Repair Of Iliac Artery Aneurysms Research Articles

Editor's Choice – Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameterexceeds3.5cm, as opposed to 3.0cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Long Term Outcomes of Iliac Artery Aneurysm (IAA) and Abdominal Aortic Aneurysm (AAA) Repair with Endovascular Procedures at the Parkview Heart Institute

Background: Favorable characteristics of the minimally invasive endovascular aneurysm repair (EVAR), such as a reduced recovery time, have led physicians and patients alike to elect for this procedure over open repair. Longitudinal study on endovascular repair has raised concerns regarding an increased rate of late failure leading to rupture and overall higher rates of re-intervention for patients.
 Objective: This project compares the outcomes of endovascular stent graft repairs of AAA and IAA at Parkview Heart Institute over a certain time span.
 Methods & Design: This study is a retrospective review of patients (N=89) with AAA/IAA repair since 2014. The EPIC online medical record is the main tool in data extraction while statistical analysis was conducted via Microsoft Excel (p = 0.05).
 Results: Males, ages 51-75 y.o., White population, non-Hispanics, and BMI rating of 1-30 were observed to have more AAAs. A significant decrease in length of stay over historical averages was observed with at most 1-3 days and minimal complications. Most causes for re-interventions were due to endo-leaks. More than 60% of patients with AAA and EVAR have a significant past medical history of smoking, hypertension, and chronic obstructive pulmonary disease. Finally, most pre- and post-operative aneurysms sizes are within 41-60 mm in diameter.
 Conclusion and Potential Impact: This study analyzed 89 patients that experienced AAA instead of IAA. Certain populations, such as being male, ages 51-75 y.o., White population, non-Hispanics, and BMI rating of 1-30 with past medical history characteristics are frequent in patients with EVAR. The procedure has minimal complications in comparison to open abdominal surgery, and this study will add to the literature by aiding physicians’ determination of the best course of action for treating patients with AAA/IAA.

Comparison of Perioperative Outcomes of Patients with Iliac Aneurysms Treated by Open Surgery or Endovascular Repair with Iliac Branch Endoprosthesis

Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE. The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions. Sixty-seven patients (96% male) were treated with OS (n=25, mean age 68±8years) or IBE (n=42, mean age 73±8years; P=0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P=0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5±3.4 vs. 1.7±1.4days for IBE, P<0.0001 and ICU LOS 3.3±2.1 vs. 0.1±0.4days, P<0.0001). Estimated blood loss was higher for patients undergoing OS (4,732±2,540mL) compared to patients treated with IBE (263±451mL, P<0.0001), resulting in higher RBC transfusion requirements (1.5±2.4 vs. 0.2±0.8 units, P=0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P=0.09). Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.

Upside-down techniqueを用いたGore Excluder contralateral legによるステントグラフト内挿術を施行した総腸骨動脈瘤の1例

Upside-down techniqueを用いたGore Excluder contralateral legによるステントグラフト内挿術を施行した総腸骨動脈瘤の1例

Midterm Results After Abandoning Routine Preemptive Coil Embolization of the Internal Iliac Artery During Endovascular Aneurysm Repair

Purpose: To analyze the results of endovascular repair of common iliac artery (CIA) aneurysms without preemptive coil embolization of the internal iliac artery (IIA). Materials and Methods: Between January 2010 and July 2016, 79 patients (mean age 74.3±8.4 years; 76 men) underwent endovascular repair extending into the external iliac artery owing to a CIA aneurysm. The procedure was performed for a ruptured aneurysm in 22 (28%) patients. Eighty-one IIAs were intentionally covered. The median CIA diameter was 37 mm (range 20–90). The primary outcomes were the occurrence of type II endoleaks and the incidence of buttock claudication. Results: Five (6%) patients died within 30 days (4 with ruptured aneurysms and 1 elective case). Two type II endoleaks originating from a covered IIA were recorded; one required an endovascular intervention because of aneurysm growth. The other patient died of a rupture based on an additional type III endoleak. Mean follow-up was 37.6±26.3 months. Nineteen (26%) patients required a secondary intervention. Buttock claudication was reported in 21 (28%) of 74 patients and persisted after 1 year in 7. No severe ischemic complications as a result of IIA coverage were recorded, and no revascularization was required during follow-up. Conclusion: Treatment of CIA aneurysms by overstenting the IIA without preemptive coil embolization is safe and has a low risk of type II endoleak and aneurysm growth. Persisting buttock claudication is rare.

Customized endovascular repair of common iliac artery aneurysms

Open technique for elective repair of iliac artery aneurysms can be safely performed with good outcomes but not inconsequential morbidity. An endovascular approach has been shown to have both periprocedural and postoperative advantages with equivalent outcomes. Endovascular repair of common iliac arteries (CIAs) without sacrificing the hypogastric artery using an iliac branch device is a complex endovascular technique requiring a proximal seal zone that may be absent in larger CIA aneurysms. We present two cases in which CIA aneurysms were repaired with a customized endovascular technique using the benefit of the aortic bifurcation for stability in addition to providing a long proximal seal zone with the AFX device (Endologix, Irvine, Calif) paired with the iliac branch device (W. L. Gore & Associates, Flagstaff, Ariz) for internal iliac artery preservation.

Isolated iliac artery aneurysms : Interventional treatment

Isolated iliac artery aneurysms occur considerably less often than abdominal aortic aneurysms. Mainly older men are affected by this disease. Most of these aneurysms are asymptomatic and are incidentally detected during cross-sectional imaging. Iliac aneurysms with adiameter larger than 3 cm are at risk for rupture, which is associated with high morbidity and mortality. To prevent their rupture as well as for symptomatic or ruptured aneurysms, endovascular treatment has recently been established as the primary approach due to the decreased morbidity and mortality compared to open repair. Endovascular aneurysm exclusion is performed with stent grafts, and depending on the anatomy, by adjunctive internal iliac artery embolization. Up to aquarter of treated patients will require additional endovascular revisions during the long term. Reliable imaging follow-up likely increases the safety of elective or emergent endovascular iliac artery aneurysm repair.

Internal Iliac Artery Aneurysm Repair with Iliac Branch Endoprothesis

Internal Iliac Artery Aneurysm Repair with Iliac Branch Endoprothesis

A Rare Complication of Iliac Artery Aneurysm Repair in Patient with Behçet’s Disease: Psoas Muscle Abscess

A Rare Complication of Iliac Artery Aneurysm Repair in Patient with Behçet’s Disease: Psoas Muscle Abscess

Prospective, multicenter study of endovascular repair of aortoiliac and iliac aneurysms using the Gore Iliac Branch Endoprosthesis

ObjectiveThe GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, Ariz) is an iliac branch stent graft system designed to preserve internal iliac artery perfusion during endovascular repair of aortoiliac aneurysms (AIAs) and common iliac artery (CIA) aneurysms (CIAAs). We report the 6-month primary end point results of the IBE 12-04 United States pivotal trial for endovascular treatment of AIAs and CIAAs using the IBE device. MethodsThe trial prospectively enrolled 63 patients with AIA or CIAA who underwent implantation of the IBE device at 28 centers in the United States from 2013 to 2015. All patients underwent placement of a single IBE device. Twenty-two patients (34.9%) with bilateral CIAs were enrolled after undergoing staged coil or plug embolization (21 of 22) or surgical revascularization (1 of 22) of the contralateral internal iliac artery. Follow-up at 30 days and 6 months included clinical assessment and computed tomography angiography evaluation as assessed by an independent core laboratory. The primary effectiveness end point was freedom from IBE limb occlusion and reintervention for type I or III endoleak and ≥60% stenosis at 6 months, and the secondary effectiveness end point was freedom from new onset of buttock claudication on the IBE side at 6 months. ResultsMean CIA diameter on the IBE side was 41.0 ± 11.4 mm (range, 25.2-76.3 mm). There were no procedural deaths, and technical success, defined as successful deployment and patency of all IBE components and freedom from type I or III endoleak, was 95.2% (60 of 63). Data for 61 patients were available for primary and secondary effectiveness end point analysis. Internal iliac limb patency was 95.1% (58 of 61), and no new type I or III endoleaks or device migrations were observed at 6 months. The three patients with loss of internal iliac limb patency were asymptomatic, and freedom from new-onset buttock claudication on the IBE side was 100% at 6 months. New-onset buttock claudication occurred on the non-IBE treatment side in six of 21 patients (28.6%) who underwent staged internal iliac artery coil embolization. ConclusionsThese results confirm that the IBE device is effective at treating CIAAs and AIAs, maintaining blood flow into the internal iliac artery, and avoiding complications associated with internal iliac artery sacrifice. Follow-up will be continued for 5 years to establish the long-term durability of iliac aneurysm repair with the IBE device.

VH09 Total Robotic Repair of Bilateral Common Iliac Artery Aneurysms With Sutureless Anastomosis Technique for Internal Iliac Artery Preservation

VH09 Total Robotic Repair of Bilateral Common Iliac Artery Aneurysms With Sutureless Anastomosis Technique for Internal Iliac Artery Preservation

Health-related quality of life prospectively evaluated by the 8-item short form after endovascular repair versus open surgery for abdominal aortic aneurysms.

Open repair for infra-renal abdominal aortic and iliac artery aneurysms (AAAs) is a robust treatment. On the other hand, endovascular aneurysm repair (EVAR) has been widespread because of its less invasiveness. However, patients after EVAR frequently require postoperative radiographic examinations and may feel anxiety for their endoleaks. We prospectively evaluated Health-related Quality of Life of the patients with these two fashions using the 8-item Short Form (SF-8). From 2011 to 2013, 89 consecutive elective cases of AAAs were treated. They were prospectively divided into EVAR and open repair groups but not randomly. The exclusion criteria were as follows: perioperative status for other surgeries, infectious aneurysm, severely deteriorated conditions, and patients who cannot answer for these questionnaire or show their consent. The SF-8 questionnaire was completed through interviews preoperatively, and at 1, 3, 6, and 12 months after treatment. The SF-8 questionnaire was completed for 55 cases [EVAR group (ER): 25, open repair group (OR): 30]. There was no significant difference between these groups regarding patients' characteristics except congestive heart disease. The preoperative scores of the SF-8 were similar in both groups except physical function and social function, which were lower in ER (p < 0.05). There was no operative death in both groups. Operative duration and hospital stay in EVAR were significantly shorter than those in OR (p < 0.05). Follow-up rate at 1, 3, 6, and 12 months was 100, 100, 68.0, and 64.0% in ER, and 100, 90.0, 80.0, and 66.6% in OR, respectively. During follow-up, both groups had no AAAs associated death. Regarding changes of the SF-8 scales, there were some trends at physical component summary score (PCS) and mental component summary score (MCS) in ER. The PCS decreased at 1month, gradually increased at 3months, and levelled off until 12months. The MCS increased at 1 and 3months, but gradually went down and almost stayed at the same level as preoperative one at 12months. In OR, PCS and MCS decreased at 1 month and after that increased gradually at 3 and 6months, and stayed the same at 12months. The MCS recovered to preoperative score earlier than the PCS. In this study, EVAR did not show any significant mental disturbance based on the SF-8 for 1-year comparing to open repair.

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass

Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass. Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded. The cohort of 10 patients was all men with a mean age of 71years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8days (range: 1-9days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8months (range: 0.5-36months). All bypasses remained patent. Although branched graft technology continues to evolve, strategies to maintainadequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.

Results of Repair of Iliac Artery Aneurysms with the Sandwich Technique

Patients undergoing endovascular repair (EVAR) of aortoiliac or iliac artery aneurysm may require sacrifice of one or both internal iliac arteries (IIAs). Until Food and Drug Administration–approved commercial grafts became available, endovascular IIA preservation was accomplished using the “sandwich” technique, but limited information is available regarding the results of this method. After obtaining institutional review board approval, we identified patients undergoing IIA preservation with the sandwich technique during EVAR at our institution. The patients have been followed prospectively since being identified to record patency rates and vascular symptoms or events. Twenty-four procedures were performed from 2011 through 2015 to treat iliac artery aneurysms. Fourteen of these procedures were done with concomitant EVAR using different endografts (Gore Excluder 11, Endologix AFX 2, Cook Zenith 1). Five were done to extend a previous EVAR that had developed a type Ib endoleak, 2 for an isolated external iliac artery aneurysm, 3 for an anastomotic aneurysm from a previous aortobiiliac graft, and 2 for isolated iliac aneurysm repair. There were 25 sandwich grafts (unilateral in 19, bilateral in 6). Contralateral embolization was performed in 5 cases. Immediate success rates were high, and patency rates were excellent at intermediate follow-up. Intraoperative type 3 endoleaks were not uncommon but usually resolved postoperatively. Endovascular IIA preservation is feasible with currently available devices using this technique. This procedure is recommended for preservation of the IIA during endovascular treatment of aortoiliac and iliac artery aneurysms when anatomy requires IIA preservation.

心不全症状を合併した総腸骨動脈瘤・総腸骨動静脈瘻に対してステントグラフト内挿術を施行した1例

心不全症状を合併した総腸骨動脈瘤・総腸骨動静脈瘻に対してステントグラフト内挿術を施行した1例

Iliac Artery Aneurysms

The terminal abdominal aorta divides into the common iliac arteries at the L4 level. At the level of the sacrum, the common iliac arteries divide into the external iliac arteries and internal iliac (hypogastric) arteries. This review covers aneurysms of the iliac arteries, with discussion of the anatomy, clinical evaluation, investigative studies, management, and follow-up imaging. Figures show common presenting configurations of iliac artery aneurysms, examples of open repair techniques for common iliac artery aneurysms, example of internal iliac artery revascularization in the setting of common iliac artery aneurysm repair, examples of endovascular repair techniques for common iliac artery aneurysms, complex hybrid repair of multiple iliac aneurysms, examples of open repair techniques for internal iliac artery aneurysms, and examples of endovascular repair for internal iliac artery aneurysms. Tables list normal diameters reported by the Subcommittee on Reporting Standards for Arterial Aneurysms, rate of growth of aneurysms based on size at presentation, presenting signs and symptoms of iliac artery aneurysm, and location, rupture, and mortality reported in the literature. This review contains 7 highly rendered figures, 4 tables, and 91 references Keywords: Iliac artery aneurysms; IAA; Common iliac artery aneurysms; Internal iliac artery aneurysm; IIAA; External iliac artery aneurysm

Open Surgical Repair for Inflammatory Abdominal Aortic and Iliac Artery Aneurysms

This study was performed to investigate the outcomes of surgical treatment for inflammatory abdominal aortic aneurysms (IAAAs) and inflammatory iliac artery aneurysms (IIAAs). We retrospectively reviewed the charts of patients who underwent open surgical repair (OSR) between January 2000 and June2013. Nine male and 2 female patients (median age, 67years) were treated. Five of the 11 patients who underwent OSR developed hydronephrosis, and ureteral stents were placed preoperatively. There were no intraoperative complications during OSR. After OSR, the conditions of 4 of 5 patients with preoperative hydronephrosis improved. During the follow-up period with a mean of 51months (range, 6-120months), 2 patients with OSR developed aneurysmal changes at the anastomosis site (84 and 21 postoperative months, respectively), and reintervention for both patients was needed. One patient died because of malignant disease at 96months postoperatively. OSR can be safely performed for IAAAs and IIAAs. When an inflammatory aneurysm, especially an IIAA, is complicated by hydronephrosis, OSR might be an effective treatment procedure.

PC022. Results of Endovascular Repair of Iliac Artery Aneurysms in the GREAT Registry

PC022. Results of Endovascular Repair of Iliac Artery Aneurysms in the GREAT Registry

IP003. Midterm Results of Internal Iliac Artery Preservation Using the Sandwich Technique During Endovascular Aneurysm Repair

Patients undergoing endovascular repair (EVAR) of aortoiliac or iliac artery aneurysm may require sacrifice of one or both internal iliac arteries. Until FDA approved commercial grafts are available, internal iliac artery (IIA) preservation has been accomplished using the “sandwich” technique (ST) or surgeon modified grafts, but limited information is available regarding their results. After obtaining IRB approval, we identified patients undergoing IIA preservation with the ST during EVAR at our institution. The patients have been followed up prospectively since being identified to record patency rates and vascular symptoms or events. Twenty-four procedures (22 men, 2 women) were performed from 2011 to 2015 to treat iliac artery aneurysms. The mean age was 74 years. Fourteen of these were done with concomitant EVAR using different endografts (Gore, 11; Endologix, 2; Cook, 1). Five were done to extend a previous EVAR that had developed a type Ib endoleak, 2 for an isolated external iliac artery aneurysm, 3 for an anastomotic aneurysm from a previous aortobiiliac graft, and 2 were for isolated iliac aneurysm repair. There were 25 sandwich grafts (unilateral in 19, bilateral in 6). Contralateral embolization was performed in 5 cases. Percutaneous femoral access was possible in 19, contralateral embolization was necessary in 5, and brachial delivery was needed in 18. Immediate technical success was 100%, average values for operative time was 210 minutes, estimated blood loss was 381 mL, fluoroscopy time was 45 minutes, contrast volume was 145 mL, and length of stay was 2.2 days. Mean follow-up time was 19 months (1-47). There were nine type III endoleaks observed on completion angiography, eight resolved on follow-up CTA, and one required endoprosthetic extension. Six patients have stable type II endoleaks. Two patients were lost to follow-up but of the remaining, 96% of the external iliac limbs were patent and 96% of internal iliac limbs were patent. No patient had buttock claudication or bowel ischemia. Endovascular IIA preservation is feasible with currently available devices using this technique. Immediate success rates are high and patency rates are excellent at intermediate followup. Intraoperative type III endoleaks are not uncommon but usually resolve postoperatively. This procedure is recommended for preservation of the IIA during endovascular treatment of aortoiliac and iliac artery aneurysms when anatomy requires internal iliac artery salvage.

両側水腎症を合併した炎症性腹部大動脈瘤・両側総腸骨動脈瘤に対し腹部ステントグラフト内挿術を行った1 例

両側水腎症を合併した炎症性腹部大動脈瘤・両側総腸骨動脈瘤に対し腹部ステントグラフト内挿術を行った1 例