Aneurysmal iliac arteries do not portend future iliac aneurysmal enlargement after endovascular aneurysm repair for abdominal aortic aneurysm

External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm

OBJECTIVE

Aneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE).

METHODS

Using the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb <20 mm; group 2, BBT with either a unilateral or bilateral limb >20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak.

RESULTS

The records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was -7.2 mm, -6.1 mm, -4.6 mm, and -6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group.

CONCLUSIONS

The present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

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.

Impact of Compliance with Anatomical Guidelines of "Bell-Bottom" Iliac Stent Grafts for Ectatic or Aneurysmal Iliac Arteries

OBJECTIVE

To evaluate the impact of compliance with anatomical guidelines on outcomes of endovascular aortic aneurysm repair using "bell-bottom" stent grafts (BBSGs).

METHODS

This is a retrospective review from January 1999 to May 2012 of patients who underwent endovascular infrarenal abdominal aneurysm repair and whose iliac limbs were greater than 18 mm in diameter. Computed tomography angiography was utilized for compliance with anatomical guidelines as stated in manufacturer's instructions for use (IFU). The primary outcome observed was iliac limb events. The secondary outcome observed was the need for re-intervention due to BBSG failure.

RESULTS

Of the 376 BBSGs, 55 (15%) in 27 patients met IFU. Aneurysm exclusion was achieved in all patients. The mean follow-up was 44 ± 30 months. Twenty-eight patients (11%) had 29 iliac limb events (12 type 1b endoleaks, 4 aneurysm sac growth, 4 stenosis/kink, 4 retrograde migrations, 2 component separations, 2 ruptures and 1 limb occlusion); all among patients treated outside of IFU (p < 0.04). The rate of aneurysm sac enlargement was similar between both groups, at 56%, respectively, between those treated within and those treated outside of IFU. On multivariate regression analysis, larger common iliac artery (CIA) (HR 1.088, 95% CI 1.016-1.166, p = 0.016), greater CIA tortuosity (HR 2.352, 95% CI 1.004-5.509, p = 0.048) and limbs with more than two characteristics that did not meet IFU criteria (HR 3.84, 95% CI 1.15-12.83, p = 0.03) were associated with higher rates of BBSG events and re-interventions.

CONCLUSIONS

BBSGs effectively seal ectatic CIAs. But rates of iliac limb events and re-interventions are higher among patients who do not meet IFU criteria. The larger CIA diameter, the greater CIA tortuosity and more than two criteria not met by IFU were associated with BBSG failure and re-intervention.

Outcomes of bell-bottom technique compared to standard endovascular aneurysm repair

OBJECTIVE

The bell-bottom technique is a widely used technique to treat aortoiliac aneurysms with preservation of the hypogastric arteries. The published data are scarce with conflicting results regarding the evolution. The aim of this study was to compare the outcomes of patients submitted to endovascular abdominal aortic aneurysm repair with standard technique (S-EVAR) versus bell-bottom technique.

METHODS

This retrospective cohort study compared the outcomes of standard endovascular aneurysm repair (<16 mm iliac limbs) and bell-bottom technique (≥16 mm iliac limbs) in a tertiary vascular center between 2010 and 2015. The end points of this study were type IB endoleak, reintervention and 30-day mortality. The follow-up protocol included CT scans within 30 days of implantation and 12 months. Duplex ultrasound was performed yearly thereafter.

RESULTS

Two hundred and three patients were treated with bell-bottom technique (n = 84, mean age 72.2 ± 8.9) and S-EVAR (n = 119, mean age 72.7 ± 8.4). The overall 30-day mortality was 1.9%, with no significant difference between groups. There was higher prevalence of coronary heart disease in the bell-bottom technique group compared to the S-EVAR group (41.6% vs. 18.4%, p < 0.01). One patient in the S-EVAR group (0.85%) and four patients in the bell-bottom technique (4.6%) developed type IB endoleak. The mean follow-up period was 35.2 ± 30.4 months. By Kaplan-Meier analysis, freedom from type IB endoleak in 80 months was 85.2% in the bell-bottom technique group and 98.7% in the S-EVAR group (p = 0.05). The freedom from reintervention in 80 months was 74.0% in the bell-bottom technique group and 94.1% in the S-EVAR group (p = 0.6).

CONCLUSIONS

This study shows lower freedom from type IB endoleak in the bell-bottom group compared to the standard repair group. There is no significant difference in reoperation rate and 30-day mortality.

Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone

BACKGROUND

Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure.

METHODS

We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA.

RESULTS

Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P = 0.02).

CONCLUSIONS

Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.

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

BACKGROUND

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.

METHODS

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 180 days postoperatively. The primary end point was the IIA patency rate of the IBSG device at 180 days postoperatively. Secondary end points comprised the postoperative technical success rate and clinical success rate at 30 and 180 days. Descriptive statistics and the Clopper-Pearson exact method were used to analyze the data.

RESULTS

Seventy-three patients (mean age, 69.6 years; 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 180 days 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.

CONCLUSIONS

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 5 years to confirm the durability of the device.

Anatomical Predictors of Flared Limb Complications in Endovascular Aneurysm Repair

Purpose: To evaluate possible predictors of complications with flared iliac stent-graft limbs for ectatic common iliac arteries (CIAs) associated with abdominal aortic aneurysms treated with endovascular aneurysm repair (EVAR). Materials and Methods: A retrospective comparative analysis was conducted of 533 EVAR patients (mean age 75 years; 442 men) treated between 2012 and 2017 who had complications associated with the stent-graft limbs (n=1066). Complications, including type Ib endoleak, type IIIa endoleak, and limb occlusion, were compared between patients with nondilated (<16 mm) CIAs treated with standard iliac limbs (SLs, n=808) vs patients with ectatic CIAs treated with flared limbs (FLs, n=258). Follow-up included a duplex scan at 3, 6, and 12 months and yearly thereafter; computed tomography angiography was performed in case of iliac complications. Risk factors for iliac complications in FLs were investigated using Cox regression and Kaplan-Meier analyses; results of the regression analysis are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: Overall, no iliac complications occurred at 30 days, but over a mean follow-up of 38±8 months, there were 10 (1%) events (4 limb occlusions, 6 type Ib endoleaks): 7 (3%) in FLs and 3 (0.4%) in SLs (p=0.20). Kaplan-Meier analysis found no differences at 5 years in SLs vs FLs for freedom from limb occlusion (99%±1% vs 98%±1%, respectively; p=0.30) or type Ib endoleak (96%±3% vs 97%±1%, respectively; p=0.44). Similarly, the overall 5-year iliac complication rates were similar in SLs vs FLs (96%±3% vs 95%±2%, p=0.21). Regression analysis found CIA length ≤30 mm (HR 4.7, 95% CI 1.02 to 21.6, p=0.04) and a diameter ≥20 mm (HR 7.8, 95% CI 1.05 to 64.8, p=0.03) to be independent predictors of iliac complications in FLs. Kaplan-Meier estimates of iliac complication–free survival in FLs were significantly worse when the CIA length was ≤30 mm (79%±9% vs 98%±1%, p=0.003) or the diameter was ≥20 mm (85%±7% vs 99%±1%, p=0.02). The combination of both risk factors produced significantly poorer iliac complication–free survival compared with cases in which there was one or no risk factor (67%±19% vs 96%±2% vs 99%±1%, respectively; p<0.001). Conclusion: Iliac limb complications are infrequent in EVAR, regardless of the type of iliac limb chosen; however, CIAs ≤30 mm in length or ≥20 mm in diameter significantly increased the risk of late iliac complications in FLs. If both characteristics were present, this risk was further elevated.

Endovascular Treatment of Aorta-Iliac Aneurysms with a Flared Iliac Limb

Endovascular abdominal aneurysm repair (EVAR) relies on the quality of the proximal and distal landing zone. Reinterventions are higher in patients with suboptimal landing zone. The study aimed to evaluate reintervention rate after endovascular treatment of an aorta-iliac aneurysm using the flared iliac limbs. The retrospective study included 179 patients treated with EVAR at a single university hospital institution from January 2011 to January 2014 of which 75 patients (42%) were treated with flared iliac limb stent graft and 104 patients (58%) were treated with a nonflared iliac limb stent graft. There were 165 male patients (92%), mean age was 75.8 ± 6.6 years. Thirty-six patients underwent secondary treatment accounting for overall reintervention rate of 20%. Endoleak type 1b occurred in 13 patients (7%), followed by endoleak type 1a in six patients (3%). Endoleak type 2 occurred in seven patients (4%) requiring the treatment due to abdominal aortic aneurysm (AAA) enlargement, endoleak type 3 in three patients (2%), and leg stent graft thrombosis in seven patients (4%). In 143 patients (80%), there were no secondary interventions during the follow-up period. Reintervention due to endoleak type 1b was statistically significantly higher in a flared iliac limb group ( p  < 0.02) with the rate of 7.2% compared with 1.9% rate in nonflared iliac limb group. The mean follow-up was 44.3 ± 20.4. Overall mortality was 33%. Flared iliac limb with a distal diameter of ≥ 20 mm, show a higher rate of iliac limb reintervention in a follow-up period due to endoleak type 1b.

Bilateral May-Thurner syndrome refractory to iliac aneurysm repair

Venous complications of iliac artery aneurysms are rare. We report the case of bilateral iliac aneurysms that resulted in iliac vein outflow obstruction despite endovascular aneurysm repair. In our patient, bilateral iliac vein stenting resulted in symptom resolution.

A Comparative Study of the Efficacy by using Different Stent Grafts in Bell-Bottom Technique for the Treatment of Abdominal Aortic Aneurysm Concomitant with Iliac Artery Aneurysm

BACKGROUND

Bell-bottom technique (BBT) is one method to preserve the internal iliac artery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) that extends to iliac artery. The data on the efficacy of this technique are still limited. We sought to evaluate the midterm efficacy of BBT by using different stent grafts in the treatment of AAA combined with iliac artery aneurysm (IAA).

METHODS

From January 2011 to December 2016, AAA patients with IAA using BBT to preserve the internal iliac artery were retrospectively analyzed in our institution. Patients were followed up at 3, 6, and then every 12 months after surgery. The outcomes among 3 types of stent grafts (Zenith, Excluder, and Endurant) were compared. BBT-related end points including type Ib endoleak, IAA sac expansion, distal neck expansion, and rupture during follow-up were compared. Other events including perioperative death, any other types of endoleak, and corresponding management were also documented.

RESULTS

A total of 125 patients with 141 IAAs were identified. Ninety-eight patients (78.4%) with 113 lesions (80.4%) received a median follow-up time of 38 months. The incidence of type Ib endoleak was 22.9%, 8.3%, 11.9%, and 14.2% (P = 0.19) in Zenith, Excluder, Endurant group, and total patients, respectively. The incidence of IAA sac enlargement was 17.1%, 5.6%, 7.1%, and 9.7% (P = 0.20). The incidence of IAA rupture was 8.6%, 0.0%, 0.0%, and 2.7% (P = 0.03). The incidence of IAA neck enlargement was 34.3%, 13.9%, 16.7%, and 21.2% (P = 0.07). Totally, 14 cases (10.7%) received further treatment for BBT-related issues.

CONCLUSIONS

Although BBT remains a safe and effective treatment option to preserve internal iliac artery during standard EVAR with acceptable complication rates in Asians, different IAA rupture rates were found among 3 different stent grafts. Our data for the first time revealed that the type of stent grafts has influence on the final clinical outcome. Based on that, iliac extension should be selected appropriately while treating AAA-IAA.

Endovascular therapeutic options for the treatment of aortoiliac aneurysms

About 20% of patients with abdominal aortic aneurysms have associated iliac aneurysms. Distal sealing during the endovascular treatment of aortic-iliac aneurysms is a challenge that has led to the emergence of several technical options to achieve this goal over the years. Internal iliac artery embolization is associated with the risk of ischemic complications, such as gluteal necrosis, lower limb neurological deficit, colonic ischemia, impotence and gluteal claudication. This article summarizes the technical options for endovascular treatment of aortoiliac aneurysms with different approaches to preserving the patency of internal iliac arteries.

Preservation of hypogastric flow and control of iliac aneurysm size in the treatment of aortoiliac aneurysms using the Nellix EndoVascular Aneurysm Sealing endograft

OBJECTIVE

The purpose of this study was to determine the long-term effectiveness of endovascular aneurysm sealing (EVAS) in the treatment of complex aortoiliac aneurysms with preservation of hypogastric artery flow.

METHODS

We reviewed all patients with abdominal aortic aneurysms (AAAs) and common iliac aneurysms (CIAs) enrolled and treated in prospective studies of EVAS using the Nellix endograft (Endologix, Irvine, Calif) at two centers from 2008 to 2014. Patients with 1 year or more of computed tomography follow-up underwent quantitative morphometric assessment by two independent vascular radiologists blinded to clinical outcome results. Hypogastric patency and CIA diameter changes over time were assessed and compared in three treatment groups: totally excluded CIA, partially excluded CIA, and untreated CIA.

RESULTS

Among 125 patients with EVAS, 68 patients (mean age, 75 ± 8 years; 79% men) had both AAA (mean diameter, 55.8 ± 2.0 mm) and CIA (median diameter, 23.4; interquartile range, 21.3-27.0 mm), with bilateral CIAs in 33 patients. Treatment of 101 CIAs included complete CIA exclusion in 40 (39.6%), partial CIA exclusion in 33 (32.7%), and no CIA treatment in 28 (27.7%), with successful AAA exclusion in all patients. Internal iliac flow was preserved in all 122 hypogastric arteries that were patent before treatment (14 hypogastric arteries were occluded at baseline). During the 5-year follow-up period (median follow-up, 24.7 months; range, 11.5-61.7 months), three patients required secondary treatment with hypogastric occlusion and graft extension to the external iliac. Thus, internal iliac flow was maintained in 98% of at-risk hypogastric arteries. There were no aneurysm-related clinical events, except for the three secondary treatments. Totally excluded iliac aneurysms did not change in diameter over time (P = .85), whereas untreated CIAs enlarged at a rate of 0.16 mm/y (95% confidence interval, 0.09-0.23; P < .0001). Partially excluded CIAs enlarged at a higher rate of 0.59 mm/y (95% confidence interval, 0.47-0.71; P < .0001). Enlargement ≥3 mm occurred only in partially treated CIAs larger than 3 cm.

CONCLUSIONS

EVAS was effective in treating aortoiliac aneurysms with preservation of internal iliac patency in most cases. Complete CIA exclusion prevented aneurysm enlargement over time, whereas partial exclusion did not prevent continued CIA enlargement, particularly in larger aneurysms.

Dilatation of Common Iliac Arteries after Endovascular Infrarenal Abdominal Aortic Repair with Bell-Bottom Extension

Objective

Endovascular techniques to treat abdominal aortic aneurysms results in lower morbidity and mortality rates. However, dilation of the common iliac arteries prevents adequate distal sealing, which compromises the procedure success. The aim of this study is report the long-term outcomes of patients with abdominal aortic aneurysms associated with aneurysm of the common iliac artery following endovascular repair using a bifurcated bell-bottom stent graft.

Methods

This is a retrospective study that evaluated patients treated with bifurcated bell-bottom extension stent grafts to repair an infrarenal abdominal aortic aneurysm and who had at least one common iliac artery with dilatation > 1.5 cm for at least 12 months after the endovascular intervention.

Results

Thirty-eight patients with a mean age of 70.4±8.2 years were included. Stent graft placement was followed by dilation of the common iliac artery aneurysms in 35.3% of cases; endoleak and reoperation rates were 17.6% and 15.7%, respectively. Younger patients showed a higher rate of artery diameter increase following the procedure. The average arterial dilation was 16% in the first year, 29% in the second year, 57% in the third year and 95% from the fourth year until the end of follow-up.

Conclusion

Repair of infrarenal abdominal aortic aneurysms with bifurcated bell-bottom type stents when there is common iliac artery dilation is a good therapeutic option to preserve hypogastric flow. The rate of endoleak was 17.6%, and 15.7% of cases required reoperation. Younger patients are more likely to experience dilation of the common iliac artery after the procedure.

Fate of Enlarged Iliac Arteries After Endovascular or Open Abdominal Aortic Aneurysm Repair

Purpose: To examine the fate of untreated ectatic and aneurysmal common iliac arteries (CIAs) after open treatment and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods: Databases of scientific literature were searched between January 1980 and February 2016 to identify publications on the follow-up of ectatic and aneurysmal CIAs after open or endovascular AAA repair. The primary outcome measure was the increase of iliac artery diameter during follow-up. The secondary outcome was the subsequent reintervention rate during follow-up. Results: Only 3 open AAA and 3 EVAR studies containing 1239 patients met the inclusion criteria for analysis. In the open AAA group, ectatic iliac arteries (defined as 12–18 mm) had a diameter progression of 1.7 to 1.8 mm during a follow-up period of 51.6 to 85.2 months. The aneurysmal iliac arteries (>18 mm) in the open repair group showed a faster growth (2.3–3.0 mm) in a follow-up period of 50.4 to 85.2 months. The pooled assessment of arteries ≥18 mm had a mean growth of 2.56 mm at 60 months of follow-up. In the entire open AAA cohort, the reintervention rate for CIA transformation was <1%. In the EVAR studies, arbitrary cutoff sizes of 16 to 20 mm for ectatic arteries and >20 mm for aneurysmal arteries were used. During a follow-up of 39.2 to 60 months, the diameter progression was 1.5 mm for the 16-mm iliac arteries and 2.7 mm for the 20-mm iliac arteries. The need for endovascular reinterventions was similar in patients with previously normal or enlarged CIAs. Conclusion: After open AAA repair, the overall size of CIA aneurysms grows slowly, but enlarged CIAs >20 mm in EVAR patients show faster growth during follow-up. However, the need for secondary interventions was similar in patients with normal or enlarged CIAs post EVAR.

Using a surgeon-modified iliac branch device to preserve the internal iliac artery during endovascular aneurysm repair: single-center experiences and early results

Background:

To evaluate the feasibility of a new surgeon-modified iliac branch device (IBD) technique to maintain pelvic perfusion in the management of common iliac artery (CIA) aneurysm during endovascular aneurysm repair (EVAR).

Methods:

From January 2011 to December 2013, a new surgeon-modified IBD technique was performed in department of vascular surgery of Peking Union Medical College Hospital in five patients treated for CIA aneurysm with or without abdominal aortic aneurysm. A stent-graft limb was initially deployed in vitro, anastomosed with vascular graft, creating a modified IBD reloaded into a larger sheath, with or without a guidewire preloaded into the side branch. The reloaded IBD was then placed in the iliac artery, with a covered stent bridging internal iliac artery and the branch. Finally, a bifurcated stent-graft was deployed, and a limb device was used to connect the main body and IBD.

Results:

Technical successes were obtained in all patients. The mean follow-up length was 24 months (range: 6–38 months). All grafts remained patent without any sign of endoleaks. There were no aneurysm ruptures, deaths, or other complications related to pelvic flow.

Conclusions:

Using the surgeon-modified IBD to preserve pelvic flow is a feasible endovascular technique and an appealing solution for personalized treatment of CIA aneurysm during EVAR.

Fate of Aneurysmal Common Iliac Artery Landing Zones Used for Endovascular Aneurysm Repair

PURPOSE

To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR).

METHODS

This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality.

RESULTS

The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak.

CONCLUSION

Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

Use of aortic extension cuffs for preserving hypogastric blood flow in endovascular aneurysm repair with aneurysmal involvement of common iliac arteries

BACKGROUND

Intentional hypogastric artery covering during endovascular repair of abdominal aortic aneurysms (EVAR) can carry a non-negligible rate of complications; to preserve pelvic blood flow, several approaches are in use, such as sandwich techniques, branched iliac devices, or the use of aortic extender cuffs in a bell-bottom configuration. We assess the performance of the latter for treatment of common iliac artery aneurysms during EVAR.

METHODS

Prospective gathering of data in 21 dilated common iliac arteries (18-25 mm) with coexisting abdominal aorta aneurysm, which were treated from 2005 to 2010 and received a GORE(®) Excluder endograft and one (n = 14) or several aortic extenders in a bell-bottom configuration. Control group consisted of 136 EVARs performed with the same device in the same time frame. Median follow-up was of 47 months, with contrast-enhanced computed tomography assessment 1 month after the procedure and yearly thereafter.

RESULTS

Age and comorbidities were homogeneously distributed among groups, although the aortic aneurysm diameter was lower in the bell-bottom group (50 mm vs. 58.2 mm, P < 0.001). There was no 30-day mortality registered in this group, and only one patient died during follow-up (5.3%), without relation with the aneurysmal disease. No significant differences were found in reintervention (15.8% vs. 14.7%, P = 0.707) or endoleak rates (36.8% vs. 38.9%, Fisher P = 1). There were no type I and four type II endoleaks, two of which precised treatment for sac growth. Endoleak-free survival (P = 0.994) and reintervention-free survival (P = 0.563) did not show differences either.

CONCLUSION

Bell-bottom technique is a feasible and safe alternative for preserving hypogastric blood flow, and does not imply a higher risk of reintervention or endoleak at 3-year follow-up.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation

INTRODUCTION

A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability.

METHODS

Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared.

RESULTS

We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002).

CONCLUSIONS

The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.