Elsevier

International Journal of Cardiology

Volume 222, 1 November 2016, Pages 332-339
International Journal of Cardiology

Endovascular anatomic reconstruction of the iliac bifurcation with covered stentgrafts in sandwich-technique for the treatment of complex aorto-iliac aneurysms

https://doi.org/10.1016/j.ijcard.2016.07.226Get rights and content

Abstract

Objective

Endovascular anatomic reconstruction of iliac artery bifurcation in aorto-iliac aneurysms using commercial stentgrafts in sandwich-technique by bilateral transfemoral approach.

Methods

24 patients (mean 73.8 ± standard deviation 6.8 years) with complex aorto-iliac aneurysms (AAA): n = 17; diameter 64 ± 15 [48–100] mm; common-iliac-artery (CIA): n = 27; 43 ± 15 [30–87] mm; internal-iliac-artery (IIA): n = 14; 28 ± 8 [15–43] mm) were prospectively enrolled for EVAR with preservation of the IIA (n = 31; bi-lateral n = 7).

Maintenance of antegrade flow to IIA by iliac reconstruction was performed in sandwich-technique prior to EVAR.

Follow-up of 15.0 ± 10.8 [1–40] months included contrast-enhanced ultrasound and computed-tomography after 1 week, 3, 6 and every 12 months.

Results

Initial technical success for anatomic reconstruction of the iliac arteries in 31 instances was 100%. Primary patency of iliac neo-bifurcations was 90.9% (20/22) at 6 months and 84.2% (16/19) at 1 year. Postprocedural gutter-endoleaks type 1b were obvious in 6.5% (2/31) of cases, which disappeared 3 months later. Aortic/iliac aneurysm-size after 1 year decreased (> 5 mm) in 61.5% of patients. No aneurysm-size increase or late rupture occurred.

Conclusions

Endovascular reconstruction of the iliac bifurcation with commercial standard stentgrafts is safe and effective. Transfemoral approach allows extension of distal landing zone for EVAR while preserving the internal iliac artery blood-flow, even in unfavorable iliac anatomy.

Introduction

Abdominal aortic aneurysms (AAA) are associated with iliac artery aneurysms in up to 40% of patients [1], [2]. Proximal and distal fixation and sealing is crucial for successful endovascular aortic repair (EVAR). The common iliac artery (CIA) typically serves as the distal landing zone for the iliac limb extension for aorto-iliac stentgrafts. If the diameter of available limb extensions is inappropriate for distal sealing, alternative landing zones in the external iliac artery (EIA), or alternative techniques are required [3]. Limb extension into the EIA typically requires occlusion of at least the proximal part of the internal iliac artery to avoid endoleakage. Unfortunately, embolization of the IIA may lead to significant (gluteal) claudication, erectile dysfunction or seldom colonic/sigmoid ischemia. The risk is significantly increased in the presence of disease or occlusion of the deep femoral artery with or without concurrent femoral-popliteal segment disease. Furthermore, colonic ischemia will be more likely in the presence of superior mesenteric artery and celiac trunk disease, as well as peripheral small vessel disease in the IIA-territory, which will compromise collaterals [4], [5], [6].

An option for IIA-preservation is the use of an iliac side-branch device (ISBD). However, unfavorable conditions including dimension of the CIA, access vessels or tortuosity may constitute technical contraindications [3], [7], [8]. Alternatively, implantation of standard stentgrafts through a trans-brachial or subclavian access has been successfully used to overcome these technical drawbacks. Experience with these innovative techniques is still limited making further evaluation necessary [9], [10], [11], [12].

The purpose of our study was to prospectively evaluate the results of a standardized transfemoral approach to preserve antegrade pelvic perfusion via the hypogastric artery. Primary objectives included technical feasibility and mid-term results using regular commercially available “off-the-shelf” materials in complex aorto-iliac aneurysms. Instead of three access sites, a bi-lateral transfemoral approach was used without an additional transbrachial or subclavian access.

Section snippets

Methods

During 2010–2015, 24 consecutive male Caucasian patients with complex aorto-iliac aneurysms unsuitable for open or endovascular repair with ISBD were prospectively enrolled at two experienced tertiary centers for endovascular iliac artery bifurcation reconstruction. Demographic data, aneurysm characteristics and co-morbidities are presented in Table 1. Inclusion criteria consisted of uni- or bilateral aneurysms of CIA ≥ 30 mm, or IIA aneurysms defined as diameter more than twice of the IIA. In all

Results

Overall, 24 patients underwent percutaneous transfemoral reconstruction of an iliac neo-bifurcation for preservation of the hypogastric artery. A total of 31 anatomic reconstructions of iliac neo-bifurcations were performed; unilateral in 17 and bilateral in 7 patients. Initial technical success rate for iliac artery reconstruction was 100%. Aneurysm-size of the CIA (n = 27) on the right side (n = 12) was 41 ± 15 [30–87] mm and on the left (n = 15) 46 ± 15 [31–81] mm. Bilateral CIA-aneurysms were observed

Discussion

Treatment of aorto-iliac aneurysms is not standardized. A variety of surgical and endovascular techniques with or without different approaches for hypogastric artery preservation have been described [4], [6], [12], [13], [14], [15], [16]. Implantation of commercially available iliac side-branch devices (ISBD) is an established technique for maintenance of the internal iliac artery perfusion. However, usage is more sophisticated compared to standard EVAR. Most importantly, patient selection has

Conclusion

The described sandwich-technique is well applicable for patients anatomically not suitable for iliac side-branch devices. Endovascular preservation of the hypogastric artery by reconstruction of an iliac neo-bifurcation is achievable by standard available stentgrafts. The bilateral transfemoral approach makes an additional transbrachial access un-necessary. The favorable mid-term results are very encouraging. Extension of the distal landing zone with off-the-shelf materials has the potential

Disclosures and contributions

All authors takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Conflict of interest

All authors report no relationships that could be construed as a conflict of interest.

References (30)

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All authors have made substantial contributions to the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article and revising it critically for important intellectual content, final approval of the manuscript.

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