Cross-over Deployment of a Tapered Stent Graft to Repair a Ruptured Isolated Internal Iliac Aneurysm

We report the case of a 72-year-old man who presented with a left ruptured internal iliac aneurysm (IIA). A percutaneous cross-over approach was used to coil-embolize the 3 distal branches of the IIA. A tapered endograft limb was then delivered via the right common femoral artery using a femorofemoral through-and-through cross-over approach. The widest part of the graft was deployed in the common iliac artery and the smallest in the external iliac artery. This percutaneous endovascular technique opens up new perspectives in emergency care for ruptured internal iliac artery aneurysms.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

BACKGROUND

The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair.

METHODS

From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year.

RESULTS

A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention.

CONCLUSIONS

IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.

Durability of iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms

OBJECTIVE

This study evaluated and compared the long-term clinical outcomes of endovascular repair of infrarenal aortoiliac aneurysms (EVAR) vs EVAR with preservation of antegrade internal iliac artery (IIA) perfusion using iliac branched devices (EVAR-IBDs).

METHODS

From October 1998 to August 2015, patients with infrarenal aortoiliac aneurysmal (AIA) disease at high risk for conventional open surgery were enrolled in a prospective physician-sponsored investigational device exemption trial. Clinical data of 75 patients treated with EVAR-IBD and 255 with standard EVAR were analyzed. Technical success, perioperative outcomes, mortality, device patency, endoleak rates, and reinterventions during a follow-up of 10 years were analyzed.

RESULTS

There were 87 IBDs deployed in 75 patients. Technical success rate was 97%. Mortality at 30 days was 1.3%. Freedom from aneurysm-related mortality at 3, 5, and 10 years was 99%. Freedom from a type I or III endoleak at 3, 5, and 10 years was 99%. Freedom from secondary reinterventions at 3, 5, and 10 years was 86%, 81%, and 81%, respectively. Primary patency of the IBDs at 3, 5, and 10 years was 94%, 94%, and 77%, respectively. Twenty-four percent of patients underwent EVAR for concomitant AIA disease (EVAR-AIA), and 78% were managed by staged IIA embolization before EVAR. No statistically significant difference in freedom from aneurysm-related mortality, limb occlusions, or endoleak rates was identified in patients with EVAR-AIA vs EVAR-IBD (P > .05). There were significantly more secondary reinterventions in the EVAR-AIA group compared with the EVAR-IBD group (hazard ratio, 0.476, 95% confidence interval, 0.226-1.001; P = .045).

CONCLUSIONS

EVAR of infrarenal AIAs with preservation of antegrade flow to the IIA using IBDs is feasible with long-term sustained durability. Serious considerations should be given to the use of IBDs in patients with infrarenal AIAs meeting appropriate anatomic criteria.

Zenith Bifurcated Iliac Side Branch Device: Mid-term Results and Assessment of Risk Factors for Intraoperative Thrombosis

BACKGROUND

The aim of this study is to evaluate the short- and mid-term results of the Zenith bifurcated iliac side branch device (ZBIS) in the treatment of common iliac artery (CIA) aneurysms, and to assess risk factors for intraoperative internal iliac artery (IIA) thrombosis.

METHODS

All patients who underwent endovascular treatment of either an isolated CIA aneurysm or an aortoiliac aneurysm using the ZBIS device in the departments of vascular surgery of Strasbourg (France) and Lausanne (Switzerland) between January 2010 and December 2014 were retrospectively collected.

RESULTS

Thirty-one implantations were performed: 30 patients underwent 31 endovascular CIA aneurysm treatments with the ZBIS device. Mean operative time was 188 min. Technical success was obtained in 26 implantations (84%). In 5 implantations (16%), the final angiogram revealed an IIA thrombosis. Thirty-day mortality was 3.2%. Thirty-day morbidity was 13.3%. Mean follow-up was 15 months. Overall survival was 96% at 1 year and 89% at 2 years. In intention-to-treat analysis, primary patency of the internal iliac side branch was 84% at 1 year and 76% at 2 years (5 peroperative IIA occlusions and 1 late occlusion). Freedom from reintervention was 89% at 1 and 2 years. One case of type III endoleak and 2 cases of type II endoleaks were identified. Only type III endoleak required an additional intervention with a covered stent. Aneurysm diameter decreased in 15 implantations (48%) and remained stable in 16 implantations (52%). Clinical, radiological, and peroperative parameters were analyzed to identify risk factor for intraoperative thrombosis of the internal iliac side branch. Notion of intraoperative difficulties (any additional procedure that was not initially planned and increasing the operating time) appeared as a risk factor in multivariate analysis (P < 0.01, standard deviation 1.27, odds ratio 30.6).

CONCLUSIONS

The main findings of our study is that the procedure can be difficult to perform in particular conditions and can lead to peroperative failure in these cases, highlighting the need for adequate patients screening. When technical success is obtained, outcomes can be considered as satisfactory.

Bilateral Staged Computed Tomography-Guided Gluteal Artery Puncture for Internal Iliac Embolization in a Patient with Type II Endoleak

Repair of isolated iliac aneurysm with stent-graft implantation and internal iliac coverage may induce significant type II endoleak from patent internal iliac refilling leading to ongoing aneurysm growth. Subsequent treatment of such complication can be challenging especially in case of bilateral iliac involvement. Open repair is technically demanding and often a high risk procedure, while embolization via transfemoral approach is unviable due to the stent-graft coverage precluding direct antegrade access between the common and the internal iliac lumen. Percutaneous retrograde embolization from superior gluteal artery is a feasible technique in case of impossible access through the origin of internal iliac artery.

Common iliac and hypogastric aneurysms: open and endovascular repair

Currently, there are a variety of open surgical, endovascular, and hybrid options to treat iliac artery aneurysms (IAA). Anatomy of the common iliac artery (CIA) with regard to proximal and distal neck, involvement of the iliac bifurcation, and choice to preserve the ipsilateral internal iliac artery (IIA) all play a role in the decision process towards the preferred treatment method. This manuscript describes the available open surgical and endovascular techniques for the treatment of IAA. Indications, advantages and limitations, and outcomes of each technique are discussed.

Early experience with the Excluder® iliac branch endoprosthesis

AIM

Dilation of one or both common iliac arteries (CIAs) is a major concern in endovascular aneurysm repair (EVAR). One option for CIA aneurysm repair is hypogastric embolization followed by endograft extension into the external iliac artery. However, hypogastric occlusion does not always go unpunished and it may lead to ischemic complications. Aim of the paper was to evaluate early results with the Gore® Excluder® Iliac Branch Endoprosthesis (IBE) in the treatment of iliac aneurysms associated or not with abdominal aortic aneurysms.

METHODS

Between November 2013 and April 2014, in our Institution 7 Gore IBE were implanted in 5 patients. Technical success, 30-day mortality and complications were investigated.

RESULTS

Technical success and branch patency was 100%. There was no 30-day mortality. In 1 of the 2 bilateral cases an endovascular relining with bare stents was required due to a compression of iliac legs at level of aortic bifurcation.

CONCLUSION

Use of Gore IBE device in the treatment of aorto-iliac disease is feasible and safe. Late results are necessary to evaluate the performance of this endograft in the long term.

[Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery bypass graft]

We present the case of a 77 year-old patient scheduled for coronary artery bypass. During the infusion of levosimendan as preconditioning for surgery, a rupture of right common iliac artery occurred. Surgery was delayed and an urgent aorto-bifemoral bypass was performed. We believe that the rupture of the artery was triggered by an increase in transmural pressure due to the inotropic effects of levosimendan in a dilated diseased vessel. To our knowledge, there are no cases of aneurysm rupture as a complication during levosimendan infusion, but the coincidence of events in time strongly suggests some kind of causal relationship.

Decision-making and techniques in hypogastric artery revascularization

The aim of this article was to describe and discuss the currently available endovascular and open surgical techniques to preserve or occlude the hypogastric artery during aortoiliac aneurysm repair and thus support the process of decision-making in hypogastric artery revascularization.

Endovascular preservation of pelvic circulation with external iliac-to-internal iliac artery "cross-stenting" in patients with aorto-iliac aneurysms: a case report and literature review

Endovascular success depends heavily upon anatomical suitability for secure graft placement. Common iliac artery (CIA) aneurysms frequently extend close to the iliac bifurcation, requiring distal fixation in the external iliac artery (EIA), in turn excluding the internal iliac artery (IIA). The preservation of circulation to at least one IIA artery is highly recommended. We report an endovascular technique for complete preservation of the hypogastric arteries of an aorto-iliac aneurysm extending into the iliac bifurcation and hypogastric artery. A left CIA aneurysm involving the iliac bifurcation was excluded with a covered Fluency stent-graft (Bard Inc., New Jersey, USA) deployed from the EIA into the IIA followed by the internal deployment of a Luminex uncovered stent (Bard Inc.) extended into one branch of the hypograstric artery. IVUS evaluation was essential in determining precise aneurysm and sealing zone measurements. Complete preservation of hypogastric circulation was achieved. The placement of the uncovered stent effectively extended the sealing zones without covering either of the hypogastric distal branches and concurrently corrected the Fluency stent kinking due to severe arterial tortuosity. In CIA aneurysms involving the IIA, an uncovered stent can extend the sealing zones, whilst maintaining complete preservation of pelvic circulation and offers support to the covered stent-graft. IVUS seems necessary for precise neck evaluation.

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).

Branched iliac bifurcation: 6 years experience with endovascular preservation of internal iliac artery flow

OBJECTIVE

The objective of the current study was to share a 6-year experience with the iliac bifurcation device (IBD) and determine its safety and effectiveness in patients with common iliac artery aneurysms.

METHODS

Between 2001 and 2006, 46 patients were prospectively enrolled in a single institution study on the IBD. Indications included unilateral or bilateral common iliac artery aneurysms (CIAA) (combined or not with abdominal aortic aneurysm endovascular repair). The first 26 patients were intended to receive a first generation unibody IBD and the following 20 patients the second generation, modular, IBD.

RESULTS

In 33 patients out of 46 attempted (technical success per patient 72%), 35 iliac bifurcated devices (2 patients received bilateral IBD) out of 51 attempted (technical success per vessel 69%), were successfully implanted. The technical success rate (per vessel) was 58% for the first generation device and 85% for the second generation device. Inability to introduce the side branch into the IIA and intraoperative occlusions were the main reasons for technical failure. Among these failures, only two patients required open conversions. The mean +/- SD follow-up (radiological and clinical) of the 33 patients with a total of 35 successful IBD implantations was 26 +/- 17 months (median 24, range 3 to 60). During the follow-up period out of 35 successfully-implanted iliac bifurcation devices, four (11%) hypogastric side branch occlusions occurred, all within the first 12 months. Cumulative IBD side branch patency was 87% at 60 months. Comparing the first with the second generation IBD outcomes, cumulative patency rates at 2 years revealed no statistical difference (P = .774). No endoleak, and particularly no IBD, modular side branch disconnection, no late rupture, or deaths have yet been encountered.

CONCLUSIONS

Preservation of pelvic circulation in high risk patients treated for bilateral or unilateral common iliac aneurysms combined or without AAA is feasible and secure exclusively by endovascular repair. New generation iliac bifurcated devices show a favourable intraoperative performance and long-term outcomes.

Endovascular abdominal aortic aneurysm repair in patients with common iliac artery aneurysms – Initial experience with the Zenith bifurcated iliac side branch device

OBJECTIVE

To present our initial experience with the Zenith bifurcated iliac side branch device that preserves internal iliac artery flow whilst excluding aorto-iliac aneurysms.

METHODS

Between November 2005 and October 2006, data was prospectively collected on 8 patients in whom this device was used; 2 aorto-bi-iliac aneurysms, 3 aorto-uni-iliac aneurysms, 1 solitary common iliac aneurysm, 1 distal type 1 endoleak, and 1 internal iliac aneurysm.

RESULTS

No mortality or major complications resulted from use of this device. The median fluoroscopy time was 53 minutes (range 38 to 105) and a median of 102 g of iodine (range 84 to 130) as contrast were used. One patient required a blood transfusion and only one of the eight side branches occluded. There has been no endoleak related to the device in the median follow-up period of 6 months (1 to 14 months).

CONCLUSION

This device provides an alternative for the management of patients with aorto-iliac aneurysms that is safe and less complex than, previously described, hybrid procedures that preserve internal iliac flow.

Iliac Conduit for Renal and Visceral Artery Access During Endovascular Repair of a Pararenal Aneurysm with a Fenestrated Stent-Graft

PURPOSE

To report a technique for fenestrated stent-graft repair involving a conduit implanted at the origin of a patent aneurysmal common iliac artery (CIA) in a patient with a pararenal aortic aneurysm and iliac artery occlusion.

CASE REPORT

A 60-year-old man with multiple comorbidities presented with an 8-cm abdominal aortic aneurysm (AAA) with no infrarenal neck according to computed tomography (CT). Both CIAs were aneurysmal; the left was occluded, as were the left internal and external iliac arteries and the inferior mesenteric artery. Two patent accessory renal arteries were depicted. Because an infrarenal neck was absent, treatment with a fenestrated endograft was performed under general anesthesia. The right CIA was approached via an oblique retroperitoneal incision. A 10-mm polytetrafluoroethylene tube graft was implanted on the origin of the right CIA aneurysm in an end-to-side fashion to facilitate delivery of a Zenith endograft constructed with 2 small fenestrations for the renal arteries, 1 large strut-free fenestration for the superior mesenteric artery, and a scallop for the celiac trunk. The proximal fenestrated body of the Zenith device was introduced via the right iliac artery by direct puncture of the common femoral artery. The conduit was used to cannulate the 3 fenestrations for subsequent deployment and for delivery of the distal Zenith aortomonoiliac device. The procedure was completed successfully, but 12 hours after surgery, the patient developed a significant right retroperitoneal hematoma, which was treated surgically. CT confirmed patency of all visceral arteries and no endoleak. One month after the initial procedure, he had recovered totally and was discharged.

CONCLUSION

Iliac conduits could widen the feasibility of fenestrated endografting in patients unfit for open surgery with pararenal aneurysms and challenging iliac anatomy. However, this adjunctive procedure has its own morbidity.

Classic and endovascular surgical management of isolated iliac artery aneurysms

AIM

Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique.

METHODS

Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time.

RESULTS

There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion.

CONCLUSIONS

Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.

Preservation of pelvic circulation with hypogastric artery bypass in endovascular repair of abdominal aortic aneurysm with bilateral iliac artery aneurysms

PURPOSE

The endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) with a bilateral common iliac artery aneurysm (CIAA) often requires exclusion of the bilateral hypogastric artery (HA), which can be associated with pelvic ischemic complications such as erectile dysfunction and buttock claudication. This study assessed the effect of HA bypass on improving pelvic circulation.

METHODS

Five patients who underwent endovascular repair with HA bypass for an AAA with bilateral CIAA were evaluated. In all patients, the patency of the inferior mesenteric artery and bilateral HAs arteries was confirmed with preoperative computed tomography (CT) scans and angiography. During EVAR, penile blood flow was monitored with pulse-volume plethysmography measuring the penile brachial pressure index (PBI), and bilateral buttock blood flow was monitored with near-infrared spectroscopy measuring the gluteal tissue oxygenation index (TOI). An aortouni-external iliac artery stent graft with a crossover bypass was performed after embolization of the contralateral HA. HA bypass was performed between the crossover bypass graft and the ipsilateral HA via a retroperitoneal incision.

RESULTS

Unilateral coil embolization of the contralateral side HA trunk slightly decreased blood flow to the contralateral side buttock but did not cause significant changes in penile blood flow. At the completion of EVAR, the levels of both PBI and the contralateral side TOI were significantly lower than the baseline levels. After ipsilateral side HA revascularization with HA bypass, both PBI and bilateral gluteal flow returned almost to the baseline levels. Postoperative angiography and CT scans demonstrated the patency of all HA bypasses and no endoleaks. None of the patients experienced new onset of erectile dysfunction or buttock claudication 1 month after surgery.

CONCLUSION

Bilateral HA interruption during EVAR for AAA with bilateral CIAA was associated with significant depletion of both penile and gluteal blood flow. Intraoperative monitoring of PBI and TOI at the bilateral buttocks showed significant improvement of both parameters after HA bypass. HA bypass is an excellent procedure to improve pelvic circulation despite its increased surgical complexity.

EndoFit Stent-Graft Repair of Isolated Common Iliac Artery Aneurysms With Short Necks

PURPOSE

To evaluate the feasibility and efficacy of repairing isolated iliac artery aneurysms with short proximal necks (<10 mm) by implanting the EndoFit stent-graft.

METHODS

Seven patients (6 men; median age 73 years, range 70-78) were diagnosed with an isolated common iliac artery (CIA) aneurysm that featured a short proximal landing zone, complicating endovascular treatment. The median aneurysm diameter was 4.4 cm (range 3.5-7.0), and the median proximal neck length was 7 mm (range 5-9).The aneurysms were treated using the EndoFit stent-graft, which can be deployed in a short proximal landing zone. The modified technique involves the deployment of the graft directly above the aneurysm sac without obstructing the contralateral iliac axis, thus affixing the bare proximal stent in the terminal aorta. Follow-up was performed by clinical evaluation and computed tomography at 1, 6, and 12 months postoperatively.

RESULTS

The EndoFit stent-graft was successfully deployed in all cases, with complete aneurysm exclusion. In 1 case, the deployment of a second cuff was necessary to secure complete aneurysm exclusion. The median follow-up was 18 months, during which no deaths occurred, and no endoleak or stent-graft migration was observed. Endograft thrombosis occurred in 1 case due to graft angulation caused by external iliac artery stenosis and kinking. None of the aneurysms has ruptured, and there have been no serious complications.

CONCLUSION

Direct endoluminal repair of isolated CIA aneurysms with short proximal necks is feasible using this technique. Efficacy and long-term results are to be confirmed by larger scale series over a long time period.

[Ultrasound diagnosis in endoprosthesis of lower extremity arterial aneurysms with "Hemobahn"- and "Viabahn"-eluted stents]

The paper presents the results of color duplex scanning (CDS) in 7 patients treated at the Unit of Vascular Surgery, Clinical Hospital No. 83, from 2002 to 2006, in whom 5 Hemobahn grafting stents and 2 Viabahm ones were implanted into the lower limb arterial aneurysms and the proximal anastomoses of the iliofemoral alloshunts "Gore-tex". A grafting stent was individually selected for each specific case. All the examinees were males. The patients' age was 60 to 70 years. The results of endovascular interventions were assessed, by analyzing color duplex scanning (CDS) of a grafting stent implantation area in early postoperative periods (days 1-3), further by the scheme following 1, 3, 6, and 12 months and then twice a year. Endovascular intervention areas were studied by the standard procedure on Logic-500 and Vivid-700 ultrasound apparatuses (USA) with a 7.5-MHz linear transducer and a 3.5-MHz convection transducer. In the postoperative period, multiprojection scanning was used to detect stent configuration impairments. According to the data of examination using the CDS technique, a surgical success was noted in 100% of cases. In all cases, stage, adequate aneurysmal stenting along with the restoration of the geometry of proximal anastomoses of iliofemoral alloshunts, iliac and superficial femoral arteries with exclusion of aneurysms from blood flow was diagnosed at a hospital stage. Follow-up ultrasonography revealed no changes in the area of endovascular intervention. Thus, as a highly informative, noninvasive technique, CDS can assess the results of implantation of grafting stents into the arteries and shunts of the lower extremities in both early and late postoperative periods.

Computed Tomography and Ultrasound in Follow-up of Patients after Endovascular Repair of Abdominal Aortic Aneurysm

The purpose of this study was to compare our experience with duplex ultrasonography (US) and computed tomography (CT) for the routine follow-up of patients after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). We reviewed the electronic charts and radiologic exams of the first 125 patients (113 males, 12 females, median age of 76 years, range 48-98 years) with AAA treated by EVAR from June 1996 to November 2001. Our follow-up protocol included serial CT and US at regular intervals after the procedure (before discharge, at 1 month, and then every 6 months). Adequacy of each exam, ability to detect endoleaks, measurements of AAA diameter, and ability to determine graft patency were compared. For endoleak detection, comparison between CT and US was done using CT as the gold standard. A total of 608 exams, 337 CTs and 271 US, were performed 1 day to 5 years after endovascular aneurysm repair; 98% of CT and 74% of US were technically adequate. Contrary to CT, the proportion of adequate US exam was significantly less in patients with higher body mass index (BMI > or = 30 = 54% vs. BMI < 30 = 81%, p < 0.001) and for pre-discharge US compared to the post-discharge US (54% vs. 88%, p = 0.0005). Concurrent scan pairs were obtained in 252 instances in 107 patients (1-8 pairs per patient). Excellent correlation between AAA diameter measured on CT and US was noted (correlation coefficient of 0.9, p < 0.0001). However, agreement was poor. CT anteroposterior (AP) and transverse measurements were on average 2.9 mm (95% limits of agreement = -7 to 13 mm) and 1.8 mm (95% limits of agreement = -9 to 12 mm) greater than US. For AAA diameter change, there was no case of increase AP diameter on CT. However, in 23% (29/128 pairs of sets) of US, an increase in AAA size that could have influenced patient management (> or = 4 mm) was reported despite no change demonstrated on CT. For endoleak detection, sensitivity and specificity of US compared to that of CT was 25% and 89%. Similar sensitivity and specificity were noted when we excluded the first set (25% and 95%), sets done prior to 2000 (30% and 89%), inadequate CT or US scans (31% and 98%), or duplicate sets of results for each patient (28% and 81%). Of the 27 endoleaks missed on US in 17 patients, 2 were type I endoleaks. None of the four endoleaks seen only on US were type I endoleak. US usefulness prior to discharge was reduced by the high rate of inadequate exam, especially in obese patients. Despite the excellent correlation in AAA diameter between US and CT, there was significant disagreement in AAA diameter measurement and diameter change. Sensitivity of nonstandardized US for endoleak was low compared to CT. CT remains our primary imaging study after EVAR, but standardization of post-EVAR US technique may improve its accuracy.

Ultrasound evaluation of abdominal aortic and iliac aneurysms and mesenteric ischemia

The role of US in imaging of the abdominal vasculature has broadened over recent years. Long considered the modality of choice in the detection of AAA, its use has expanded to diagnosing and monitoring IAAs and PAAs, screening for mesenteric ischemia, and posttreatment monitoring of endovascular stents.

A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair

PURPOSE

Hypogastric artery embolization (HAE) is often performed in endovascular aortoiliac aneurysm repair to prevent potential endoleak, and this can be associated with pelvic ischemic sequelae. This prospective study was performed to evaluate the clinical outcome of HAE in patients who underwent endovascular aortoiliac aneurysm repair.

METHODS

During a 15-month period, 12 patients who underwent either unilateral or bilateral HAE for endovascular aortoiliac aneurysm repair were prospectively evaluated. All patients underwent preoperative and postoperative penile pressure measurement and pulse-volume recording evaluation. Angiographic features relating to pelvic collaterals and clinical outcomes relating to pelvic ischemia were evaluated.

RESULTS

Unilateral HAE was performed in eight patients (67%), and bilateral HAE was performed in four patients (33%). Mean reductions in penile brachial index (PBI) after unilateral and bilateral HAE were 13 +/- 6% (not significant) and 39 +/- 14% (P <.05), respectively. Erectile dysfunction occurred in three patients for unilateral HAE (38%) and in two patients for bilateral HAE (50%), with an overall PBI reduction of 36 +/- 12% (P <.01). No significant change in thigh brachial or ankle brachial index occurred after HAE. Hip and buttock claudication occurred in four patients for unilateral HAE (50%) and in two patients for bilateral HAE (50%), with an overall PBI reduction of 18 +/- 9% (P <.05). Other associated pelvic ischemic complications after bilateral HAE included one scrotal skin sloughing (25%) that occurred 3 days after aortic endografting and one sacral decubitus (25%) that occurred 4 months after aortic endografting. With analysis of angiographic collateral patterns, diseased profunda femoral artery (PFA; >50% stenosis) was noted in four patients, all in whom post-HAE pelvic ischemic symptoms developed (P <.05). In contrast, only four of the remaining eight patients with normal or mild PFA disease had pelvic ischemic sequelae after HAE.

CONCLUSION

Erectile dysfunction after HAE correlates with significant reduction in PBI. Severe pelvic ischemic symptoms are more likely to occur after bilateral HAE, which should be avoided if possible. Moreover, patients with diseased PFA are at risk of development of pelvic ischemia after HAE. Our data suggest a potential role of concomitant profundapalsty at the time of aortic endografting to improve pelvic collateral flow and reduce pelvic ischemia in this subset of patients with HAE.

Deformation of self-expanding stent-grafts complicating endovascular peripheral aneurysm repair

PURPOSE

To demonstrate the deformation of self-expandable stents after endovascular repair of peripheral aneurysms.

METHODS AND RESULTS

The Corvita Endoluminal Graft was used to treat a traumatic false aneurysm of the right subclavian artery and a common iliac artery aneurysm in 2 patients. In the subclavian case, the stent-graft showed a "cigar-shaped" deformation with hemodynamically significant stenoses at the proximal and distal ends at 3 months. In the second case, the same type of deformity was noted only 1 day after implantation. Two months later, the stent-graft occluded, necessitating surgical repair.

CONCLUSIONS

Both cases demonstrate the possibility of stent deformation of self-expanding stent-grafts implanted at arterial sites not subject to external compression.

Isolated iliac artery aneurysms in patients with or without previous abdominal aortic aneurysm repair

BACKGROUND

Isolated iliac artery aneurysms (IAA) in patients with or without previous abdominal aortic aneurysm (AAA) repair are rare. We wanted to compare the presentation, distribution, treatment, outcome and patterns of subsequent aneurysm formation in these patients.

METHODS

We retrospectively reviewed patients with isolated IAA over a 10-year period. Patients with primary isolated IAA (group 1) were compared with patients who presented with IAA after previous AAA repair (group 2).

RESULTS

There were 23 patients in each group. Demographics and comorbidities were similar. No aneurysms were detected outside of the iliac system in group 1; 22% of patients in group 2 had other aneurysms. The mean time after AAA repair to IAA diagnosis was 8.8 +/- 3.2 years for operated on patients. The in-hospital mortality was 0% for elective cases and 50% for emergency cases for both groups. Three patients in group 2 (13%) developed new aneurysms during follow-up, whereas the only new aneurysm in group 1 was a contralateral IAA.

CONCLUSIONS

Patients with new IAA after AAA repair have a greater tendency to develop further aneurysms in other sites, synchronously or metachronously. The time to detection of new IAA after AAA repair is at least 5 years in most cases. In both groups, a quarter to a third of patients present with rupture, with a resultant mortality of 30% to 50%, whereas those operated on electively have minimal morbidity and almost no mortality.

Quality control during endovascular aneurysm repair: monitoring aneurysmal sac pressure and superficial femoral artery flow velocity

PURPOSE

To use intraoperative aneurysmal sac pressure measurement and flow monitoring of the superficial femoral artery (SFA) to ensure complete exclusion of the aneurysm from the circulation.

METHODS

A 5F catheter was positioned in the aneurysmal sac of 15 consecutive patients undergoing endovascular aortomonoiliac aneurysm repair between February and September 1997. The catheter was connected to an external pressure transducer allowing pressure monitoring throughout the operation and for 24 hours postprocedurally. Flow velocity was monitored in the contralateral SFA by insonation with a 2-MHz Doppler ultrasound probe.

RESULTS

No technical defect was observed in the deployment of 10 endografts, which demonstrated marked reduction in sac pressure and good flow in the lower limb. The mean aneurysm pressure dropped from 123 to 57 mmHg after graft insertion. In 5 cases, monitoring detected problems during the endograft procedure. In 3, incomplete stent deployment was detected by a failure of sac pressure to fall following stent inflation and by the presence of flow in the contralateral femoral artery. In the other 2 cases, a distal endoleak was detected by direct injection of contrast into the sac.

CONCLUSIONS

Measuring aneurysm pressure in combination with SFA Doppler flow monitoring can detect complications of endovascular aneurysm repair.