Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair

Internal Iliac Artery Aneurysm Ruptures with No Visualized Endoleak 2 Years after Endovascular Repair

We report a case of an 83-year-old man with a ruptured internal iliac artery (IIA) aneurysm after endovascular repair, which was treated via the ligation of IIA and tight suture of the aneurysm sac. Although there were no findings of obvious endoleak after endovascular treatment, the IIA aneurysm increased in size and eventually ruptured. We presumed that pressure to IIA aneurysm via the embolized IIA led to rupture. Aneurysm sac expansion may lead to a rupture despite no endoleak being detected; therefore, close follow-up or re-intervention must be considered. Tight embolization of IIA may prevent endotension in the same case.

Endovascular management of an isolated common iliac artery aneurysm: a case report

Isolated iliac artery aneurysms are rare, and treatment by conventional surgery gives good results. Endovascular repair of such aneurysms has recently become the preferred form of treatment, provided the appropriate anatomy for endovascular repair exists. We report the case of a 60-year-old man admitted in our department for an aneurysm of the left primitive iliac artery revealed by intermittent claudication and treated by a covered stent after embolization of the hypogastric artery by an Amplatzer Vascular Plug with a good result. This case highlights the importance of preservation of the collaterals of the hypogastric artery when you treat such entity; in order to avoid transient gluteal claudication and sexual dysfunction.

Percutaneous approach options for embolization of endoleak after iliac artery aneurysm repair: stick the sac or stick the gluteal artery

Internal iliac artery aneurysms (IIAAs), isolated or associated with abdominal aortic aneurysms, are at rupture risk with growth. Treatment is recommended when symptomatic or greater than 3 cm. Surgical or endovascular therapy should exclude the arterial origin and outflow branches. If all outflow branches are not completely embolized, an endoleak can develop, pressurizing the sac leading to growth and rupture. Accessing the arteries involved can be technically challenging and understanding potential targets is critical. We describe two percutaneous approaches for treatment: percutaneously accessing the sac from an anterior trans-iliopsoas approach and percutaneously accessing the gluteal artery from a posterior approach.

Atypical Type 2 Endoleak from an Artery Supplying the Psoas Major Muscle Following Endovascular Repair in a Case of Isolated Common Iliac Artery Aneurysm

In this report, we present a rare case of type 2 endoleak (T2EL) from an artery supplying the psoas major muscle, following an endovascular repair of a common iliac artery aneurysm (CIAA). A 79-year-old male underwent endovascular aneurysm repair (EVAR) for the right isolated CIAA using stent graft, with embolization of the ipsilateral internal iliac artery. The aneurysm was stable for 2 years, after which a follow-up CT revealed a 5 mm increase in the CIAA diameter and an endoleak of unknown origin. Conventional and CT angiographies revealed the source to be a branch from the ipsilateral deep circumflex iliac artery supplying the psoas major muscle that had developed an anastomosis at its terminal end with the vasa vasorum at the CIAA. Transarterial embolization of T2EL using glue was performed successfully, following which the T2EL disappeared.

Colon perforation due to embolization coil for internal iliac aneurysm

Coil migration is an extremely rare but hazardous complication of aneurysmal coil embolization. Only 1 case report has described coil migration following endovascular exclusion to gastrointestinal (GI) tract. We report the experience of a case of colon penetration caused by embolization coil placed for internal iliac aneurysm. A 66-year-old man visited the Emergency Department for hematochezia that had persisted for 3 months. Stent insertion and coil embolization of left internal iliac artery aneurysm had been performed on the patient 18 months ago. Colonoscopy was performed. It suggested penetration of sigmoid colon by embolization coil and diverticulum. Angiography revealed extravasation of contrast media at left internal iliac artery. Covered stent deployment was done in the left internal iliac artery. One week after the stent insertion, the patient underwent anterior resection, aneurysm resection, and coil removal. The patient recovered without complications. He was discharged at 2 weeks after the operation.

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.

Strategy for Isolated Iliac Artery Aneurysms

We retrospectively reviewed 41 patients with isolated iliac artery aneurysms presenting over a 21-year period. The mean age was 72 years. Mean aneurysmal diameter was 6.0 cm (range, 3.2–13 cm). The aneurysms were located in the common iliac artery in 31 patients, internal iliac artery in 7, and both arteries in 3. Rupture occurred in 20 patients (49%). The frequency of rupture of isolated iliac artery aneurysms was significantly higher than that of abdominal aortic aneurysms (8%) during the same period. The 30-day mortality was 9.8%; death in all 4 patients was due to rupture of the aneurysm. The surgical procedure was aneurysmectomy and replacement with a bifurcated prosthetic graft in 24 patients (59%), closure of the common iliac artery with a femorofemoral crossover in 7, minilaparotomy in 3, thromboexclusion in 6, and endoluminal stent-graft repair in one. In contrast to abdominal aortic aneurysms, isolated iliac artery aneurysms can be treated by various methods other than replacement with a bifurcated prosthetic graft. When selecting a strategy for such aneurysms, it is important to choose an approach appropriate to the location and risk, because of the frequency of rupture.

Direct aneurysm sac catheterization and embolization of an enlarging internal iliac aneurysm using cone-beam CT

Since cone-beam computed tomography (CT) has been adapted for use with a C-arm system it has brought volumetric CT capabilities in the interventional suite. Although cone-beam CT image resolution is far inferior to that generated by traditional CT scanners, the system offers the ability to place an access needle into position under tomographic guidance and use the access to immediately begin a fluoroscopic procedure without moving the patient. We describe a case of a "jailed" enlarging internal iliac artery aneurysm secondary to abdominal aortic aneurysm repair, in which direct percutaneous puncture of the internal iliac artery aneurysm sac was performed under cone-beam CT guidance.

Retrograde hypogastric artery embolization to treat iliac artery aneurysms growing after aortoiliac repair

Transarterial embolization of the feeding internal iliac artery branches via the hypogastric-femoral collateral pathway was feasible in four patients with expanding iliac artery aneurysms and occluded internal iliac artery origins after aortoiliac repair.

Case report. A novel approach to the management of a ruptured Type II endoleak following endovascular repair of an internal iliac artery aneurysm

Endovascular repair of isolated iliac artery aneurysms is an established safe and effective management option. Type II endoleak is a potential complication, but rarely results in significant morbidity or mortality. We report a case of a patient who presented with a ruptured internal iliac artery aneurysm secondary to a Type II endoleak. To our knowledge this and the following method of managing this have not been previously reported. Established methods of managing endoleaks, such as intravascular transfemoral embolisation and open or laparoscopic ligation, were not possible. Therefore, we resorted to a novel approach to this type of aneurysm and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.

State of the art: management of iliac artery aneurysmal disease

Although relatively uncommon, isolated iliac artery aneurysms are associated with significant risk of rupture and death. Clinical presentation can be confusing and ultrasound or CT imaging is paramount in establishing the diagnosis and anatomical extent of disease. Important considerations prior to intervention include determination of proximal neck, involvement of the internal iliac artery, and status of the contralateral internal iliac artery. Endovascular repair has evolved as the first choice treatment option for patients with anatomically suitable iliac artery aneurysms. In uncommon circumstances when endovascular treatment may result in significant pelvic ischemia or the primary symptoms are related to extrinsic compression of adjacent structures, surgical repair may be the preferred option.

Endovascular management performed percutaneously of isolated iliac artery aneurysms

PURPOSE

To report about the endovascular treatment of isolated iliac artery aneurysms (IIAA) with stentgraft placement and transluminal or CT-guided embolization of the internal iliac artery or the combination of these methods.

METHODS AND MATERIALS

Over a period of 5.6 years, 36 interventions were performed in 20 patients with 23 IIAAs. In a retrospective analysis patient records were reviewed. The CT-angiography follow-up was evaluated for the presence of re-perfusion of the IIAA and for change of aneurysm diameter.

RESULTS

Primary success was achieved in 15/23 aneurysms (65%), and secondary success in 21/23 aneurysms (91%). In 5/23 cases two interventions and in 1/23 cases three interventions were necessary to achieve secondary success. Embolization alone, as a therapy for aneurysms involving only the internal iliac artery, had a success rate of 27%. No procedure-related minor or major complications occurred. Mean decrease of aneurysm size during a mean observation period of 14.1 months was 6.9% which was not significant (p=0.3; 95% confidence interval +7-21%).

CONCLUSION

Endovascular therapy of isolated iliac artery aneurysms performed percutaneously has become a treatment alternative to open surgical repair. This method is feasible and safe with low procedure-related morbidity and mortality. However, on average more than one intervention has to be performed to achieve successful permanent exclusion of the aneurysm and embolization alone in isolated internal iliac artery aneurysms is not sufficient.

Endovascular repair of a common iliac artery aneurysm using the Cook Zenith abdominal aortic aneurysm Endovascular Graft Converter

Isolated common iliac artery aneurysm is a rare condition that is treated aggressively because of its high risk of rupture. Endovascular abdominal aortic aneurysm (AAA) repair has recently been extended to the clinical management of the iliac artery aneurysm. Stent grafts have been used successfully to exclude iliac artery aneurysms. Successful graft deployment and aneurysm exclusion require adequate seal and fixation at the proximal and distal attachment sites. This article presents a high-risk surgical patient whose 6.8-cm-diameter iliac artery aneurysm was repaired with a Zenith AAA Endovascular Graft Converter (Cook, Bloomington, Indiana). This device is normally used to convert an aortobiiliac endograft to an aortouniiliac endograft during AAA repair. The tapered 80-mm-long graft has diameters of 24 mm proximally and 12 mm distally. Completion arteriogram demonstrated exclusion of the iliac artery aneurysm with no evidence of endoleak. No postoperative complications occurred. No endoleak was seen on the follow-up abdominal computed tomography scan.

Endovascular treatment of isolated iliac artery aneurysms: 2-year follow-up

PURPOSE

The aim of this study was to assess the effectiveness of endovascular treatment of isolated iliac artery aneurysms (IAAs).

MATERIALS AND METHODS

Between March 1999 and March 2004, 15 isolated IAAs in 13 patients (mean age: 71.8 years) were selected for endovascular repair by means of a covered stent or stent-graft: 12 were in the common iliac artery (2 with the proximal end 12 mm from the aortic bifurcation and 2 involving the distal hypogastric artery), and three were in the external iliac artery. The preoperative study and the follow-up (at 3, 6 and 12 months and yearly thereafter) were performed by computed tomography (CT) angiography.

RESULTS

Primary technical success was obtained in all cases, without periprocedural complications. Two patients died within 3 months and were not considered for follow-up. Follow-up (mean duration: 25 months, range: 6-60 months) in the remaining 11 patients, affected by 13 aneurysms, showed aneurysm exclusion in nine cases and progressive shrinkage of the aneurysmal sac in four cases, whereas in the other five, the size of the aneurysm remained unchanged. In a patient with bilateral IAA, bilateral proximal endoleaks were observed after 2 years, and the patient was treated with a bifurcated aortic stent-graft. In another patient with a large aneurysm, a left aortofemoral bypass became necessary after 2 months because of stent-graft dislodgement. In another patient, an endoleak from the hypogastric artery occurred after 2 years but was not treated.

CONCLUSIONS

Endovascular treatment of isolated IAA is a feasible procedure that is less invasive than surgery and yields excellent short-and midterm results. However, a longer follow-up and larger patient series are needed to verify the long-term efficacy of this form of treatment.

Isolated iliac artery aneurysms: endovascular versus open elective repair

OBJECTIVE

To compare endovascular and open repair of isolated or solitary iliac artery aneurysms (SIAAs).

METHODS

We present the results of 55 patients with 58 SIAAs that were treated between January 1998 and December 2005 in two European university hospitals. In one center, the standard procedure, if not contraindicated, was endovascular repair, and 32 (58.2%) consecutive patients with 33 SIAAs were treated by using only endovascular techniques (endovascular iliac aneurysm repair; EVIAR). In the second center, 23 (41.8%) consecutive patients with 25 SIAAs were treated by conventional surgical techniques because advanced endovascular skills were not available before late 2005. EVIAR included coil embolization of the hypogastric artery in 13 of the 33 cases with aneurysmal involvement of the internal iliac artery. In the "open" group of patients, midline laparotomy and a transperitoneal approach with bifurcated aortoiliac graft replacement was performed in 4 cases, and a lower lateral abdominal incision with a retroperitoneal approach and iliac replacement was performed in 19 cases.

RESULTS

The mean follow-up period was similar in both groups (EVIAR, 35.3 +/- 21.3 months; open, 31.3 +/- 19.9 months). The two groups of patients had similar demographic and clinical characteristics compared with previous reported series, and data analysis revealed a statistically significant difference between the two groups only in hypertension. The early and mid-term outcomes and especially the 3-year primary patency rates were also similar between the two groups (EVIAR, 97%; open, 100%). In the EVIAR group, there was no evidence of endoleaks, kinking, or graft migration, and 26 aneurysms remained stable, whereas in 7 aneurysms a slight decrease in size (>10% in diameter) was observed. Comparison of operative time, intraoperative blood loss, and postoperative hospital stay revealed significant differences (P < .001) in favor of the endovascular group. Secondary intervention was not necessary in any patient in either group during the entire follow-up period.

CONCLUSIONS

Elective management with endovascular or open techniques of isolated iliac aneurysms can be accomplished with very low morbidity and mortality rates. Better intraoperative and early postoperative outcomes, as well as the durable mid-term results in our EVIAR-treated patients, indicate that endovascular techniques could be offered as first-line therapy of SIAAs.

The Endovascular Management of Iliac Artery Aneurysms

BACKGROUND

Isolated aneurysms of the iliac arteries are uncommon. Previously treated by conventional surgery, there is increasing use of endografts to treat these lesions.

PURPOSE

The purpose of this study was to assess the efficacy, safety, and durability of the stent-grafts for treatment of iliac artery aneurysms (IAAs). The results of endografting for isolated IAAs over a 10-year period were analyzed retrospectively. The treatment methods differed depending on the anatomic location of the aneurysms. Twenty-one patients (1 woman, 20 men) underwent endovascular stent-graft repair, with one procedure carried out under emergency conditions after acute rupture. The mean aneurysm diameter was 4.6 cm.

RESULTS

The procedural technical success was 100%. There was zero 30-day mortality. Follow-up was by interval CT scans. At a mean follow-up of 51.2 months, the stent-graft patency rate was 100%. Reintervention was performed in four patients (19%): one patient (4.7%) with a type I endoleak and three patients (14.3%) with type II endoleaks.

CONCLUSION

We conclude that endovascular repair of isolated IAAs is a safe, minimally invasive technique with low morbidity rates. Follow-up results up to 10 years suggest that this approach is durable and should be regarded as a first treatment option for appropriate candidates.

Tratamento endovascular de aneurisma de ilíaca roto: relato de caso

A taxa de mortalidade cirúrgica do aneurisma de ilíaca roto é similar à do aneurisma de aorta abdominal roto, devido à sua localização profunda na pelve, dificuldade de exposição distal da ilíaca decorrente do hematoma, bridas devido a laparotomia prévia e proximidade com ureter e estruturas venosas. O objetivo do presente estudo é enfatizar o procedimento endovascular como mais uma opção na correção dessas lesões. Relata-se o caso de um paciente de 60 anos de idade, submetido a derivação com enxerto aorto-biilíaco prévio com prótese há 5 anos, por aneurisma de aorta abdominal infra-renal, apresentando rotura de aneurisma em segmento remanescente da ilíaca comum esquerda. Estava hemodinamicamente estável após ressuscitação com fluidos e foi submetido ao tratamento endovascular de urgência, com a exclusão do aneurisma e ausência de vazamentos.

Endovascular treatment of ruptured iliac aneurysm previously treated by endovascular means

A patient with a ruptured iliac aneurysm was admitted to the Emergency Department in hypovolemic shock. He had previously undergone surgical treatment for an infrarenal abdominal aortic aneurysm, which was managed with a terminal-terminal Dacron tube graft. Subsequently, he developed two iliac aneurysms, which were treated endovascularly with two wall-grafts in the right and one wall-graft in the left iliac arteries. He suffered chronic renal failure and arterial hypertension. Contrast-enhanced computed tomography showed rupture of the right iliac aneurysm and dislocation of the two wall-grafts. He was treated in an emergency situation with the implantation of an iliac endograft that bridged the two wall-grafts, which resulted in hemostasis and stabilization of his condition. Five days later, in an elective surgical situation, he was treated with the implantation of an aorto-uni-iliac endograft combined with a femoral-femoral bypass. He was discharged 5 days later in good condition. At the 4 year follow-up visit, the endoprosthesis remained in place with no evidence of an endoleak. In conclusion, overlapping of endografts should be avoided, if possible. Strict surveillance of the endovascularly treated patient remains mandatory.

Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Endovascular management of isolated iliac artery aneurysms

OBJECTIVE

We reviewed our experience with endovascular treatment of isolated iliac artery aneurysms (IAAs).

METHODS

Medical records for consecutive patients undergoing endovascular IAA repair from 1995 to 2004 were reviewed. Computed tomography (CT) angiograms were used to assess IAA location, size, and presence of endoleaks after endovascular repair. Rates of primary patency and freedom from secondary interventions were estimated using the Kaplan-Meier life-table method.

RESULTS

From July 1995 to November 2004, 45 patients (42 men), with a mean age of 75 years, underwent endovascular repair of 61 isolated IAAs: 41 common iliac, 19 internal iliac, and one external iliac. Five patients (11%) were symptomatic, although none presented with acute rupture. The mean preoperative IAA diameter was 4.2 +/- 1.7 cm. Fifteen patients (33%) had prior open abdominal aortic aneurysm repair. Local or regional anesthesia was used in 28 cases (62%). Thirty-four patients (75%) were treated with unilateral iliac stent-grafts, eight (18%) with bifurcated aortic stent-grafts, and three (7%) with coil embolization alone. Perioperative major complications included one early graft thrombosis that eventually required conversion to open repair and one groin hematoma that required operative evacuation. On follow-up, late complications included one additional graft thrombosis and one late death after amputation. No late ruptures occurred after endovascular repair, with a mean follow-up of 22 months (range, 0 to 60 months). The mean postoperative length of stay was 1.3 +/- 1.0 days. On postoperative CT scans obtained at 1, 6, 12, 24, and 36 months, aneurysm shrinkage was noted in 18%, 29%, 57%, 67%, and 83% of IAAs, respectively, compared with the baseline diameter. One hypogastric aneurysm enlarged in the presence of a later identified type II endoleak. Five endoleaks were noted (4 type II, 1 indeterminate) at 1 month, with four other endoleaks (1 type II, 1 type III, 2 indeterminate) identified on later CT scans. At 2 years, primary patency was 95%, and freedom from secondary interventions was 88%.

CONCLUSIONS

Endovascular repair of isolated IAAs appears safe and effective, with initial results similar to those after endovascular abdominal aortic aneurysm repair.

Isolated Iliac Artery Aneurysms

Isolated aneurysms of the iliac arteries are extremely rare, comprising less than 2% of all aneurysmal disease. These aneurysms are typically seen in older men. Their natural history, although fairly indolent, carries a significant risk of rupture when the aneurysms have attained a large size. Their operative mortality is significantly higher when undertaken as an emergent versus elective procedure, underscoring the importance of early diagnosis and appropriate management. This article reviews the literature with regard to the natural history, diagnostic workup, and treatment of iliac artery aneurysms. For patients undergoing elective repair, preoperative imaging with computed tomography or magnetic resonance is advocated. Repair is recommended for good-risk patients with aneurysms larger than 3.5 cm. A working classification based on aneurysmal anatomy is provided along with an outline of the suggested open and endovascular surgical options. Results of open and endovascular strategies are summarized and follow-up recommendations are proposed.

Transcatheter Embolization of Hypogastric Artery Aneurysms: Lessons Learned

Transcatheter embolization of hypogastric artery aneurysms has become an attractive therapeutic alternative for many patients with this difficult lesion. Because of the increasing use of stent grafting for treatment of abdominal aortic aneurysms, transcatheter embolization of normal-caliber hypogastric arteries has become an almost routine procedure, usually accomplished with little morbidity. Applying this treatment to aneurysmal hypogastric arteries, however, involves greater technical complexity and a significantly higher risk of ischemic complications. We present three cases to illustrate the technical challenges of hypogastric aneurysm embolization, the potentially devastating ischemic complications, and the clinical situations that may predispose to poor outcomes.

Successful endovascular treatment of a ruptured internal iliac aneurysm

Internal iliac artery aneurysms (IIAs) are rare but can be the source of considerable morbidity when rupture occurs. IIAs have traditionally been treated with direct surgical exclusion or ligation. More recently, the advent of endovascular techniques have been adapted to treat isolated common and IIAs in lieu of elective surgical correction. This case report describes an 81-year-old patient with multiple medical problems and a symptomatic IIA, initially diagnosed with computed tomographic scan. Arteriography results showed extravasation of contrast from a left IIA. The aneurysm was treated with endovascular exclusion, with multiple coils in the IIA followed by placement of a covered stent within the common and external iliacs to exclude the orifice of the IIA. The patient tolerated the procedure well, and at 2 months after the procedure, no endoleak was present on follow-up computed tomographic scan results. At 12 months postprocedure, the patient has remained well. This case shows that endovascular therapies may offer a good treatment option in symptomatic or ruptured IIA, particularly in a patient who is at poor operative risk.

Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference

OBJECTIVE

Endoleaks and endotension are critically important complications of some endovascular aortic aneurysm repairs (EVARs). For the resolution of controversial issues and the determination of areas of uncertainty relating to these complications, a conference of 27 interested leaders was held on November 20, 2000.

METHODS

These 27 participants (21 vascular surgeons, five interventional radiologists, one cardiologist) had previously answered 40 key questions on endoleaks and endotension. At the conference, these 40 questions and participant answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus (prevailing opinion), or disagreement.

RESULTS

Conference discussion added two modified questions for a total of 42 key questions for the participants. Interestingly, consensus was reached on the answers to 24 of 42 or 57% of the questions, and near consensus was reached on 14 of 42 or 33% of the questions. Only with the answers to four of 42 or 10% of the questions was there persistent controversy or disagreement.

CONCLUSION

The current endoleak classification system with some important modifications is adequate. Types I and II endoleak occur after 0 to 10% and 10% to 25% of EVARs, respectively. Many (30% to 100%) type II endoleaks will seal and have no detrimental effect, which never or rarely occurs with type I endoleaks. Not all endoleaks can be visualized with any technique, and increased pressure (endotension) can be transmitted through clot. Aneurysm pulsatility after EVAR correlates poorly with endoleaks and endotension. An enlarging aneurysm after EVAR mandates surgical or interventional treatment. These and other conclusions will help to resolve controversy and aid in the management of these vexing complications and should also point the way to future research in this field.

Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience

OBJECTIVE

To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992.

SUMMARY BACKGROUND DATA

Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy.

METHODS

During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded.

RESULTS

The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3).

CONCLUSION

With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair.

Hypogastric artery aneurysm rupture after endovascular graft exclusion with shrinkage of the aneurysm: significance of endotension from a "virtual," or thrombosed type II endoleak

Type II endoleaks, resulting from retrograde branch flow, after endovascular graft aneurysm exclusion are considered benign because they usually thrombose and are commonly associated with stable or shrinking aneurysm sacs. We report a hypogastric artery aneurysm rupture from endotension from an undetected, thrombosed Type II endoleak, associated with sac shrinkage. The patient had undergone an endovascular graft repair of a 4-cm right common iliac artery and 9-cm hypogastric artery aneurysm with distal hypogastric artery coil embolization. Serial computed tomography scans revealed no endoleak and a hypogastric aneurysm thrombosis with shrinkage. Eighteen months later, the aneurysm ruptured as a result of pressurization from backbleeding, patent branches.