One Year Outcomes of an International Multicentre Prospective Cohort Study on the Gore Excluder Iliac Branch Endoprosthesis for Aorto-Iliac Aneurysms

Five-year outcomes for bell bottom, iliac branch endoprosthesis, and coil and cover approaches from the GREAT registry

OBJECTIVE

There are a variety of methods used today to treat common iliac aneurysms with endovascular techniques. Of these approaches, little is known about whether a particular limb strategy influences endoleak, reintervention, or aneurysm regression rates. We present 5-year data comparing endoleak, stent graft migration, fracture, aneurysm sac dynamics, and aortic rupture rates among patients treated with bell bottom limbs (BB), iliac branch endoprosthesis (IBE), and coil and cover (CC) approaches from the Global Registry for Endovascular Aortic Treatment registry. Secondary end points were all-cause mortality, stroke, reintervention, and paraplegia.

METHODS

Subjects from the GORE Global Registry for Endovascular Aortic Treatment were enrolled over a 5-year period from October 2017 to August 2022. We included 924 subjects in this study. Statistical data was generated on R software and limb groups were compared using the Pearson's χ2 test and the Kruskal-Wallis rank-sum test.

RESULTS

We found no statistical difference in endoleak rates, stent graft migration, fracture, or aortic rupture when stratified by limb strategy. There was no difference between limb approaches with regard to aneurysm sac dynamics among those with abdominal aortic aneurysms and common iliac aneurysms. Similarly, no statistical difference between limb strategies was found in all-cause mortality, stroke, paraplegia, or reintervention rates. Among patients that required an additional graft during reintervention, the highest rates were found within the IBE group 8.6%, compared with BB group 2.2% and CC group 1.3% (P = .006).

CONCLUSIONS

Overall, there was no difference among limb strategies in endoleak rates, stent graft migration, aneurysm sac dynamics, aortic rupture rates, or our secondary end points. Increased rates of reintervention requiring an additional graft within the IBE group is noteworthy and must be weighed against the adverse effects of hypogastric sacrifice with the CC approach or potentially less advantageous seal zones in the BB approach. This finding suggests that all limb approaches have equivalent effectiveness in managing the aneurysmal common iliac artery; thus, the choice of limb strategy should be individualized and remain at physician discretion. Future research should include a more robust sample size to reproduce these findings.

Endovascular repair of bilateral isolated common iliac artery aneurysms with unsuitable anatomy utilizing an aortic bifurcated unibody endograft and modified sandwich technique to preserve pelvic blood flow: a case series

Bilateral isolated common iliac artery aneurysms (CIAAs) are rare, and endovascular repair of CIAAs has emerged as an alternative to traditional open surgical repair. The primary goal of therapy is to exclude the aneurysm sac while maintaining perfusion of at least one internal iliac artery (IIA) to prevent pelvic ischemia. Although the iliac branch device (IBD) has improved the feasibility of preserving the IIA, its applicability is limited to a specific subset of aneurysm anatomy. We present a case series of three patients with bilateral isolated CIAAs in whom preoperative CT scans revealed an absence of a landing zone, the diameter of proximal CIA diameter was less than 13.0 mm, and normal diameter of the nonaneurysmal infrarenal aorta, making it challenging to use an IBD alone or a standard bifurcated aortic endograft to provide a proximal landing zone for iliac artery stenting. To overcome the small diameter of the infrarenal aorta, we implanted an aortic bifurcated unibody endograft. Then, we utilized a balloon-expandable covered stent-graft with overdilation as a modified sandwich technique to create an "eye of the tiger" configuration to prevent gutter leakage. The final angiography performed during the procedure revealed successful exclusion of the aneurysms, with blood flow to the right IIA and no type III endoleak. During the postoperative follow-up period, no patients exhibited symptoms associated with pelvic ischemia. There were no endoleaks or sac expansions on the two-year follow-up CT scans, and all external and internal iliac graft limbs were patent. This study demonstrated that a combination of an aortic bifurcated unibody endograft and a modified sandwich technique can effectively treat bilateral isolated CIAAs with certain anatomical constraints.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry

PURPOSE

To evaluate the clinical utility of the Gore Excluder iliac branch endoprosthesis (IBE) for Japanese patients with aortoiliac aneurysms.

MATERIALS AND METHODS

This was a multicenter retrospective cohort study (J-Preserve Registry). Patients undergoing endovascular aortic repair using the Gore Excluder IBE for aortoiliac aneurysms between August 2017 and June 2020 were enrolled. Data pertaining to the baseline and anatomical characteristics, technical details, and clinical outcomes were collected from each institution. The primary endpoints were technical success, IBE-related complications, and reinterventions. Secondary endpoints were mortality, aneurysm size change, and reintervention during follow-up. Technical success was defined as accurate deployment of the IBE without type Ib, Ic, or III endoleaks on the IBE sides on completion angiography. A change in aneurysm size of 5 mm or more was taken to be a significant change.

RESULTS

We included 141 patients with 151 IBE implantations. Sixty-five IBE implantations (43.0%) had at least one instruction for use violation. Twenty-two patients (15.6%) required internal iliac artery (IIA) embolization for external iliac artery extension on the contralateral side. Of 151 IBE implantations, 19 exhibited IIA branch landing zones due to IIA aneurysms. Mean maximum and proximal common iliac artery (CIA) diameters were 32.9±9.9 mm and 20.5±6.9 mm, respectively. The mean CIA length was 59.1±17.1 mm. The IIA landing diameter and length were 9.0±2.3 mm and 33.8±14.6 mm. The overall technical success rate was 96.7%. There were no significant differences in IBE-related complications (2.3% vs 5.3%, p=0.86) or IBE-related reinterventions (1.5% vs 5.3%, p=0.33) between the IIA trunk and IIA branch landing groups. The mean follow-up period was 635±341 days. The all-cause mortality rate was 5.0%. There were no aneurysm-related deaths or ruptures during the follow-up. Most patients (95.7%) had sac stability or shrinkage.

CONCLUSION

The Gore Excluder IBE was safe and effective for Japanese patients in the midterm. Extending the IIA device into the distal branches of the IIA was acceptable, which may permit extending indications for endovascular aortic aneurysm repair of aortoiliac aneurysms to more complex lesions.

CLINICAL IMPACT

This study suggests clinical benefits of the Gore Excluder IBE for Japanese patients, despite 43% of the IBE implantations having at least one IFU violation.

Endovascular Aneurysm Repair Using Physician-Modified Fenestrated Endurant Contralateral Limb for Internal Iliac Artery Preservation

CLINICAL IMPACT

We developed a novel Endovascular aortic repair technique for internal iliac artery preservation using a physician modified Endurant contralateral limb. This procedure was safe and reliable for preserving internal iliac artery flow in 24 patients with common and internal iliac artery aneurysms. We believe that our technique has the potential to expand the anatomic indications for internal iliac artery preserving procedures.

Patent iliolumbar artery increase no risk of type II endoleaks after endovascular abdominal aortic aneurysm: a case-control study

Objective

The aims of the present study were to explore the risk factors for type 2 endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) and the association between T2ELs and the iliolumbar artery.

Materials and methods

A single-center, retrospective case-control study in West China Hospital was conducted among patients with infrarenal abdominal aortic aneurysm (AAA) who underwent EVAR between June 2010 and June 2019. The associations of patient characteristics, anatomical factors, internal iliac artery embolization, and ILA with the primary outcome were analyzed. The secondary objective was to analyze survival and reintervention between the T2EL group and the non-T2EL group. Kaplan-Meier survival, propensity matching analysis and multivariate logistic regression analysis were used.

Results

A total of 603 patients were included. The median follow-up was 51 months (range 5.0-106.0). There was a significant difference in the diameter of the lumbar artery (LA), middle sacral artery (MSA) and inferior mesentery artery (IMA), proportion of thrombus and LA numbers. The univariate analysis showed that T2ELs were more likely to develop more thrombus in aneurysm cavity (OR = 0.294, p = 0.012), larger MSA (OR = 1.284, p = 0.04), LA (OR = 1.520, p = 0.015), IMA (OR = 1.056, p < 0.001) and more LAs (OR = 1.390, p = 0.019). The multivariate analysis showed that the number of LAs (HR: 1.349, 95% CI: 1.140-1.595, p < .001) and the diameter of the IMA (HR: 1.328, 95% CI: 1.078-1.636, p = 0.008) were significantly associated with T2ELs. There were no new findings from the propensity score matching. The reintervention-free survival rates were significantly different between the two groups (p = 0.048). Overall survival and AAA-related death rates were not different between the two group. This was consistent with the PSM analysis.

Conclusion

The iliolumbar artery and the different internal iliac artery interventions may not increase the incidence of T2ELs. But the numbers of LAs and IMA diameter were independent risk factors for T2Els. T2ELs was associated with the reintervention but did not affect long-term survival or increase aneurysm-related mortality after EVAR.

Differences in Cardiac-Pulsatility-Induced Displacement and Geometry Changes between the Cook ZBIS and Gore IBE: Postoperative Comparison Using ECG-Gated CTA Scans

To what extent the stentgraft design of iliac branch devices (IBDs) relates to dynamic deformation is currently unknown. Therefore, this study aimed to quantify and compare displacement and geometry changes during the cardiac cycle of two common IBDs. This paper presents a two-center trial with patients treated with a Zenith bifurcated iliac side (ZBIS) or Gore iliac branch endoprosthesis (IBE). All patients underwent a retrospective electrocardiogram (ECG)-gated computed tomographic angiography (CTA) during follow-up. Cardiac-pulsatility-induced displacement was quantified for the following locations: (neo) bifurcation of the aorta, IBD flow divider, distal markers of the internal iliac artery (IIA) component and first IIA bifurcation. Geometrical parameters (length, tortuosity index, curvature and torsion) were quantified over centerlines. Displacement was more pronounced for the IBE than the ZBIS, e.g., craniocaudal displacement of 0.91 mm (0.91-1.13 mm) vs. 0.57 mm (0.40-0.75 mm, p = 0.004), respectively. The IBDs demonstrated similar geometrical parameters in the neo-common iliac artery and distal IIA, except for the larger dynamic curvature and torsion of the distal IIA in IBEs. The IBEs showed more dynamic length and curvature change compared to the ZBIS in the stented IIA. The IIA trajectory showed more pronounced deformation during the cardiac cycle after placement of an IBE than a ZBIS, suggesting the IBE is more conformable than the ZBIS.

Five-year outcomes from a prospective, multicenter study of endovascular repair of iliac artery aneurysms using an iliac branch device

OBJECTIVE

We have reported the 5-year results of a pivotal prospective, multicenter study conducted in the United States of a specifically designed iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) for endovascular repair of aortoiliac aneurysms and common iliac artery aneurysms.

METHODS

A total of 63 patients (98.4% male; mean age, 70 years) with aortoiliac or common iliac artery aneurysms had undergone implantation of a single IBE device and a bifurcated aortoiliac stent graft. Patients with bilateral common iliac artery aneurysms (n = 22; 34.9%) had undergone either staged occlusion or surgical revascularization of the contralateral internal iliac artery before study enrollment. At 5 years, 36 of the 63 patients had completed the final study follow-up examinations, including clinical examinations (n = 35) and computed tomography (n = 32), with the results evaluated by an independent core laboratory and adverse events adjudicated by a clinical events committee.

RESULTS

At 5 years, freedom from all-cause mortality was 85.7% and freedom from aneurysm-related mortality was 100%. The nine deaths that had occurred (range, 132-1898 days) were adjudicated as unrelated to the aneurysm or procedure. Primary patency of the internal and external iliac artery IBE limbs was 95.1% and 100%, respectively. No patients had experienced new-onset buttock claudication on the IBE side or self-reported new-onset erectile dysfunction. The common iliac artery diameter on the IBE side was either unchanged or had decreased by ≥5 mm in 30 of the 31 patients (96.8%) with a baseline (1 month) and 5-year (range, 1641-2006 days) computed tomography scan available. Of the 31 evaluable patients, 9 (29.0%) had had an increase of ≥5 mm in the aortic diameter, 5 of whom had had a concurrent type II endoleak. No type I or type III endoleaks or device migration were identified by the core laboratory. Six patients had undergone eight secondary interventions, including five interventions for a type II endoleak. The freedom from secondary intervention was 90.5%.

CONCLUSIONS

The 5-year results of our prospective, multicenter study have confirmed the safety, efficacy, and durability of the IBE device for the treatment of aortoiliac and iliac artery aneurysms. The device effectively prevented common iliac artery aneurysm rupture, maintained the patency of the internal iliac artery, and avoided the complications associated with internal iliac artery sacrifice. Although common iliac artery aneurysm enlargement was rare, abdominal aortic enlargement was more common, suggesting that the outcomes of endovascular aneurysm repair might be different for patients with or without associated common iliac artery aneurysms.

The Impact of Iliac Artery Anatomy on Distal Landing Zone After EVAR During the 12-Month Follow-Up

BACKGROUND

Proximal sealing zone has been the main interest in endovascular abdominal aortic aneurysm repair (EVAR), although the distal landing zone remodeling may also affect EVAR durability. The aim of this study was to assess iliac anatomy and its potential impact on distal landing zone adverse events after EVAR during the 12-month follow-up.

METHODS

A prospective data collection of patients treated with standard bifurcated EVAR devices for abdominal aortic aneurysm was undertaken between 2017 and 2019. Patients that received extension to the external iliac artery were excluded. Follow-up included computed tomography angiography (CTA) at the 1st and 12th month postoperatively. The common iliac artery (CIA) diameter was assessed in three levels: origin (just below the aortic bifurcation), distally (just above the iliac bifurcation) and the middle of the distance between these two landmarks. Iliac angle, tortuosity indexes, relining and oversizing were also analyzed. Distal landing zone-related adverse events were any limb related re-intervention, endoleak type Ib, graft migration, limb stenosis, or occlusion.

RESULTS

In total, 268 iliac limbs (134 patients) were included. In all three levels, the mean iliac artery diameters increased at 12-month follow-up. At the origin of the CIA, the diameter increased from 18.7 ± 10.5 mm to 19.9 ± 9.4 mm (P = 0.04), at the middle portion of the CIA, the diameter changed significantly from 15.5 ± 5.1 mm to 17.4 ± 5.4 mm (P < 0.001) and at the distal CIA, from 14.6 ± 3.3 mm to 15.1 ± 3.9 mm (P = 0.03). The iliac angle remained stable (P = 0.14) while the CIA index decreased significantly from 1.17 ± 0.13 to 1.11 ± 0.09 (P < 0.001). The mean value of oversizing was 21.5 ± 14.5% and affected distal iliac diameter increase (P < 0.001). The composite outcome of distal landing zone adverse events was not associated to diameter changes at any level. In 57 cases, a distal iliac diameter ≥18 mm was recorded. The estimated oversizing was lower (16.3 ± 11.8%) compared to <18 mm arteries (22.5 ± 14.9%, P = 0.01). At 12-month follow-up, iliac diameters remained stable in the ≥18 mm group. Endoleak type Ib was more common in iliac arteries ≥18 mm [3 (5.3%) vs. 1 (0.5%) (P = 0.04)] at 12-months.

CONCLUSIONS

Post-EVAR iliac artery dilation does not seem to have an impact on distal landing zone adverse events during the 12-month follow-up. Aggressive oversizing may be related to iliac dilation. EVAR patients with iliac arteries ≥18 mm are at higher risk for ET Ib.

Contemporary Management of Abdominal Aortic Aneurysms

PURPOSE OF REVIEW

Abdominal aortic aneurysms (AAA) can carry extremely high mortality rates and most will only present with symptoms with impending rupture. We present an overview of management of this disease process starting with screening, to medical management, surveillance and treatment options currently available, as well as those being studied for future use.

RECENT FINDINGS

Screening has been proven to reduce the mortality rate. There still remains a paucity of data to support medical therapies to help mitigate the rate of aneurysm growth and prevent rupture. However, on the topic of repair, there have been advancements in endovascular devices which have broadened the scope of treatment for patients with anatomy not amenable to standard endovascular repair or those who are not suitable candidates for open surgical repair. Appropriate surveillance, risk factor modification, and operative repair, when indicated, are the cornerstones of contemporary management of AAAs. Advancements in endovascular technologies have allowed us to treat more patients. Further research is warranted on non-operative medical therapies.

Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms

INTRODUCTION

Isolated iliac artery aneurysms (IAA), accounting for 2-7 percent of all abdominal aneurysms, are nowadays often treated with the use of iliac branched endografts. Although outside of the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an EVAR device, for the treatment of isolated IAA. In this study we aim to describe the outcomes of the use of the Gore IBE device, without support of an infrarenal EVAR device, for the exclusion of isolated IAA.

DESIGN

This study is an international multicenter retrospective cohort analysis.

METHOD

All patients that were treated with a solitary IBE for IAA exclusion from 11-01-2013 up to 31-12-2018 were retrospectively reviewed. The primary outcome was technical success. Secondary outcomes included mortality, intraoperative and postoperative complications, and re-interventions.

RESULTS

In total 18 European and American centers participated, including 51 patients in which 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. There was no 30-day mortality and a 98.1% patency of both the internal and external iliac artery was found at 24-months follow-up. At 24-months follow-up, 81.5% of patients were free of complications and 90% were free of a secondary intervention.

CONCLUSION

Treatment with a solitary IBE is a safe and, at midterm, effective treatment strategy in selected patients with a solitary IAA.