Endovascular exclusion of bilateral common iliac artery aneurysms with preservation of internal iliac artery perfusion

U Stent-Graft Technique as a Treatment for Homolateral Metachronous Common Iliac and Internal Iliac Arteries Aneurysms after Open Surgery

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

Complex common and internal iliac or aortoiliac aneurysms and current approach: individualised open-endovascular or combined procedures

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates.

Feasibility of a Branched Stent-Graft in Common Iliac Artery Aneurysms

PURPOSE

To evaluate the short-term feasibility, efficacy, and safety of a modular bifurcated stent-graft with an internal iliac artery (IIA) side branch for endovascular repair of aortoiliac aneurysms.

METHODS

Between 2002 and 2005, 10 male patients (median age 75 years, range 59-83) were treated with a bifurcated stent-graft that included a unilateral side branch for the IIA. The median diameters of the abdominal aortic and common iliac artery (CIA) aneurysms were 56 mm (range 33-80) and 40 mm (range 27-60), respectively. Four patients were treated mainly for the CIA aneurysm. Postoperative endoleaks, patency rate, and vessel morphology were determined with contrast-enhanced computed tomography (CT).

RESULTS

All endografts were implanted in the desired position. One IIA occluded intraoperatively, and 1 external iliac artery occlusion was noted 6 months postoperatively; both occlusions were asymptomatic and remain untreated. Three graft-related endoleaks were treated with implantation of adjunctive stent-grafts (2 intraoperative and 1 late). Median follow-up by CT was 2 months (1 week to 32 months). One patient died of myocardial infarction 13 days postoperatively; the stent-graft was patent at autopsy.

CONCLUSION

Stent-grafts with an IIA side branch offer an opportunity to repair aortoiliac aneurysms without sacrificing the IIA. Implantation of the IIA branch is more complex than routine endovascular aneurysm repair and may have contributed to a periprocedural cardiac death. More patients and longer follow-up are needed to verify these data.

Endovascular Exclusion of Symptomatic Bilateral Common Iliac Artery Aneurysms With Preservation of an Aneurysmal Internal Iliac Artery Via a Reverse-U Stent-Graft

PURPOSE

To report a technique to maintain flow to an aneurysmal internal iliac artery (IIA) when treating bilateral common iliac artery (CIA) aneurysms with an aortomonoiliac stent-graft and femorofemoral bypass.

TECHNIQUE

First, an external iliac artery (EIA) to IIA endograft is placed distal to the IIA aneurysm then the contralateral IIA is embolized with coils. An aortomonoiliac stent-graft extending to the contralateral EIA is placed, and the procedure is completed with a femorofemoral bypass.

CONCLUSION

Endovascular treatment of bilateral CIA aneurysms and combined with a unilateral IIA aneurysm is a technically demanding procedure. An endovascular repair with retrograde (reverse-U stent-graft) hypogastric artery preservation can be considered a first choice until the use of branched iliac stent-grafts becomes more widespread.

Stent-Grafts for Unruptured Abdominal Aortic Aneurysms: Current Status

Aortic stent-grafts were introduced at the beginning of the 1990s as a less invasive method of dealing with aortic aneurysms in patients with poor cardiovascular reserve. The numbers of procedures performed worldwide has increased exponentially despite the current lack of any substantial evidence for long-term efficacy in comparison with the gold standard of open surgical grafting. This review summarizes the evolution of the abdominal aortic stent-graft, the techniques used for assessment and deployment, and the effect of the procedure on both the patient and the device. The recent publication of two national multicenter trials has confirmed that the endovascular technique confers a 2.5-fold reduction in 30-day mortality in comparison with open surgery. However, over 4 years of follow-up, there is a 3-fold increase in the risk of reintervention and the overall costs are 30% greater with endovascular repair. Although the improvement in aneurysm-related mortality persists in the mid-term, because of the initial reduction in perioperative mortality, the all-cause mortality rate at 4 years is actually no better than for open surgery. Longer-term data from the randomized trials are awaited as well as results from the latest trials utilizing state-of-the-art devices. Whilst the overall management of abdominal aortic aneurysms has undoubtedly benefited from the introduction of stent-grafts, open repair currently remains the gold standard treatment.