Bifurcation (ZBIS; Cook Medical Europe LTD, Limerick, Ireland) graft. Patient characteristics and follow-up data on 63 patients following branched iliac artery repair using the ZBIS device were evaluated and compared between patients with and without iliac reinterventions. A competing risk regression model was analyzed to identify independent predictors of reinterventions, and to predict the reintervention risk. ZBIS implantation's technical success rate was 100%, and we observed no in-hospital mortality. Internal iliac artery patency was 93% during a median [first quartile, third quartile] follow-up of 19 [5, 39] months. Thirty-two iliac reinterventions were performed in 23 patients (37%) after a mean time of 3.0 months (IQR: 0.4-6.8) (time to first reintervention). Endoleaks type I and II were the most common indication for reinterventions (n=14, 61%). The internal iliac artery's diameter [subdistribution hazard ratio (sHR): 1.046; P=0.0015] and a prior abdominal aortic intervention (sHR: 0.3331; P=0.0370) were identified as significant variables in the competing risk regression model for a reintervention. The risk for reintervention was 33% (95% CI: 20-46%), and 46% (95% CI: 28-63%) after 12 and 36 months, respectively. Endovascular repair of degenerative iliac artery aneurysms with Zenith Branch Iliac Bifurcation device is a feasible and safe option. Perioperative morbidity and mortality are low with good graft patency rates. The risk for secondary iliac artery interventions is considerable and highlights the need for patients with iliac disease to undergo continuous follow-up in a dedicated vascular center.

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair.

This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications. Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors. IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication. The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Technical Feasibility and Safety of a Snare-Less, EVAR-First Technique for Iliac Branch Endoprosthesis.

The purpose of this study was to evaluate the technical feasibility, safety, and early outcomes of a snare-less, endovascular abdominal aortic aneurysm repair (EVAR)-first technique (SET) for iliac branch endoprosthesis (IBE) placement. We retrospectively reviewed all patients who received IBEs between July 2018 and March 2022. Patients were divided into 2 categories based on method of IBE deployment: SET or Standard. Primary endpoints were technical success, major adverse events, mortality, reintervention, internal iliac artery (IIA) patency, and freedom from IIA branch instability. Technical success was defined by successful deployment of both the EVAR and the IBE with maintained patency of the IIA and no stent graft migration. There were 20 patients (90% male, median age 72 [65.4-74.5] years) who underwent IBE placement. Among these, 5 (33.3%) underwent SET to treat 5 common iliac artery (CIA)/IIA aneurysms, while the remaining 15 (66.7%) underwent standard IBE deployment with through-and-through femoral access (n=13) or trans-brachial access (n=2) to treat 19 CIA/IIA aneurysms. Overall median renal to iliac bifurcation length was 169 (152-177) mm, with 9 patients falling short of the minimum of 165 mm for on-label IBE placement. Median contrast used was 148 (120-201) mL, fluoroscopy time 42.8 (35.0-49.8) minutes, estimated blood loss 200 (100-275) mL, and procedure time 192 (167-246) minutes, with no significant differences between the 2 groups. Technical success was achieved in 100% of cases. At 30 days, there were no mortalities or major adverse events in either group; there were 100% IIA patency, no IIA instability, and no reinterventions in both groups. Median follow-up in the SET group was 5.7 (5.5-6.2) months, with 1 death at 6 months and 1 type 1B endoleak at 6 months requiring reintervention. Median follow-up for the Standard group was 1.6 (0.8-2.1) years with 2 non-aneurysm-related deaths and no reinterventions at 1 year. SET for IBE is a safe and effective approach that decreases technical complexity and mitigates anatomic barriers to IBE placement. SET for IBE is a safe and effective approach to IBE placement that decreases technical complexity. A critical component to this technique is a large bore sheath with a stiff steerable tip. Importantly, this approach also mitigates anatomic barriers to IBE placement, expanding applicability of IBE technology to patients who may be otherwise ineligible.

Outcomes of the Gore® Excluder® Iliac Branch Endoprosthesis Using Self Expanding or Balloon-Expandable Stent Grafts for the Internal Iliac Artery Component.

The GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Arizona) was developed to be used in combination with a self-expanding stent graft (SESG) for the internal iliac artery (IIA) bridging stent. Balloon-expandable stent grafts (BESGs) are an alternative for the IIA, offering advantages in sizing, device tracking, precision, and lower profile delivery. We compared the performance of SESG and BESG when used as the IIA bridging stent in patients undergoing EVAR with IBE. This is a retrospective review of consecutive patients who underwent EVAR with IBE implantation at a single center from October 2016 to May 2021. Anatomic and procedural characteristics were recorded via chart review and computed tomography (CT) postprocessing software (Vitrea® v7.14). Devices were assigned to SESG vs. BESG groups based on the type of device landing into the most distal IIA segment. Analysis was performed per device to account for patients undergoing bilateral IBE. The primary endpoint was IIA patency, and secondary endpoint was IBE-related endoleak. During the study period, 48 IBE devices were implanted in 41 patients (mean age 71.1 years). All IBE devices were implanted in conjunction with an infrarenal endograft. There were 24 devices in each of the self-expanding internal iliac component (SE-IIC) and balloon-expandable internal iliac component (BE-IIC) groups. The BE-IIC group had smaller diameter IIA target vessels (11.6±2.0 mm vs. 8.4±1.7 mm, p<0.001). Mean follow-up was 525 days. Loss of IIA patency occurred in 2 SESG devices (8.33%) at 73 and 180 days postprocedure, and in zero BESG devices, however, this difference was not statistically significant (p=0.16). There was 1 IBE-related endoleak requiring reintervention during the study period. A BESG device required reintervention due to Type 3 endoleak at 284 days. There were no significant differences in outcomes between SESG and BESG when used for the IIA bridging stent in EVAR with IBE. The BESGs were associated with using 2 IIA bridging stents and were more often deployed in smaller IIA target arteries. Retrospective study design and small sample size may limit the generalizability of our findings. This series compares postoperative and midterm outcomes of self expanding stent grafts and balloon expandable stent grafts (BESG) when used as the internal iliac stent graft as part of a Gore® Excluder® Iliac Branch Endoprosthesis (IBE). With similar outcomes between the two stent-grafts, our series suggests that some of the advantages of BESG, device sizing, tracking, deployment, and profile, may be able to be leveraged without impacting the mid-term performance of the IBE.

Outcomes of “Anterior Versus Posterior Divisional Branches of the Hypogastric Artery as Distal Landing Zone for Iliac Branch Devices”: The International Multicentric R3OYAL Registry

Objective: The aim of this multicentric registry was to assess the outcomes of “anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL).” Methods: The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability. Results: A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P = .18). Occurrence of any adverse event was noted in 14% of patients in both groups (P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001). Conclusions: The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA. Clinical Impact The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.

Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis

PurposeThe purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz). MethodsWe retrospectively reviewed all consecutive patients treated for aortoiliac aneurysms using IBE between 2014 and 2020. IIA stenting was performed using either the IIA side branch SESG or a Gore VBX BESG (W. L. Gore). Indications for use of BESGs were “up-and-over” IBE technique for type IB endoleak after prior endovascular aortic aneurysm repair (EVAR), short IIA length, and need for IIA extension into divisional branches (outside instructions for use). End points included technical success, freedom from buttock claudication, primary IIA patency, and freedom from IIA branch instability (eg, branch-related death or rupture, occlusion, disconnection, or reintervention for stenosis, kink, or endoleak), freedom from type IC/IIIC endoleak, and freedom from secondary interventions. ResultsThere were 90 patients (86 males and 4 females) with a mean age of 74 ± 7 years treated by EVAR with 108 IBEs. Choice of stent was BESG in 43 and SESG in 65 targeted IIAs. BESGs were used more frequently in patients with prior EVAR (22% vs 2%; P = .003,), isolated IBEs (31% vs 2%; P < .001), and in patients with IIA aneurysms requiring stenting into divisional branches (36% vs 5%; P < .001). Technical success was similar for BESGs and SESGs (97% vs 100%; P = .40), respectively. The mean follow-up was 25 ± 16 months (range, 11-34 months). At 2 years, freedom from buttock claudication was 100% for BESG and 95 ± 3% for SESG (Log-rank 0.26), with no difference in primary patency (BESG, 100% vs SESG, 94 ± 4%; Log-rank 0.94). There were four (9%) IIA-related endoleaks in the BESG group and one (2%) in the SESG group (P = .08). Freedom from IIA branch instability was 87 ± 6% for BESG and 96 ± 3% for SESG at 2 years (Log-rank 0.043). Freedom from type IC/IIIC endoleak was 87 ± 7% for BESG and 98 ± 2% for SESG at the same interval (Log-rank 0.06). There was no difference in freedom from reinterventions for BESG and SESG (92 ± 6% vs 98 ± 2%; Log-rank 0.34), respectively. ConclusionsBESGs were used more frequently during IBE procedures indicated for failed EVAR, isolated common iliac aneurysms, and IIA aneurysms requiring extension into divisional branches. Despite these differences and BESG being used outside instructions for use, both stent types had similar primary patency, freedom from buttock claudication, and freedom from reinterventions. However, BESGs were associated with higher rates of IIA-related branch instability.

Should Bilateral Iliac Branch Devices Become the Standard of Care for Aorto-iliac Aneurysm Repair?

Endovascular techniques for aortic aneurysms involving the iliac artery have evolved during the last decades from routine embolisation of the internal iliac artery (IIA) to preservation of the IIA, with iliac branch devices having become the first line treatment option whenever anatomically feasible.1,2 Although clinical studies and systematic reviews have shown excellent technical success, with extremely low morbidity and mortality rates in the peri-operative period, satisfactory device integrity, and target vessel patency in the midterm, there is a scarcity of data related to the long term clinical benefits of IIA patency.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis Using Division Branches of the Internal Iliac Artery as Distal Landing Zones

Purpose: To evaluate the outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) using division branches of the internal iliac artery (IIA) as distal landing zones. Materials and Methods: Between January 1, 2014, and December 31, 2018, 74 patients (mean age 74±7 years; 72 men) treated for aortoiliac or common iliac artery aneurysms had an IBE deployed with distal landing of the side branch within the main trunk (n=60) of the internal iliac artery (IIA) vs within a division branch (n=25). Thirteen (17%) patients received bilateral IBE implantations for a total of 85 vessels evaluated. Early endpoints were technical success, 30-day mortality, 30-day major adverse events (MAEs), and 30-day major access complications. Late endpoints were survival, primary and secondary IIA patency, freedom from IIA branch instability, freedom from new-onset buttock claudication, and aneurysm sac diameter changes. Time-dependent outcomes were reported as Kaplan-Meier curves with differences assessed using the log-rank test. Estimates are presented with the 95% confidence interval (CI). Results: The overall technical success rate was 97%, with 1 technical failure per group (p=0.43). Two patients, one from each group, died within 30 days (p=0.43). No significant differences were seen in the rates of 30-day MAEs (7% vs 17%, p=0.35) or major access complications (9% vs 11%, p>0.99) for patients receiving distal landing in the main trunk vs a division branch, respectively. The mean follow-up for the entire cohort was 19±12 months. The overall 1-year survival rate was 94% (95% CI 74% to 99%). The primary and secondary patency rates at 1 year were 98% (95% CI 88% to 99%) vs 95% (95% CI 72% to 99%, p=0.72) and 98% (95% CI 88% to 99%) vs 100% (p=0.41) for the main trunk vs division branch groups, respectively. Freedom from IIA branch instability estimates were also similar at 1-year follow-up [93% (95% CI 82% to 97%) vs 90% (95% CI 66% to 97%), p=0.29], as were the freedom from new-onset buttock claudication estimates [98% (95% CI 86% to 99%) and 94% (95% CI 67% to 99%), respectively; p=0.62]. Mean sac diameter change was 5.4±5.3 mm, not significantly different between the groups (p=0.85). Conclusion: Use of the posterior or anterior division of the IIA as a distal landing zone for the Gore Excluder IBE was safe and efficacious in the midterm. This technique may permit extending indications for endovascular repair of aortoiliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Long-term assessment is needed to affirm the efficacy of this technique.

Endovascular Repair of Aortoiliac or Common Iliac Artery Aneurysm Using the Lifetech Iliac Bifurcation Stent Graft System: A Prospective Multicenter Clinical Study

Sacrifice of the internal iliac artery (IIA) may result in ischemic manifestations after aortoiliac aneurysm (AIA) or common iliac artery aneurysm (CIAA) endovascular repair. This study sought to evaluate the safety and efficacy of a new Iliac Bifurcation Stent Graft (IBSG; Lifetech Scientific, Shenzhen, China) system for revascularization of the IIA. Patients who underwent implantation of the IBSG at 8 centers in China from September 2015 to June 2018 were enrolled. Clinical and computed tomography angiography follow-up assessments were conducted at 30 and 180days postoperatively. The primary end point was the IIA patency rate of the IBSG device at 180days postoperatively. Secondary end points comprised the postoperative technical success rate and clinical success rate at 30 and 180days. Descriptive statistics and the Clopper-Pearson exact method were used to analyze the data. Seventy-three patients (mean age, 69.6years; 91.8% men) were eligible for this trial, and 59 patients were eligible for primary effectiveness end-point analysis. AIA was present in 55 patients (75.34%) and CIAA in 18 patients (24.66%). The iliac artery aneurysms were unilateral in 69 patients (94.52%) and bilateral in 4 patients (5.48%). Overall technical success was 89.04% (65 of 73 patients). IIA patency at 180days was 96.61% (57 of 59 patients). Sexual dysfunction occurred in 1 patient (1.69%), and 2 patients (3.39%) experienced buttock claudication. There was no mortality, type III endoleak, stent migration, kinking, or fracture during the procedure and follow-up. The IBSG implantation system is a safe and effective technique for IIA preservation during AIA or CIAA endovascular repair. The high technical success rate, IIA patency rate, and low complication rate are promising. Follow-up will be continued for 5years to confirm the durability of the device.

The patency of internal iliac arteries and its role in the development of buttock claudication syndrome in the remote period after open infrarenal aortic aneurysm repair

The OBJECTIVE was to study the patency of the internal iliac artery and its effect to gluteus muscles blood supply and frequency of buttock claudication occurrence in the remote period after open infrarenal aortic aneurysm repair. MATERIAL AND METHODS. Examination of 37 patients after open infrarenal aortic aneurysm repair included collection of complaints, anamnesis, making CT scan with contrast and pelvic perfusion tomography. These methods allowed to assess the patency of the prosthesis and iliac arteries, calculate average blood flow rate in buttock muscles and frequency of buttock claudication occurrence depending on the lesion of the internal iliac arteries. RESULTS. Five-year patency of the internal iliac artery was 93 %. In case of passable internal iliac artery, the average blood flow rate in the ipsilateral buttock muscles was authentically higher than the same indicator in groups with stenotic or occlusive lesion of the internal iliac artery and its branches. In case of the disturbed internal iliac artery patency, the frequency of occurrence of the buttock claudication in the same side reached 50 %. CONCLUSION. High five-year internal iliac artery patency after open infrarenal aortic aneurysm repair attested the necessity of preservation the main blood flow in these arteries during the open infrarenal aortic aneurysm repair for the purpose of buttock claudication prevention. The CT scan allowed to evaluate the internal iliac artery patency and the average blood flow rate in the buttock muscles through perfusion tomography method which was necessary for differential diagnosis of the buttock claudication syndrome.

Outcomes of an iliac branch endoprosthesis using an “up-and-over” technique for endovascular repair of failed bifurcated grafts

ObjectiveType IB endoleak after endovascular aneurysm repair may be treated by an iliac branch endoprosthesis (IBE) through brachial access for internal iliac artery (IIA) stenting. The aim of this study was to evaluate outcomes of the IBE using an “up-and-over” transfemoral technique in patients with prior aortic repair compared with the standard technique in patients with de novo iliac aneurysms. MethodsWe reviewed the clinical data of patients treated for aortoiliac aneurysms using Gore IBE (W. L. Gore & Associates, Flagstaff, Ariz) between 2014 and 2017. The up-and-over technique was indicated in patients with type IB endoleak or common iliac aneurysms after prior aortic repair with bifurcated endografts or surgical grafts. End points were technical success, mortality, major adverse events, IIA patency, freedom from IIA branch instability (composite end point of any IIA branch-related complication leading to aneurysm rupture, death, occlusion, component separation, or reintervention to maintain branch patency or to treat a branch-related separation or endoleak), and freedom from secondary interventions or new-onset buttock claudication. ResultsThere were 53 patients (51 male; 74 ± 8 years old) treated by 62 IBEs (9 bilateral). Standard technique was used in 36 patients (43 IBEs) and up-and-over technique in 17 (19 IBEs). Three patients had contralateral IIA embolization. Total procedure time, contrast material volume, and radiation dose averaged 168 ± 98 minutes, 140 ± 50 mL, and 1096 ± 1009 mGy, with no difference between techniques. Technical success was achieved in 98% of patients. Eleven patients had extension of IIA bridging stent into the posterior branch (eight standard, three up-and-over). Four patients (8%) had major adverse events due to estimated blood loss >1000 mL in all patients. There was no 30-day mortality after a median follow-up of 7 months (interquartile range, 3-12 months). There were two IIA stent occlusions (all standard), three iliac-related type I endoleaks (one standard, two up-and-over), and four secondary interventions (three standard, one up-and-over). At 1 year, patients treated by standard or up-and-over technique had similar primary patency (94% ± 4% vs 100%; P = .38) and secondary patency (97% ± 3% vs 100%; P = .54) and freedom from IIA branch instability (90% ± 6% vs 93% ± 7%; P = .48), secondary intervention (84% ± 8% vs 90% ± 9%; P = .63), and new-onset buttock claudication (90% ± 6% vs 100%; P = .35). ConclusionsEndovascular repair using IBE was associated with high technical success, no mortality, and low rate of complications using either the standard technique for de novo aneurysms or an up-and-over technique for patients with failed bifurcated endografts or grafts. The up-and-over technique should be considered a suitable alternative to brachial access in patients who require distal extension using IBEs.

Bifurcated-bifurcated aneurysm repair is a novel technique to repair infrarenal aortic aneurysms in the setting of iliac aneurysms

BackgroundUp to 40% of abdominal aortic aneurysms (AAAs) have coexistent iliac artery aneurysms (IAAs). In the past, successful endovascular repair required internal iliac artery (IIA) embolization, which can lead to pelvic or buttock ischemia. This study describes a technique that uses a readily available solution with a minimally altered off-the-shelf bifurcated graft in the IAA to maintain IIA perfusion. MethodsFrom August 2009 to May 2015, 14 patients with AAAs and coexisting IAAs underwent repair with a bifurcated-bifurcated approach. A 22-mm or 24-mm bifurcated main body device was used in the IAA with extension of the “contralateral” limb into the IIA. Intraoperative details including operative time, fluoroscopy time, and contrast agent use were recorded. Outcome measures assessed were operative technical success and a composite outcome measure of IIA patency, freedom from reintervention, and clinically significant endoleak at 1 year. ResultsFourteen patients underwent bifurcated-bifurcated repair during the study period. Technical success was achieved in 93% of patients, with successful treatment of the AAA and IAA and preservation of flow to at least one IIA. The procedure was performed with a completely percutaneous bilateral femoral approach in 92% of patients. Three patients had a type II endoleak on initial follow-up imaging, but none were clinically significant. There were no cases of bowel ischemia or erectile dysfunction. One patient had buttock claudication ipsilateral to IIA coil embolization (contralateral to bifurcated iliac repair and preserved IIA) that resolved by 6-month follow-up. Two patients required reinterventions. One patient presented to his first follow-up visit on postoperative day 25 with thrombosis of the right external iliac limb ipsilateral to the bifurcated iliac repair, which was successfully treated with thrombectomy and stenting of the limb. This same patient presented at 83 months with growth of the preserved IIA to 3.9 cm and underwent coil embolization of the aneurysm. Another patient presented for surveillance 44 months after his original repair with component separation of the mating stent and the iliac bifurcated stent grafts. This was treated with a limb extension and endoanchors to fuse the endografts. Of the 13 patients who underwent bifurcated-bifurcated repair, 100% of the preserved IIAs remained patent at last follow-up. The composite outcome measure of IIA patency and freedom from reintervention and clinically significant endoleak at 1 year was 92% (n = 12/13). ConclusionsIn this small retrospective review, bifurcated-bifurcated aneurysm repair of aortoiliac aneurysms with preservation of perfusion to the IIA is technically feasible and safe with good short-term and midterm results in male patients.

Iliac and femoro-popliteal arteries morphological CTA features as determinants of outcome after standard EVAR procedures.

To evaluate the impact of iliac artery's diameters, tortuosity, and peripheral vascular patency on outcome of elective endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) in 2 high volume vascular centers' experience. A retrospective study was conducted on a prospectively collected database between 2010 and 2012. Anatomical features at pre-operative computed tomography (CTA) considered as potentially influencing outcomes were: iliac diameters, tortuosity (expressed as a ratio), and calcifications, bilateral internal iliac artery (IIA) patency, and presence of Trans-Atlantic Inter-Societies Consensus (TASC) II C/D femoro-popliteal occlusive disease (PAD). Outcome measures were reintervention and mortality rates at follow-up. Two-hundred-eighty-nine patients' CTA preoperative images were reviewed with a mean of 1148±328 images per patient analyzed. Mean common iliac artery (CIA) diameters calculated in the narrowest point were 12.8±4 mm and 12.9±3.9 mm, and mean external iliac artery (EIA) diameters were 7.7±1.6 mm 7.8±1.7 mm, respectively on right and left side. Mean tortuosity ratios were 0.8±0.1 (0.40-0.91) and 0.8±0.1 (0.49-0.99), respectively on right and left side. PAD was present in 31 patients (10.7%). Technical success was achieved in all case, and bilateral IIA patency was preserved in 229 (79.2%) patients. No in hospital and 30-day mortality and complications were recorded. At a mean follow-up of 26 months, 30 reinterventions were required in 26 patients (8.9%), and 22 (7.6%) non AAA-related deaths were noted. Right EIA diameter ≤5 mm (P=0.0012, OR 5.2, 95% CI 1.73-15.57), and femoro-popliteal steno-obstructive disease (P=0.03, OR 3.06, 95% CI 1.02-9.20) were significantly related to reinterventions during follow-up. Iliac tortuosity ratio and calcification were not significant predictors of adverse events. This preliminary experience suggests that diameters of access vessels and the presence of femoro-popliteal steno-obstructive disease could affect the outcome of EVAR.

Patency of the contralateral internal iliac artery in aortouni-iliac endografting

This study determined the outcome of the contralateral internal iliac artery (IIA) in patients undergoing aortouni-iliac (AUI) endovascular abdominal aortic aneurysm repair (EVAR) with a femorofemoral bypass. This retrospective study evaluated 131 consecutive patients undergoing AUI EVAR with femorofemoral bypass at the McGill University Health Center from October 2001 to November 2010. One hundred patients with preoperatively patent contralateral IIA met inclusion criteria for the study. Preoperative demographics and preoperative and postoperative contrast-enhanced computed tomography (CT) scans with multiplanar reconstruction were reviewed for all patients. The last available postoperative CT imaging for all patients was identified and evaluated for contralateral IIA patency. Patency in preoperative and postoperative CT scans was defined as contrast enhancement of the IIA in continuity with the external iliac artery and absence of >50% stenosis at the origin of the IIA. Clinical outcome focused on postoperative pelvic ischemia and reported symptoms of buttock claudication. Mean age at the time of operation was 77.6± 6.7years, and 78% were male. Mean clinical follow-up was 29.2months after surgery, and mean follow-up of imaging with intravenous contrast was 30.6months. The last imaging follow-up showed 67 patients (67%) had a patent contralateral IIA and that the IIAs in 33 patients (33%) were occluded (25 [76%]) or stenotic (8 [24%]). Of the patients with IIA occlusion, 80% (20 of 25) were occluded on the first postoperative imaging (median, 8.5days). Buttock claudication was reported in 18% (6 of 33 patients) with an occluded IIA compared with only 3% (2 of 67 patients) of patients with a patent contralateral IIA on final imaging follow-up (18% vs 3%; P= .014). There were no observed cases of buttock necrosis, spinal ischemia, or colonic ischemia. Our findings suggest that AUI EVAR with femorofemoral bypass is associated with a significant incidence of contralateral IIA malperfusion on postoperative CT imaging. Occlusion appears to occur early in the postoperative period in most patients, and patient-reported buttock claudication is observed significantly more frequently in patients with an occluded IIA compared with those with a patent IIA. More serious pelvic ischemic complications were not seen in this series. Further study is required to determine whether modification of the procedure can prevent contralateral IIA occlusion and the development of buttock claudication.

Treatment of iliac artery bifurcation aneurysms with the second-generation straight iliac bifurcated device

There are few long term studies to show the safety and efficacy of iliac artery aneurysm exclusion, especially in regards to the straight iliac branched device. The objective of our study was to add our data with a mean follow-up of 32months to the existing data available. Patients undergoing iliac bifurcation procedure either as standalone or in combination with abdominal aortic aneurysm exclusion at two vascular centers had data prospectively gathered between 2004 and 2014. Collected data was analyzed for baseline characteristics, procedural events, and clinical follow-up; variables included endoleaks, reinterventions, and internal iliac artery (IIA) closure. A total of 45 iliac vessels in 41 patients (36 male) with a mean age of 70.4years were treated with the iliac branched device. Procedural success was achieved in 85% (35/41) of patients and 87% (39/45) vessels with no intraoperative death. Of the six technical failures, three occurred due to failure to place the straight iliac branched device or stent properly. Two occurred because of endoleaks at the end of the procedure, and one occurred because the IIA side-branch occluded and could not be reopened. The mean patient follow-up was 32.0± 27.3months (range, 0-109months). During this time period, the IIA patency rate on an intention-to-treat basis was 81%, and the freedom from endoleak rate on an intention-to-treat basis was 76% per patient. The freedom from reintervention per patient was 75%. No patient reported symptoms of pelvic ischemia and permanent buttock claudication. In this study with mean follow-up of 32months, treatment with iliac bifurcated devices is a safe and durable option in a carefully selected population of patients with iliac artery bifurcation aneurysms.

BS2. High Angulation and Short Neck Length Do Not Impact AAA Sac Expansion After Repair Using the Lombard Aorfix Device

Angulated (≥60°) infrarenal aortic necks and short neck lengths, are associated with sac expansion following EVAR. Aorfix (Lombard Medical), a conformable stent graft designed for highly angulated necks, was investigated in the U.S. Pythagoras Trial. We hypothesized that sac expansion may be independent of neck angle and length after AAA repair with Aorfix grafts. Trial data were assessed with mutivariable modeling for factors associated with sac regression/expansion (R/E), defined as change in maximum aneurysm diameter of ≥5 mm on annual follow-up computed tomography (CT) compared with the last preoperative scan). Sac expansion after Aorfix implantation was compared in “standard angle” (<60°) and “high angle” (≥60°) proximal necks. Neck length measurements were performed per protocol by a core laboratory, M2S. A total of 210 patients with implants were followed up ≥30 days; neck angle was ≥60° in 151 (71.9%), < 60° in 59 (28.1%). Mean neck length was 23.1 mm. Follow-up, including CT imaging, was available at 1 year (n = 165), 2 years (n = 142), 3 years (n = 106), and 4 years (n = 70). Sac size decreased or was unchanged in 98.8% (1 year), 95.1% (2 years), 94.3% (3 years), and 92.9% (4 years; Fig 1). Factors associated with sac regression at 4 years include less calcified plaque in the proximal aortic neck (odds ratio [OR] 3.84; P = .02) and iliac arteries (OR, 3.36; P = .04), and length of neck apposition (OR, 2.21; P = .04). Longer distance from lowest renal artery to proximal graft was associated with sac expansion at 4 years (OR, 1.89; P = .001). Sac R/E was not related to neck length, neck diameter, internal iliac artery patency, maximal aneurysm diameter, patient age or gender, and nine other demographic variables (P > .05 for all). Absence of endoleak was associated with sac regression at 1 and 2 years (OR, 5.98; P = .02; OR, 17.6; P < .001) but not at 3 and 4 years (P > .05). Neck angle was not associated with sac R/E (P > .45 all timepoints). In distinction from previous reports, increased neck angulation and neck length do not predict sac R/E with Aorfix grafts.

A Shaggy Aorta is Associated with Mesenteric Embolisation in Patients Undergoing Fenestrated Endografts to Treat Paravisceral Aortic Aneurysms

Bowel ischaemia is a life-threatening complication of endovascular aneurysm repair. This study aims to evaluate the factors associated with mesenteric ischaemia in patients undergoing fenestrated aortic endografts to treat paravisceral aneurysms. Consecutive patients undergoing double or triple fenestrated stent graft insertion were retrospectively analysed. No patients were declined surgery based on anatomic complexity. Preoperative demographics, procedure-related variables, and anatomical factors were examined. Using 3D software, the aortic thrombus volume from the coeliac axis to the lowest renal, aortoiliac tortuosity, and aortic irregularity index (as graded by 3 independent assessors, graded 0-3 based on severity) were compared. Univariate analysis was performed to identify risk factors for the development of bowel ischaemia. Ninety-nine patients underwent elective aneurysm repair (64 triple fenestrations and 35 double fenestrations), 5% of which developed bowel ischaemia, and of these 80% (4/5) died. Mesenteric ischaemia was significantly associated with increased aortic irregularity (median [range], 2 [1-3] vs 1 [0-2], P = .005, ischaemia vs no ischaemia) and increased thrombus volume (37 ± 8 vs 21 ± 12, P = .007) but not aortoiliac tortuosity (1.4 [1.2-1.5] vs 1.30 [1.2-1.7], P = .3), inferior mesenteric or internal iliac artery patency. Mesenteric ischaemia was also associated with a significantly higher preoperative creatinine (mean ± SD: 183 ± 74 vs 111 ± 43, P = .007). The presence of aortic irregularity and increased thrombus volume in the paravisceral segment predicts the occurrence of mesenteric and renal ischaemia in patients treated with fenestrated endografts. This is likely to be related to graft manipulation and catheterisation of visceral vessels.