Banding of the common iliac artery: an expedient in endoluminal correction of aortoiliac aneurysms

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.

Branched Endograft for Aortoiliac Artery Aneurysms

Iliac aneurysms can occur concomitantly in 15 to 20% of abdominal aortic aneurysms. The common iliac arteries serve as the distal landing zones for the iliac limbs of abdominal aortic stent grafts, and for most currently available devices, the maximum treatable iliac size is 20 mm. When the iliac artery diameter exceeds this, alternative landing zones or adjunctive techniques are required to achieve an adequate distal seal and fixation, which typically involves occlusion of the hypogastric artery origin and extension to the external iliac artery. The clinical sequelae of acute hypogastric occlusion mostly involve symptoms of hip and buttock ischemia (claudication), which can occur in up to 40% of cases. In this article, a novel method of endovascular management of common iliac artery aneurysms in the setting of endovascular aortic aneurysm repair is described using an investigational (United States only) iliac branch device that preserves antegrade perfusion to the hypogastric artery to decrease the potential risks of pelvic ischemia.

Tratamento endovascular do aneurisma da aorta abdominal em paciente com insuficiência renal crônica

A insuficiência renal crônica não-dialítica é uma contra-indicação relativa ao tratamento endovascular dos aneurismas da aorta abdominal. O uso de contrastes alternativos, como o gadolínio, além de fornecer imagens de baixa qualidade, está relacionado à nefrotoxicidade. Relatamos um caso de tratamento endovascular de aneurisma da aorta abdominal guiado por eco-Doppler colorido. Um paciente masculino de 82 anos, com aneurisma da aorta abdominal de 55 mm de diâmetro e clearance de creatinina de 17 ml/min, recebeu implante de endoprótese aórtica modular bifurcada, utilizando este método de imagem associado à radioscopia. Não foi empregado contraste iodado. O resultado imediato e os controles de 1 e 6 meses revelam completa exclusão do aneurisma. A função renal permanece inalterada. Concluímos que o implante de endoprótese guiado por eco-Doppler colorido em pacientes com insuficiência renal crônica não terminal e com anatomia favorável é um método factível e seguro.

Minimally invasive surgical solution in the treatment of an unusual distal type I endoleak after endovascular abdominal aortic aneurysm repair

Most distal type I endoleaks can be treated by endovascular techniques such as coil embolization of the hypogastric artery and additional stent or extension stent grafts. We report a case of a difficult type I endoleak located in the distal end of a monoiliac conical stent graft used to treat an abdominal aortic aneurysm extensively involving both common iliac arteries. Cranial migration of the endograft and incarceration in the contralateral iliac aneurysm were observed on the computed tomographic scan. The patient was submitted to a procedure that involves endovascular and limited open surgery techniques. A 26 mm balloon catheter was used to secure the proximal implantation site, and through a Gibson incision, the iliac arteries were controlled. An interpositional 8 mm regular Dacron graft was then sutured end to end between the endograft and the external iliac artery.

Is Coil Embolization of Hypogastric Artery Necessary during Endovascular Treatment of Aortoiliac Aneurysms?

The aim of this study was to evaluate the safety and efficacy of stent graft coverage of hypogastric artery in the management of aortoiliac aneurysms. Between January 2000 and December 2002, 98 patients underwent endovascular repair of aortoiliac aneurysms (EVAR). Of these, 24 (24.5%) required occlusion of one hypogastric artery to facilitate the endovascular repair. Based on the method of hypogastric artery occlusion, patients were divided in to two groups. Group A (13/24 = 54%) underwent standard coil embolization followed by hypogastric artery orifice coverage whereas group B (11/24 = 46) underwent hypogastric artery orifice coverage without coil embolization. Post-EVAR computed tomographic angiography (CTA) was used to determine occurrence of endoleaks from the hypogastric artery orifice and patency of superior gluteal artery in both groups. These findings were further correlated with presence or absence of gluteal claudication. There was no difference in age (p < 0.38) or iliac aneurysm size (p < 0.3). In group A (13 patients), occlusion of superior gluteal artery was seen in 6 (46%). Four of six (66%) patients developed severe gluteal claudication. Patients in group A were likely to require more than one intervention (p < 0.00036). No patients in group B developed occlusion of the superior gluteal artery (p < 0.04) or gluteal claudication (p < 0.046). No endoleaks were seen from the origins of hypogastric artery in either group. The follow-up period ranged from 2 to 35 months. Hypogastric artery orifice coverage without coil embolization effectively prevented retrograde endoleak without the occurrence of disabling gluteal claudication. Coil embolization of the hypogastric artery may be unnecessary during treatment of aortoiliac aneurysm.

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE

Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure.

METHODS

Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality.

RESULTS

Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups.

CONCLUSION

Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.

Retrograde endovascular hypogastric artery preservation (REHAP) and aortouniiliac (AUI) endografting in the management of complex aortoiliac aneurysms

The preservation of internal iliac artery (IIA) flow during endovascular repair of abdominal aortic aneurysms (er-AAA) remains a controversial area. Ectasia and aneurysmal disease of the iliac arteries represent a formidable challenge to the endovascular surgeon, particularly when aortic neck length and diameter are suitable for er-AAA. We describe a procedure to maintain arterial perfusion to the pelvis during er-AAA called retrograde endovascular hypogastric artery preservation (REHAP). This technique is particularly useful in the presence of common iliac artery (CIA) and internal iliac artery (IIA) aneurysms when pelvic perfusion to one IIA needs to be maintained. A Wallgraft is first placed from the IIA to the ipsilateral EIA followed by er-AAA using an aortouniiliac graft (AUI) and a femorofemoral bypass graft (BPG). This procedure represents one alternative to maintaining pelvic perfusion using standard endovascular and surgical techniques.

A hybrid endovascular procedure to preserve internal iliac artery patency during endovascular repair of aortoiliac aneurysms

PURPOSE

To demonstrate the feasibility of a hybrid endovascular procedure to preserve blood flow in the internal iliac arteries (IIA) during aortoiliac endografting.

TECHNIQUE

When aneurysmal dilatation makes the distal neck in the common iliac artery (CIA) too short for an adequate seal, the CIA bifurcation is exposed via an extraperitoneal approach after endograft deployment. Via an arteriotomy in the CIA, the distal end of the stent-graft is sutured to the CIA bifurcation under direct vision to preserve IIA blood flow. This approach has been successful in preserving IIA blood flow in 5 of 7 endograft procedures; in the other 2, IIA occlusion was a predictable event.

CONCLUSIONS

Direct suturing of an aortoiliac stent-graft to the CIA bifurcation via an extraperitoneal approach is a useful method of maintaining IIA perfusion. However, further study is required to identify patients at high risk of pelvic ischemia who would benefit from such intervention.

Sloughing of the scrotal skin and impotence subsequent to bilateral hypogastric artery embolization for endovascular aortoiliac aneurysm repair

Sloughing of the scrotal skin is an extremely rare event due to pelvic ischemia. We report herein one case of scrotal skin sloughing and impotence after bilateral hypogastric artery embolization for endoluminal aortoiliac aneurysm repair. Postoperative penile plethysmography demonstrated a 75% reduction in the penile brachial index, suggesting that pelvic ischemia is the main culprit for this complication. The devastating morbidity in our patient underscores the importance of maintaining pelvic collateral circulation when planning for endovascular aortoiliac aneurysm repair.