- Email: [email protected]
Endovascular Hypogastric Artery Preservation During Endovascular Aneurysm Repair: A Review of Current Techniques and Devices
Accepted Manuscript Endovascular hypogastric artery preservation during endovascular aneurysm repair: A review of current techniques and devices Khaldoun Bekdache , Andrew Cha , Vladimir Neychev , Alan Dietzek PII:
S0890-5096(14)00674-8
DOI:
10.1016/j.avsg.2014.10.019
Reference:
AVSG 2198
To appear in:
Annals of Vascular Surgery
Received Date: 10 July 2014 Revised Date:
21 October 2014
Accepted Date: 25 October 2014
Please cite this article as: Bekdache K, Cha A, Neychev V, Dietzek A, Endovascular hypogastric artery preservation during endovascular aneurysm repair: A review of current techniques and devices, Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2014.10.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Review Article Endovascular hypogastric artery preservation during endovascular aneurysm repair: A review of current techniques and devices.
Corresponding author: Alan M Dietzek,
M AN U
Department of Surgery, Danbury Hospital, CT, USA
Chief, Vascular and Endovascular Surgery
TE D
Western CT Health Network – Danbury Hospital 41 Germantown Rd, Suite 101 Danbury, CT 06810
EP
Phone: 203-794-5680
AC C
Email: [email protected]
SC
Khaldoun Bekdache, Andrew Cha, Vladimir Neychev and Alan Dietzek
RI PT
ACCEPTED MANUSCRIPT
Abstract
SC
Despite the improvement of endovascular techniques, one aspect of aneurysmal
disease that continues to be challenging is the management of aortoiliac aneurysms.
M AN U
Sacrificing the hypogastric artery (HGA) for effective treatment is not without sequelae; that may include buttocks claudication, colonic ischemia, spinal cord ischemia, as well as buttock and scrotal necrosis. This should be taken into consideration particularly in patients with previous intervention or potential
TE D
additional future interventions. This review describes the current endovascular techniques for preservation of hypogastric artery perfusion. Keywords
AC C
EP
Hypogastric, endovascular, preservation, aneurysms, embolization, iliac, devices
SC
RI PT
ACCEPTED MANUSCRIPT
M AN U
Introduction
The treatment of abdominal aortic aneurysms (AAA) has undergone dramatic improvement over the last 20 years with the advent of endovascular techniques. Endovascular aneurysm repair (EVAR) for both elective and ruptured AAA's has
TE D
decreased peri-operative morbidity and mortality as well as length of stay in hospital. Although widely used for standard risk AAA patients, it has been accepted particularly for high-risk patients who would otherwise not be able to tolerate or
EP
survive conventional open repair. Despite the success of endovascular techniques, one aspect of aneurysmal disease that continues to be challenging is the management
AC C
of aortoiliac aneurysms and the associated clinical significance of sacrificing the hypogastric arteries (HGA) for effective treatment. Up to 15 - 40% of AAA's have concomitant common iliac artery aneurysms(1), and in these cases, endovascular treatment can be difficult due to the need for adequate
ACCEPTED MANUSCRIPT
RI PT
distal landing zones in order to prevent type Ib and type II endoleaks. This is especially true in cases where aneurysmal disease extends to the external iliac
arteries. However, it is still prudent and in line with basic tenets of endovascular
SC
technique to ensure proper distal coverage, which in some cases may require
occlusion of either one or both HGA's. Several open and endovascular techniques
M AN U
have been developed for preservation of hypogastric artery perfusion. The aim of this review is to examine the literature with respect to outcomes following EVAR with hypogastric artery occlusion and to describe current endovascular techniques for preservation of hypogastric artery perfusion.
TE D
Outcomes of hypogastric artery occlusion (Table 1)
Several studies have shown that HGA occlusion can be performed without consequent life threatening pelvic ischemic complications (2). Mehta and Veith et al highlighted
EP
the possible sequelae of HGA occlusion, both via endovascular and open approaches, and found them to be of low incidence and morbidity. They reported no cases of
AC C
buttock necrosis, ischemic colitis requiring laparotomy, or any deaths associated with either unilateral or bilateral HGA occlusion (2, 3). Zander et al also noted acceptable rates of pelvic ischemic complications following bilateral HGA occlusion with only one
ACCEPTED MANUSCRIPT
RI PT
of fourteen patients having persistent symptoms of buttock claudication that resolved completely within 18 months(4).
Though the majority of the sequelae following HGA occlusion, either unilateral or
SC
bilateral, are non-life threatening, other complications have been well documented. The most common pelvic ischemic complication is buttock claudication with
M AN U
incidences ranging from 1.6 - 56% (5). In a literature review by Lin et al looking at 21 peer-reviewed published reports of hypogastric embolization for EVAR, the incidence of buttock claudication was 28% for unilateral embolization and 42% for bilateral embolization. Those that underwent unilateral embolization were better able to
TE D
tolerate their buttock claudication and had higher rates of resolution without the need for further intervention. Nevertheless, persistent symptoms at 1 year have been observed in 9- 15% of patients (1, 6, 7).
EP
Colonic ischemia is another feared pelvic ischemic complication of HGA occlusion, with an incidence as high as 9% (6, 8-12). The inferior mesenteric artery is routinely
AC C
sacrificed during EVAR, and therefore loss of collateral circulation from embolization of one or both HGAs can have detrimental effects to the blood supply of the distal and sigmoid colon. This is particularly important in patients with previous colonic surgery when the Inferior mesenteric artery is sacrificed proximal to the origin of the
ACCEPTED MANUSCRIPT
RI PT
left colic artery making the ensuing blood supply unpredictable and likely diminished resulting in a theoretical increased risk of this complication. Most patients found to have colon ischemia, however, can be managed non-surgically with close observation,
SC
antibiotics, and a short period of bowel rest.
New onset erectile dysfunction has been found to occur in up to 33% (10-45%) of
M AN U
patients undergoing HGA occlusion (6). Lin et al demonstrated a significant decrease in penile pressure after bilateral HA embolization (9). Though not a life threatening consequence of HGA occlusion, this complication is considered by some patients to be quite detrimental to their overall quality of life, especially in the 15% of patients who
TE D
suffer from persistent symptoms (13).
Other rare, but devastating complications following HGA occlusion include spinal cord ischemia, buttock necrosis, scrotal skin ulceration, and sciatic nerve ischemia (3,
EP
6, 9, 14-19). For those patients undergoing HGA occlusion, the risk of complications can be compounded by severe atherosclerotic disease of the contralateral HGA, the
AC C
ipsilateral femoral system, especially the profunda femoris artery and/or the presence of a large inferior mesenteric artery. So too can the presence of thoracic aneurysm disease, the treatment of which may require compromise of spinal cord blood flow. In a recent review, Eagleton et al showed higher rates of spinal cord
ACCEPTED MANUSCRIPT
RI PT
ischemia associated with extensive endovascular procedures, particularly concomitant thoracic aneurysm repair, even when only single collateral was
occluded. In these cases outcomes were poor and mortality rates were higher (20).
SC
Other risk factors include young age and left ventricular dysfunction (7, 10-12, 14, 1719). These factors should be taken into consideration when planning for the
M AN U
aneurysm repair and whether to sacrifice or preserve the HA. (Table 2) Table 1: Outcomes of hypogastric artery occlusion Complication
Incidence (%) 1.6-56
Persistent buttock claudication
9-15
Colonic ischemia Erectile dysfunction
EP
Spinal cord ischemia
TE D
Early buttock claudication
0-9
10-45
0.4-4.8
<1%
Scrotal skin ulceration
<1%
Sciatic nerve ischemia
<1%
AC C
Buttock necrosis
ACCEPTED MANUSCRIPT
Young age Left ventricular dysfunction Previous colonic resection Presence of thoracic aortic aneurysm
Large inferior mesenteric artery
Minimizing pelvic complications
M AN U
Severe SMA, ipsilateral femoral or contra lateral HGA disease
SC
RI PT
Table 2: Relative Indications for HGA preservation
Several options are described to minimize pelvic complications; those include
TE D
limiting the hypogastric artery embolization to the main trunk rather than more distally, consequently preserving the gluteal, rectal, vesical and internal pudendal branches. Preserving collaterals from iliac and femoral circumflex branches have also
EP
proved to minimize buttock claudication (2). Staged hypogastric artery embolization is described in the literature as a means of minimizing associated complications but
AC C
there is no good data to support this strategy (7). Some published reports suggest that coverage of the hypogastric artery orifice only without embolization may reduce the incidence of buttock claudication (0-27%) and decrease the risk of more severe complications without significantly increasing the chances for a type II endoleak (0-
ACCEPTED MANUSCRIPT
RI PT
8.9%)(21-25). Thus, despite previously mentioned studies supporting HGA occlusion as a relatively benign procedure, it is well documented that pelvic ischemic
complications do occur and can affect overall quality of life. Therefore, attempts at
SC
preserving the HGA should be employed in selected patients when technically feasible (26). Open surgical methods include external iliac artery to HGA bypass,
M AN U
transposition of the HGA to the external iliac artery, as well as hybrid techniques utilizing an aortouniliac stent graft with femoro-femoral bypass. These procedures usually subject the patient to general anesthesia and the morbidities associated with open vascular surgery including bleeding, infection, and other less common but
TE D
significant complications.
Alternatively, an endovascular approach to HGA preservation may be associated with decreased morbidity and mortality, and overall length of hospital stay as compared to
EP
open procedures. They do, however, prolong the EVAR procedure and expose the patient to larger contrast and radiation doses.
AC C
In this review, we have limited our following discussion to endovascular
techniques for the preservation of hypogastric artery circulation. Endovascular techniques for hypogastric artery preservation
ACCEPTED MANUSCRIPT
RI PT
Several endovascular techniques have been described to preserve perfusion through unilateral or bilateral hypogastric arteries in complex aortoiliac aneurysmal disease. The most commonly used methods are described below.
SC
The trifurcation technique
This endovascular technique utilizing parallel stent graft deployment concept
M AN U
employs the use of multiple main body bifurcated endografts (see Figure 1). This method requires bilateral femoral access in addition to brachial access in a "topdown" approach to facilitate cannulation of the HGA. Case reports have described use of an initial main body bifurcated graft, such as a 28-mm diameter Gore Excluder
TE D
(Gore & Associates, Flagstaff, AZ) along with the placement of a flared 20mm diameter limb in the contralateral gate(27-29). A second main body 23-mm diameter bifurcated graft is then deployed into the flared limb from the ipsilateral femoral
EP
artery. Left brachial or axillary access allows cannulation of the HGA using a 12F 80cm sheath through the short limb of the second main body gate. Viabahn covered
AC C
stent grafts (11-mm x 5-cm or 13-mm x 5-cm) are then deployed extending coverage from the second main body gate into the HGA (see Figure 2). Although originally described with a Gore Excluder stent graft this technique is not limited to the use of
ACCEPTED MANUSCRIPT
RI PT
only one type of main body bifurcated graft, but rather can be utilized with a variety of FDA-approved available devices. [Insert Figure. 1]
SC
[Insert Figure. 2]
Though early case reports have noted short-term technical success, this "trifurcation"
M AN U
technique requires the use of at least five devices, which can lead to an increased risk of migration, endoleak, and graft malfunction. In addition, the need for brachial access can be associated with brachial and aortic arch injuries. Other possible disadvantages include higher procedural cost, length of procedure, increased amount
technique.
TE D
of contrast, and the fact that bilateral HGA preservation is not possible with this
The Snorkeling Technique
EP
This method entails the placement of covered stents within the external and internal iliac branches extending parallel to or within the aortic stent graft. This method, also
AC C
known as the double-barrel technique, the chimney graft, or the sandwich technique, may require access via the femoral arteries and the brachial artery depending upon which technique and device are utilized. Early reports of small series have shown promising results with technical success, defined as aneurysm occlusion without
ACCEPTED MANUSCRIPT
100% and 88-100% respectively at 1 year. (26, 30, 31).
RI PT
endoleak, of 88-100% and external iliac and hypogastric artery patency rates of 95-
Lobato et al presented their recent data, comparing their sandwich technique to coil
SC
embolization, at the International Symposium on Endovascular therapy (ISET) 2013. The rate of permanent buttock claudication was significantly higher in the coil
M AN U
embolization group (12.7 vs 2.5%) as were late type II endoleaks (15.5 vs 2.5%). Their technical success rate was 100%. Mortality, postoperative aneurysm rupture, late type I endoleaks, type III endoleaks, limb migration, occlusion and reintervention were similar in both groups(32).
TE D
One method requires bilateral femoral artery access only without the need for brachial artery access. This was initially described with the use of the Powerlink unibody endograft but has largely been replaced by the Endologix AFX device in the
EP
US and Europe (Endologix, Inc. Irvine, CA) (See Figure 3, 4) (33, 34)(35,36). A 28-mm diameter main unibody device with 16-mm diameter bifurcated limbs is deployed
AC C
and straddles the aortic bifurcation. The more proximal aortic extension (size dependent on infrarenal aortic length and aortic neck diameter) is then deployed. Cannulation of the common iliac artery limb of the stent graft on the side ipsilateral to the common iliac artery aneurysm is performed through ipsilateral femoral artery
ACCEPTED MANUSCRIPT
RI PT
access. Cannulation of the hypogastric artery is then achieved from the contralateral common femoral artery. Contralateral hypogastric artery cannulation through the endograft can be accomplished with the Endologix device because unlike other
SC
endografts, the device sits on the sits on the aortic bifurcation replicating its
geometry. With other modular devices the bifurcation is recreated more proximally
M AN U
within the aorta resulting in a steeply angulated bifurcation making wire passage over the bifurcation and through the contralateral iliac limb very difficult to accomplish. A 6-mm or 8-mm x 10-cm Viabahn endoprosthesis (Gore & Associates, Flagstaff, AZ) is then deployed within the HGA and a 16-mm diameter Powerlink iliac
TE D
limb extension is deployed within the external iliac artery for complete preservation of in-line flow by creation of a double-barrel lumen. [Insert Figure.3]
EP
[Insert Figure. 4]
Techniques have described both simultaneous and sequential deployment with the
AC C
iliac limb extension being deployed first followed by the Viabahn stent graft. Proponents for the sequential deployment believe the Viabahn covered stent graft has a stronger radial force compared to the iliac limb extension and therefore should
ACCEPTED MANUSCRIPT
risk of external iliac artery occlusion.
RI PT
be deployed afterwards in order to prevent graft in-folding and subsequent attendant
The advantages of this method are that only femoral access is necessary while
SC
permitting the preservation of one or both HGA’s. The disadvantage is that there is presently only one commercially available and FDA approved unibody graft
M AN U
(Endologix Powerlink) in the United States limiting the surgeon’s device options for treatment.
The "Brazilian or sandwich snorkeling" technique first described by Lobato, is similar to the "trifurcation" technique in that brachial access is required for cannulation of
TE D
the HGA(37). Rather than use five different stent graft devices, however, as few as three may be required (see Figure 5). Once deployment of the main body bifurcated graft is achieved via femoral artery access, the ipsilateral hypogastric artery is
EP
cannulated via left brachial or axillary artery access. An undeployed Viabahn stent graft is then placed 2cm into the HGA and an iliac limb extension is positioned parallel
AC C
to the Viabahn graft from the ipsilateral femoral artery. A 6cm overlap within the ipsilateral iliac limb is required to achieve an adequate seal. As mentioned previously, the iliac limb extension is deployed first to prevent graft in-folding and possible external iliac artery occlusion. Complete aneurysmal exclusion and HGA
ACCEPTED MANUSCRIPT
RI PT
preservation is then achieved with deployment of the contralateral iliac limb (See Figure 6). [Insert Figure. 5]
SC
[Insert Figure.6]
This technique can allow for preservation of both HGAs and is more cost effective
M AN U
compared to the "trifurcation" technique because only one main body device is used. Again, this technique can be utilized with a variety of FDA-approved available devices. Even more importantly to the surgeon, there are no restrictions based on common iliac artery diameter or length, tortuosity, or HGA diameter. Access via the
TE D
left brachial or axillary artery, however, is still associated with risks due to wire manipulation within the aortic arch. Flared Limb Technique
EP
Also known as the Bell-Bottom Technique, the flared limb technique is the most commonly used technique to preserve flow into the hypogastric artery during
AC C
EVAR(1,38-40). This entails the use of a large diameter iliac extension limb to seal the distal common iliac artery while preserving the ostium of the hypogastric artery (See Figure 7). The advantages of this technique are its relative ease technichally and the use of available off the shelf devices. The largest diameter iliac limb as of this
ACCEPTED MANUSCRIPT
RI PT
writing is a 28 Fr (Endurant), which can treat only small CIA aneurysms with a maximum diameter of 26mm. The use of aortic cuffs as iliac extensions for the treatment of slightly larger diameter CIA aneurysms has also been described
SC
(1,39,40). Early peri-operative complications and re-interventions range from 8-
22%(1,39). Type 1b endoleaks have a reported incidence of 2.2-4%. The long-term
M AN U
durability of the bell-bottom technique is unclear with concerns over further aneurysmal dilation of the iliac artery with resultant stent graft, migration and Type1b endoleaks. [Insert Figure. 7]
TE D
Iliac Branched Devices
Iliac-branched devices (IBD) are currently not commercially available in the United States, however, early results have shown high primary technical success rates but
EP
disappointing patency rates in some studies. The IBD extends from within the standard EVAR graft into the external iliac artery preserving flow in the hypogastric
AC C
artery using a side branch. This requires cannulation of the hypogastric artery with a preloaded wire from the side branch using contralateral femoral artery access. Two different designs are available, one is the straight and other is the helical IBD. Several different devices are currently commercially available for use outside of the U.S.
ACCEPTED MANUSCRIPT
RI PT
including ,Zenith bifurcated iliac side branch device, Zenith helical branch device, GORE(R) EXCLUDER(R) Iliac Branch Endoprosthesis, Medtronic, Atrium, and JoMed (See Figure. 8). There are also case reports of use of a homemade branched device
SC
(See Figure.9). [Insert Figure. 8]
M AN U
[Insert Figure. 9]
In a literature review by Karthikesalingam et al looking at nine series utilizing iliacbranched devices, early technical success was 85-100%. The review also revealed a collective 12% IBD limb occlusion rate of which 50% developed buttocks
TE D
claudication. In this review the reported type I and III endoleak was only 1.6%(41). In two studies mid-term follow up at 5 years showed promising patency rates of 87 and 91.4%. (42,43) Parlani et al reported freedom of secondary intervention of 90%
EP
at 1 year and 81.4% at 5 years (42). Even with primary technical success and acceptable outcomes however, careful patient selection is essential as severe iliac
AC C
tortuosity and aneurysmal involvement of the HGA can lead to increased procedural challenges and higher rates of type I and III endoleaks(44,45). These devices are less adaptable to complex anatomy thus limiting wider applicability. Based on the current criteria for IBD use, up to 52% of the patients may not be suitable for this device. In
ACCEPTED MANUSCRIPT
RI PT
addition, operating time, total fluoroscopy time, and the amount of contrast volume used is highly variable (41,44,45). Also, the cost of these devices will likely exceed the costs for most of the snorkel procedures. Longer-term follow-up as well as wider
SC
availability of these devices is still awaited. Conclusion
M AN U
It is clear that a planned HGA occlusion is not an entirely benign procedure. This is particularly true in patients with contralateral HGA occlusion, those undergoing concomitant endovascular repairs of a thoracic aortic aneurysm, patients with severe ipsilateral femoral arterial disease, and in younger active patients.
TE D
Technological advancements have allowed the modern vascular surgeon to utilize various methods of endovascular HGA preservation. Each method as discussed in this review is associated with particular advantages and disadvantages.
EP
Nevertheless, each approach requires extensive and diligent pre-operative planning and imaging. Many times, the method selected is patient specific due to the inherent
AC C
nature of their disease.
Once commercially available, iliac branch endografts will likely replace many of the surgeon-modified branch grafts. These procedures, although technically challenging, may be more amenable for use in patients with difficult and complex anatomy than
ACCEPTED MANUSCRIPT
RI PT
prefabricated branched endografts. Furthermore, the cost may be significantly greater for the manufactured iliac-branched endograft, a point of some concern in our present healthcare environment. Finally, current methods of unilateral or bilateral
SC
endovascular HGA preservation can be successfully achieved with minimal morbidity and mortality and should be attempted whenever technically feasible.
M AN U
References
AC C
EP
TE D
(1) Naughton PA, Park MS, Kheirelseid EA, O'Neill SM, Rodriguez HE, Morasch MD, et al. A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation. J Vasc Surg 2012 Apr;55(4):956-962. (2) Mehta M, Veith FJ, Ohki T, Cynamon J, Goldstein K, Suggs WD, et al. Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001 Feb;33(2 Suppl):S27-32. (3) Mehta M, Veith FJ, Darling RC, Roddy SP, Ohki T, Lipsitz EC, et al. Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 2004 Oct;40(4):698-702. (4) Zander T, Baldi S, Rabellino M, Rostagno R, Isaza B, Llorens R, et al. Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance. J Vasc Interv Radiol 2007 Dec;18(12):1481-1486. (5) Lin PH, Chen AY, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg 2009 Sep;22(3):193-200. (6) Farahmand P, Becquemin JP, Desgranges P, Allaire E, Marzelle J, Roudot-Thoraval F. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008 Apr;35(4):429-435. (7) Bratby MJ, Munneke GM, Belli AM, Loosemore TM, Loftus I, Thompson MM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol 2008 Mar-Apr;31(2):246-253. (8) Verzini F, Parlani G, Romano L, De Rango P, Panuccio G, Cao P. Endovascular treatment of iliac aneurysm: Concurrent comparison of side branch endograft versus hypogastric exclusion. J Vasc Surg 2009 May;49(5):1154-1161. (9) Lin PH, Bush RL, Chaikof EL, Chen C, Conklin B, Terramani TT, et al. A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair. J Vasc Surg 2002 Sep;36(3):500-506.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
(10) Criado FJ, Wilson EP, Velazquez OC, Carpenter JP, Barker C, Wellons E, et al. Safety of coil embolization of the internal iliac artery in endovascular grafting of abdominal aortic aneurysms. J Vasc Surg 2000 Oct;32(4):684-688. (11) Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, McLafferty RB. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2000 Oct;32(4):676-683. (12) Lyden SP, Sternbach Y, Waldman DL, Green RM. Clinical implications of internal iliac artery embolization in endovascular repair of aortoiliac aneurysms. Ann Vasc Surg 2001 Sep;15(5):539543. (13) Yano OJ, Morrissey N, Eisen L, Faries PL, Soundararajan K, Wan S, et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001 Aug;34(2):204-211. (14) Dalainas I. A word of caution before killing hypogastric arteries. Cardiovasc Intervent Radiol 2008 Jul-Aug;31(4):835; author reply 836. (15) Bratby MJ, Hussain FF, Walker WJ. Outcomes after unilateral uterine artery embolization: a retrospective review. Cardiovasc Intervent Radiol 2008 Mar-Apr;31(2):254-259. (16) Cynamon J, Lerer D, Veith FJ, Taragin BH, Wahl SI, Lautin JL, et al. Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognized but possibly preventable complication. J Vasc Interv Radiol 2000 May;11(5):573-577. (17) Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008 Jul-Aug;31(4):728-734. (18) Razavi MK, DeGroot M, Olcott C,3rd, Sze D, Kee S, Semba CP, et al. Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications. J Vasc Interv Radiol 2000 May;11(5):561-566. (19) Lee CW, Kaufman JA, Fan CM, Geller SC, Brewster DC, Cambria RP, et al. Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases. J Vasc Interv Radiol 2000 May;11(5):567-571. (20) Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg 2014 Jan;59(1):89-94. (21) Bharwani N, Raja J, Choke E, Belli AM, Thompson MM, Morgan RA, et al. Is internal iliac artery embolization essential prior to endovascular repair of aortoiliac aneurysms? Cardiovasc Intervent Radiol 2008 May-Jun;31(3):504-508. (22) Wyers MC, Schermerhorn ML, Fillinger MF, Powell RJ, Rzucidlo EM, Walsh DB, et al. Internal iliac occlusion without coil embolization during endovascular abdominal aortic aneurysm repair. J Vasc Surg 2002 Dec;36(6):1138-1145.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
(23) Tefera G, Turnipseed WD, Carr SC, Pulfer KA, Hoch JR, Acher CW. Is coil embolization of hypogastric artery necessary during endovascular treatment of aortoiliac aneurysms? Ann Vasc Surg 2004 Mar;18(2):143-146. (24) Mell M, Tefera G, Schwarze M, Carr S, Acher C, Hoch J, et al. Absence of buttock claudication following stent-graft coverage of the hypogastric artery without coil embolization in endovascular aneurysm repair. J Endovasc Ther 2006 Jun;13(3):415-419. (25) Papazoglou KO, Sfyroeras GS, Zambas N, Konstantinidis K, Kakkos SK, Mitka M. Outcomes of endovascular aneurysm repair with selective internal iliac artery coverage without coil embolization. J Vasc Surg 2012 Aug;56(2):298-303. (26) Worcester S. Sandwich bests coil embolization for complex AAA. Vascular Specialist, May 2013. Synopses pf Dr. AC Lobato et al ISIT 2013 presentation. (27) Casey K, Al-Khatib WK, Zhou W. Hypogastric artery preservation during aortoiliac aneurysm repair. Ann Vasc Surg 2011 Jan;25(1):133.e1-133.e8. (28) Minion DJ, Xenos E, Sorial E, Saha S, Endean ED. The trifurcated endograft technique for hypogastric preservation during endovascular aneurysm repair. J Vasc Surg 2008 Mar;47(3):658661. (29) Zander T, Baldi S, Rabellino M, Kirsch D, Llorens R, Zerolo I, et al. Bifurcated endograft (Excluder) in the treatment of isolated iliac artery aneurysm: preliminary report. Cardiovasc Intervent Radiol 2009 Sep;32(5):928-936. (30) Ricci C, Ceccherini C, Cini M, Vigni F, Leonini S, Tommasino G, et al. Single-center experience and 1-year follow-up results of "sandwich technique" in the management of common iliac artery aneurysms during EVAR. Cardiovasc Intervent Radiol 2012 Oct;35(5):1195-1200. (31) Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex aortoiliac or isolated iliac aneurysms: results of midterm follow-up. J Vasc Surg 2013 Feb;57(2 Suppl):26S34S. (32) Lobato AC. A Prospective Comparison Study Between Hypogastric Artery EndoRevascularization with "Sandwich Technique" versus Coil Embolization in Complex Aortoiliac Aneurysms. ISET 2013. (33) Kasirajan K, Gupta N. Technical tips for successful outcomes using adjunctive procedures during endovascular aortic aneurysm repair. Semin Vasc Surg 2012 Sep;25(3):161-166. (34) Voelker D, Sharma R, Pipkin N, Dod H, Sharma R. Snorkeling and EVAR of Five Aneurysms in a Single Patient. Endovascular Today 2011. (35) Diethrich EB. Novel sealing concept in the Endologix AFX unibody stent-graft. J Cardiovasc Surg (Torino) 2014 Feb;55(1):93-102. (36) Welborn MB,3rd, McDaniel HB, Johnson RC, Kennedy RE, Knott A, Mundinger GH, et al. Clinical outcome of an extended proximal seal zone with the AFX endovascular aortic aneurysm system. J Vasc Surg 2014 Oct;60(4):876-884.
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
(37) Lobato AC. Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther 2011 Feb;18(1):106-111. (38) Alvarez Marcos F, Garcia de la Torre A, Alonso Perez M, Llaneza Coto JM, Camblor Santervas LA, Zanabili Al Sibbai AA, et al. Use of aortic extension cuffs for preserving hypogastric blood flow in endovascular aneurysm repair with aneurysmal involvement of common iliac arteries. Ann Vasc Surg 2013 Feb;27(2):139-145. (39) Torsello G, Schonefeld E, Osada N, Austermann M, Pennekamp C, Donas KP. Endovascular treatment of common iliac artery aneurysms using the bell-bottom technique: long-term results. J Endovasc Ther 2010 Aug;17(4):504-509. (40) Kritpracha B, Pigott JP, Russell TE, Corbey MJ, Whalen RC, DiSalle RS, et al. Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow. J Vasc Surg 2002 May;35(5):874-881. (41) Karthikesalingam A, Hinchliffe RJ, Holt PJ, Boyle JR, Loftus IM, Thompson MM. Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device. Eur J Vasc Endovasc Surg 2010 Mar;39(3):285-294. (42) Parlani G, Verzini F, De Rango P, Brambilla D, Coscarella C, Ferrer C, et al. Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur J Vasc Endovasc Surg 2012 Mar;43(3):287-292. (43) Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Erz K, Stelter WJ. Branched iliac bifurcation: 6 years experience with endovascular preservation of internal iliac artery flow. J Vasc Surg 2007 Aug;46(2):204-210. (44) Karthikesalingam A, Hinchliffe RJ, Malkawi AH, Holt PJ, Loftus IM, Thompson MM. Morphological suitability of patients with aortoiliac aneurysms for endovascular preservation of the internal iliac artery using commercially available iliac branch graft devices. J Endovasc Ther 2010 Apr;17(2):163-171. (45) Ehsan O, Murray D, Farquharson F, Serracino-Inglott F. Endovascular repair of complex aortic aneurysms. Ann Vasc Surg 2011 Jul;25(5):716-725.
Figure Legends
AC C
Figure 1: Trifurcation technique. Parallel stent graft deployment concept with the use of multiple main body bifurcated endografts. Brachial and femoral artery access is required.
Figure 2: Trifurcation technique angiographic images. Casey K, et al. Ann Vasc Surg.
ACCEPTED MANUSCRIPT
RI PT
Figure 3: The snorkeling technique utilizing the Powerlink unibody endograft. (Endologix, Inc. Irvine, CA) Only femoral artery access is required
Figure 4: Angiographic images of femoral access only Snorkel with Unibody device.
SC
Voelker DJ, et al. EVT Oct 2011
Figure 5: The Brazilian “sandwich” technique. Parallel stent grafts using femoral and
M AN U
brachial artery access
Figure 6: Angiographic images of the Brazilian Technique. Dietzek Et al. Figure 7: Angiographic images of the Bell Bottom Technique. Dietzek Et al. Figure 8: Iliac Branched Endoprosthesis. A. Atrium, B. Medtronic, C. GORE, D. JoMed.
AC C
EP
Ther. June 2008.
TE D
Figure 9: Homemade Iliac Branched device. Ricotta et al. Perspect Vasc Surg Endovasc
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0890-5096(14)00674-8
DOI:
10.1016/j.avsg.2014.10.019
Reference:
AVSG 2198
To appear in:
Annals of Vascular Surgery
Received Date: 10 July 2014 Revised Date:
21 October 2014
Accepted Date: 25 October 2014
Please cite this article as: Bekdache K, Cha A, Neychev V, Dietzek A, Endovascular hypogastric artery preservation during endovascular aneurysm repair: A review of current techniques and devices, Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2014.10.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Review Article Endovascular hypogastric artery preservation during endovascular aneurysm repair: A review of current techniques and devices.
Corresponding author: Alan M Dietzek,
M AN U
Department of Surgery, Danbury Hospital, CT, USA
Chief, Vascular and Endovascular Surgery
TE D
Western CT Health Network – Danbury Hospital 41 Germantown Rd, Suite 101 Danbury, CT 06810
EP
Phone: 203-794-5680
AC C
Email: [email protected]
SC
Khaldoun Bekdache, Andrew Cha, Vladimir Neychev and Alan Dietzek
RI PT
ACCEPTED MANUSCRIPT
Abstract
SC
Despite the improvement of endovascular techniques, one aspect of aneurysmal
disease that continues to be challenging is the management of aortoiliac aneurysms.
M AN U
Sacrificing the hypogastric artery (HGA) for effective treatment is not without sequelae; that may include buttocks claudication, colonic ischemia, spinal cord ischemia, as well as buttock and scrotal necrosis. This should be taken into consideration particularly in patients with previous intervention or potential
TE D
additional future interventions. This review describes the current endovascular techniques for preservation of hypogastric artery perfusion. Keywords
AC C
EP
Hypogastric, endovascular, preservation, aneurysms, embolization, iliac, devices
SC
RI PT
ACCEPTED MANUSCRIPT
M AN U
Introduction
The treatment of abdominal aortic aneurysms (AAA) has undergone dramatic improvement over the last 20 years with the advent of endovascular techniques. Endovascular aneurysm repair (EVAR) for both elective and ruptured AAA's has
TE D
decreased peri-operative morbidity and mortality as well as length of stay in hospital. Although widely used for standard risk AAA patients, it has been accepted particularly for high-risk patients who would otherwise not be able to tolerate or
EP
survive conventional open repair. Despite the success of endovascular techniques, one aspect of aneurysmal disease that continues to be challenging is the management
AC C
of aortoiliac aneurysms and the associated clinical significance of sacrificing the hypogastric arteries (HGA) for effective treatment. Up to 15 - 40% of AAA's have concomitant common iliac artery aneurysms(1), and in these cases, endovascular treatment can be difficult due to the need for adequate
ACCEPTED MANUSCRIPT
RI PT
distal landing zones in order to prevent type Ib and type II endoleaks. This is especially true in cases where aneurysmal disease extends to the external iliac
arteries. However, it is still prudent and in line with basic tenets of endovascular
SC
technique to ensure proper distal coverage, which in some cases may require
occlusion of either one or both HGA's. Several open and endovascular techniques
M AN U
have been developed for preservation of hypogastric artery perfusion. The aim of this review is to examine the literature with respect to outcomes following EVAR with hypogastric artery occlusion and to describe current endovascular techniques for preservation of hypogastric artery perfusion.
TE D
Outcomes of hypogastric artery occlusion (Table 1)
Several studies have shown that HGA occlusion can be performed without consequent life threatening pelvic ischemic complications (2). Mehta and Veith et al highlighted
EP
the possible sequelae of HGA occlusion, both via endovascular and open approaches, and found them to be of low incidence and morbidity. They reported no cases of
AC C
buttock necrosis, ischemic colitis requiring laparotomy, or any deaths associated with either unilateral or bilateral HGA occlusion (2, 3). Zander et al also noted acceptable rates of pelvic ischemic complications following bilateral HGA occlusion with only one
ACCEPTED MANUSCRIPT
RI PT
of fourteen patients having persistent symptoms of buttock claudication that resolved completely within 18 months(4).
Though the majority of the sequelae following HGA occlusion, either unilateral or
SC
bilateral, are non-life threatening, other complications have been well documented. The most common pelvic ischemic complication is buttock claudication with
M AN U
incidences ranging from 1.6 - 56% (5). In a literature review by Lin et al looking at 21 peer-reviewed published reports of hypogastric embolization for EVAR, the incidence of buttock claudication was 28% for unilateral embolization and 42% for bilateral embolization. Those that underwent unilateral embolization were better able to
TE D
tolerate their buttock claudication and had higher rates of resolution without the need for further intervention. Nevertheless, persistent symptoms at 1 year have been observed in 9- 15% of patients (1, 6, 7).
EP
Colonic ischemia is another feared pelvic ischemic complication of HGA occlusion, with an incidence as high as 9% (6, 8-12). The inferior mesenteric artery is routinely
AC C
sacrificed during EVAR, and therefore loss of collateral circulation from embolization of one or both HGAs can have detrimental effects to the blood supply of the distal and sigmoid colon. This is particularly important in patients with previous colonic surgery when the Inferior mesenteric artery is sacrificed proximal to the origin of the
ACCEPTED MANUSCRIPT
RI PT
left colic artery making the ensuing blood supply unpredictable and likely diminished resulting in a theoretical increased risk of this complication. Most patients found to have colon ischemia, however, can be managed non-surgically with close observation,
SC
antibiotics, and a short period of bowel rest.
New onset erectile dysfunction has been found to occur in up to 33% (10-45%) of
M AN U
patients undergoing HGA occlusion (6). Lin et al demonstrated a significant decrease in penile pressure after bilateral HA embolization (9). Though not a life threatening consequence of HGA occlusion, this complication is considered by some patients to be quite detrimental to their overall quality of life, especially in the 15% of patients who
TE D
suffer from persistent symptoms (13).
Other rare, but devastating complications following HGA occlusion include spinal cord ischemia, buttock necrosis, scrotal skin ulceration, and sciatic nerve ischemia (3,
EP
6, 9, 14-19). For those patients undergoing HGA occlusion, the risk of complications can be compounded by severe atherosclerotic disease of the contralateral HGA, the
AC C
ipsilateral femoral system, especially the profunda femoris artery and/or the presence of a large inferior mesenteric artery. So too can the presence of thoracic aneurysm disease, the treatment of which may require compromise of spinal cord blood flow. In a recent review, Eagleton et al showed higher rates of spinal cord
ACCEPTED MANUSCRIPT
RI PT
ischemia associated with extensive endovascular procedures, particularly concomitant thoracic aneurysm repair, even when only single collateral was
occluded. In these cases outcomes were poor and mortality rates were higher (20).
SC
Other risk factors include young age and left ventricular dysfunction (7, 10-12, 14, 1719). These factors should be taken into consideration when planning for the
M AN U
aneurysm repair and whether to sacrifice or preserve the HA. (Table 2) Table 1: Outcomes of hypogastric artery occlusion Complication
Incidence (%) 1.6-56
Persistent buttock claudication
9-15
Colonic ischemia Erectile dysfunction
EP
Spinal cord ischemia
TE D
Early buttock claudication
0-9
10-45
0.4-4.8
<1%
Scrotal skin ulceration
<1%
Sciatic nerve ischemia
<1%
AC C
Buttock necrosis
ACCEPTED MANUSCRIPT
Young age Left ventricular dysfunction Previous colonic resection Presence of thoracic aortic aneurysm
Large inferior mesenteric artery
Minimizing pelvic complications
M AN U
Severe SMA, ipsilateral femoral or contra lateral HGA disease
SC
RI PT
Table 2: Relative Indications for HGA preservation
Several options are described to minimize pelvic complications; those include
TE D
limiting the hypogastric artery embolization to the main trunk rather than more distally, consequently preserving the gluteal, rectal, vesical and internal pudendal branches. Preserving collaterals from iliac and femoral circumflex branches have also
EP
proved to minimize buttock claudication (2). Staged hypogastric artery embolization is described in the literature as a means of minimizing associated complications but
AC C
there is no good data to support this strategy (7). Some published reports suggest that coverage of the hypogastric artery orifice only without embolization may reduce the incidence of buttock claudication (0-27%) and decrease the risk of more severe complications without significantly increasing the chances for a type II endoleak (0-
ACCEPTED MANUSCRIPT
RI PT
8.9%)(21-25). Thus, despite previously mentioned studies supporting HGA occlusion as a relatively benign procedure, it is well documented that pelvic ischemic
complications do occur and can affect overall quality of life. Therefore, attempts at
SC
preserving the HGA should be employed in selected patients when technically feasible (26). Open surgical methods include external iliac artery to HGA bypass,
M AN U
transposition of the HGA to the external iliac artery, as well as hybrid techniques utilizing an aortouniliac stent graft with femoro-femoral bypass. These procedures usually subject the patient to general anesthesia and the morbidities associated with open vascular surgery including bleeding, infection, and other less common but
TE D
significant complications.
Alternatively, an endovascular approach to HGA preservation may be associated with decreased morbidity and mortality, and overall length of hospital stay as compared to
EP
open procedures. They do, however, prolong the EVAR procedure and expose the patient to larger contrast and radiation doses.
AC C
In this review, we have limited our following discussion to endovascular
techniques for the preservation of hypogastric artery circulation. Endovascular techniques for hypogastric artery preservation
ACCEPTED MANUSCRIPT
RI PT
Several endovascular techniques have been described to preserve perfusion through unilateral or bilateral hypogastric arteries in complex aortoiliac aneurysmal disease. The most commonly used methods are described below.
SC
The trifurcation technique
This endovascular technique utilizing parallel stent graft deployment concept
M AN U
employs the use of multiple main body bifurcated endografts (see Figure 1). This method requires bilateral femoral access in addition to brachial access in a "topdown" approach to facilitate cannulation of the HGA. Case reports have described use of an initial main body bifurcated graft, such as a 28-mm diameter Gore Excluder
TE D
(Gore & Associates, Flagstaff, AZ) along with the placement of a flared 20mm diameter limb in the contralateral gate(27-29). A second main body 23-mm diameter bifurcated graft is then deployed into the flared limb from the ipsilateral femoral
EP
artery. Left brachial or axillary access allows cannulation of the HGA using a 12F 80cm sheath through the short limb of the second main body gate. Viabahn covered
AC C
stent grafts (11-mm x 5-cm or 13-mm x 5-cm) are then deployed extending coverage from the second main body gate into the HGA (see Figure 2). Although originally described with a Gore Excluder stent graft this technique is not limited to the use of
ACCEPTED MANUSCRIPT
RI PT
only one type of main body bifurcated graft, but rather can be utilized with a variety of FDA-approved available devices. [Insert Figure. 1]
SC
[Insert Figure. 2]
Though early case reports have noted short-term technical success, this "trifurcation"
M AN U
technique requires the use of at least five devices, which can lead to an increased risk of migration, endoleak, and graft malfunction. In addition, the need for brachial access can be associated with brachial and aortic arch injuries. Other possible disadvantages include higher procedural cost, length of procedure, increased amount
technique.
TE D
of contrast, and the fact that bilateral HGA preservation is not possible with this
The Snorkeling Technique
EP
This method entails the placement of covered stents within the external and internal iliac branches extending parallel to or within the aortic stent graft. This method, also
AC C
known as the double-barrel technique, the chimney graft, or the sandwich technique, may require access via the femoral arteries and the brachial artery depending upon which technique and device are utilized. Early reports of small series have shown promising results with technical success, defined as aneurysm occlusion without
ACCEPTED MANUSCRIPT
100% and 88-100% respectively at 1 year. (26, 30, 31).
RI PT
endoleak, of 88-100% and external iliac and hypogastric artery patency rates of 95-
Lobato et al presented their recent data, comparing their sandwich technique to coil
SC
embolization, at the International Symposium on Endovascular therapy (ISET) 2013. The rate of permanent buttock claudication was significantly higher in the coil
M AN U
embolization group (12.7 vs 2.5%) as were late type II endoleaks (15.5 vs 2.5%). Their technical success rate was 100%. Mortality, postoperative aneurysm rupture, late type I endoleaks, type III endoleaks, limb migration, occlusion and reintervention were similar in both groups(32).
TE D
One method requires bilateral femoral artery access only without the need for brachial artery access. This was initially described with the use of the Powerlink unibody endograft but has largely been replaced by the Endologix AFX device in the
EP
US and Europe (Endologix, Inc. Irvine, CA) (See Figure 3, 4) (33, 34)(35,36). A 28-mm diameter main unibody device with 16-mm diameter bifurcated limbs is deployed
AC C
and straddles the aortic bifurcation. The more proximal aortic extension (size dependent on infrarenal aortic length and aortic neck diameter) is then deployed. Cannulation of the common iliac artery limb of the stent graft on the side ipsilateral to the common iliac artery aneurysm is performed through ipsilateral femoral artery
ACCEPTED MANUSCRIPT
RI PT
access. Cannulation of the hypogastric artery is then achieved from the contralateral common femoral artery. Contralateral hypogastric artery cannulation through the endograft can be accomplished with the Endologix device because unlike other
SC
endografts, the device sits on the sits on the aortic bifurcation replicating its
geometry. With other modular devices the bifurcation is recreated more proximally
M AN U
within the aorta resulting in a steeply angulated bifurcation making wire passage over the bifurcation and through the contralateral iliac limb very difficult to accomplish. A 6-mm or 8-mm x 10-cm Viabahn endoprosthesis (Gore & Associates, Flagstaff, AZ) is then deployed within the HGA and a 16-mm diameter Powerlink iliac
TE D
limb extension is deployed within the external iliac artery for complete preservation of in-line flow by creation of a double-barrel lumen. [Insert Figure.3]
EP
[Insert Figure. 4]
Techniques have described both simultaneous and sequential deployment with the
AC C
iliac limb extension being deployed first followed by the Viabahn stent graft. Proponents for the sequential deployment believe the Viabahn covered stent graft has a stronger radial force compared to the iliac limb extension and therefore should
ACCEPTED MANUSCRIPT
risk of external iliac artery occlusion.
RI PT
be deployed afterwards in order to prevent graft in-folding and subsequent attendant
The advantages of this method are that only femoral access is necessary while
SC
permitting the preservation of one or both HGA’s. The disadvantage is that there is presently only one commercially available and FDA approved unibody graft
M AN U
(Endologix Powerlink) in the United States limiting the surgeon’s device options for treatment.
The "Brazilian or sandwich snorkeling" technique first described by Lobato, is similar to the "trifurcation" technique in that brachial access is required for cannulation of
TE D
the HGA(37). Rather than use five different stent graft devices, however, as few as three may be required (see Figure 5). Once deployment of the main body bifurcated graft is achieved via femoral artery access, the ipsilateral hypogastric artery is
EP
cannulated via left brachial or axillary artery access. An undeployed Viabahn stent graft is then placed 2cm into the HGA and an iliac limb extension is positioned parallel
AC C
to the Viabahn graft from the ipsilateral femoral artery. A 6cm overlap within the ipsilateral iliac limb is required to achieve an adequate seal. As mentioned previously, the iliac limb extension is deployed first to prevent graft in-folding and possible external iliac artery occlusion. Complete aneurysmal exclusion and HGA
ACCEPTED MANUSCRIPT
RI PT
preservation is then achieved with deployment of the contralateral iliac limb (See Figure 6). [Insert Figure. 5]
SC
[Insert Figure.6]
This technique can allow for preservation of both HGAs and is more cost effective
M AN U
compared to the "trifurcation" technique because only one main body device is used. Again, this technique can be utilized with a variety of FDA-approved available devices. Even more importantly to the surgeon, there are no restrictions based on common iliac artery diameter or length, tortuosity, or HGA diameter. Access via the
TE D
left brachial or axillary artery, however, is still associated with risks due to wire manipulation within the aortic arch. Flared Limb Technique
EP
Also known as the Bell-Bottom Technique, the flared limb technique is the most commonly used technique to preserve flow into the hypogastric artery during
AC C
EVAR(1,38-40). This entails the use of a large diameter iliac extension limb to seal the distal common iliac artery while preserving the ostium of the hypogastric artery (See Figure 7). The advantages of this technique are its relative ease technichally and the use of available off the shelf devices. The largest diameter iliac limb as of this
ACCEPTED MANUSCRIPT
RI PT
writing is a 28 Fr (Endurant), which can treat only small CIA aneurysms with a maximum diameter of 26mm. The use of aortic cuffs as iliac extensions for the treatment of slightly larger diameter CIA aneurysms has also been described
SC
(1,39,40). Early peri-operative complications and re-interventions range from 8-
22%(1,39). Type 1b endoleaks have a reported incidence of 2.2-4%. The long-term
M AN U
durability of the bell-bottom technique is unclear with concerns over further aneurysmal dilation of the iliac artery with resultant stent graft, migration and Type1b endoleaks. [Insert Figure. 7]
TE D
Iliac Branched Devices
Iliac-branched devices (IBD) are currently not commercially available in the United States, however, early results have shown high primary technical success rates but
EP
disappointing patency rates in some studies. The IBD extends from within the standard EVAR graft into the external iliac artery preserving flow in the hypogastric
AC C
artery using a side branch. This requires cannulation of the hypogastric artery with a preloaded wire from the side branch using contralateral femoral artery access. Two different designs are available, one is the straight and other is the helical IBD. Several different devices are currently commercially available for use outside of the U.S.
ACCEPTED MANUSCRIPT
RI PT
including ,Zenith bifurcated iliac side branch device, Zenith helical branch device, GORE(R) EXCLUDER(R) Iliac Branch Endoprosthesis, Medtronic, Atrium, and JoMed (See Figure. 8). There are also case reports of use of a homemade branched device
SC
(See Figure.9). [Insert Figure. 8]
M AN U
[Insert Figure. 9]
In a literature review by Karthikesalingam et al looking at nine series utilizing iliacbranched devices, early technical success was 85-100%. The review also revealed a collective 12% IBD limb occlusion rate of which 50% developed buttocks
TE D
claudication. In this review the reported type I and III endoleak was only 1.6%(41). In two studies mid-term follow up at 5 years showed promising patency rates of 87 and 91.4%. (42,43) Parlani et al reported freedom of secondary intervention of 90%
EP
at 1 year and 81.4% at 5 years (42). Even with primary technical success and acceptable outcomes however, careful patient selection is essential as severe iliac
AC C
tortuosity and aneurysmal involvement of the HGA can lead to increased procedural challenges and higher rates of type I and III endoleaks(44,45). These devices are less adaptable to complex anatomy thus limiting wider applicability. Based on the current criteria for IBD use, up to 52% of the patients may not be suitable for this device. In
ACCEPTED MANUSCRIPT
RI PT
addition, operating time, total fluoroscopy time, and the amount of contrast volume used is highly variable (41,44,45). Also, the cost of these devices will likely exceed the costs for most of the snorkel procedures. Longer-term follow-up as well as wider
SC
availability of these devices is still awaited. Conclusion
M AN U
It is clear that a planned HGA occlusion is not an entirely benign procedure. This is particularly true in patients with contralateral HGA occlusion, those undergoing concomitant endovascular repairs of a thoracic aortic aneurysm, patients with severe ipsilateral femoral arterial disease, and in younger active patients.
TE D
Technological advancements have allowed the modern vascular surgeon to utilize various methods of endovascular HGA preservation. Each method as discussed in this review is associated with particular advantages and disadvantages.
EP
Nevertheless, each approach requires extensive and diligent pre-operative planning and imaging. Many times, the method selected is patient specific due to the inherent
AC C
nature of their disease.
Once commercially available, iliac branch endografts will likely replace many of the surgeon-modified branch grafts. These procedures, although technically challenging, may be more amenable for use in patients with difficult and complex anatomy than
ACCEPTED MANUSCRIPT
RI PT
prefabricated branched endografts. Furthermore, the cost may be significantly greater for the manufactured iliac-branched endograft, a point of some concern in our present healthcare environment. Finally, current methods of unilateral or bilateral
SC
endovascular HGA preservation can be successfully achieved with minimal morbidity and mortality and should be attempted whenever technically feasible.
M AN U
References
AC C
EP
TE D
(1) Naughton PA, Park MS, Kheirelseid EA, O'Neill SM, Rodriguez HE, Morasch MD, et al. A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation. J Vasc Surg 2012 Apr;55(4):956-962. (2) Mehta M, Veith FJ, Ohki T, Cynamon J, Goldstein K, Suggs WD, et al. Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001 Feb;33(2 Suppl):S27-32. (3) Mehta M, Veith FJ, Darling RC, Roddy SP, Ohki T, Lipsitz EC, et al. Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 2004 Oct;40(4):698-702. (4) Zander T, Baldi S, Rabellino M, Rostagno R, Isaza B, Llorens R, et al. Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance. J Vasc Interv Radiol 2007 Dec;18(12):1481-1486. (5) Lin PH, Chen AY, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg 2009 Sep;22(3):193-200. (6) Farahmand P, Becquemin JP, Desgranges P, Allaire E, Marzelle J, Roudot-Thoraval F. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008 Apr;35(4):429-435. (7) Bratby MJ, Munneke GM, Belli AM, Loosemore TM, Loftus I, Thompson MM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol 2008 Mar-Apr;31(2):246-253. (8) Verzini F, Parlani G, Romano L, De Rango P, Panuccio G, Cao P. Endovascular treatment of iliac aneurysm: Concurrent comparison of side branch endograft versus hypogastric exclusion. J Vasc Surg 2009 May;49(5):1154-1161. (9) Lin PH, Bush RL, Chaikof EL, Chen C, Conklin B, Terramani TT, et al. A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair. J Vasc Surg 2002 Sep;36(3):500-506.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
(10) Criado FJ, Wilson EP, Velazquez OC, Carpenter JP, Barker C, Wellons E, et al. Safety of coil embolization of the internal iliac artery in endovascular grafting of abdominal aortic aneurysms. J Vasc Surg 2000 Oct;32(4):684-688. (11) Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, McLafferty RB. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2000 Oct;32(4):676-683. (12) Lyden SP, Sternbach Y, Waldman DL, Green RM. Clinical implications of internal iliac artery embolization in endovascular repair of aortoiliac aneurysms. Ann Vasc Surg 2001 Sep;15(5):539543. (13) Yano OJ, Morrissey N, Eisen L, Faries PL, Soundararajan K, Wan S, et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001 Aug;34(2):204-211. (14) Dalainas I. A word of caution before killing hypogastric arteries. Cardiovasc Intervent Radiol 2008 Jul-Aug;31(4):835; author reply 836. (15) Bratby MJ, Hussain FF, Walker WJ. Outcomes after unilateral uterine artery embolization: a retrospective review. Cardiovasc Intervent Radiol 2008 Mar-Apr;31(2):254-259. (16) Cynamon J, Lerer D, Veith FJ, Taragin BH, Wahl SI, Lautin JL, et al. Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognized but possibly preventable complication. J Vasc Interv Radiol 2000 May;11(5):573-577. (17) Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008 Jul-Aug;31(4):728-734. (18) Razavi MK, DeGroot M, Olcott C,3rd, Sze D, Kee S, Semba CP, et al. Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications. J Vasc Interv Radiol 2000 May;11(5):561-566. (19) Lee CW, Kaufman JA, Fan CM, Geller SC, Brewster DC, Cambria RP, et al. Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases. J Vasc Interv Radiol 2000 May;11(5):567-571. (20) Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg 2014 Jan;59(1):89-94. (21) Bharwani N, Raja J, Choke E, Belli AM, Thompson MM, Morgan RA, et al. Is internal iliac artery embolization essential prior to endovascular repair of aortoiliac aneurysms? Cardiovasc Intervent Radiol 2008 May-Jun;31(3):504-508. (22) Wyers MC, Schermerhorn ML, Fillinger MF, Powell RJ, Rzucidlo EM, Walsh DB, et al. Internal iliac occlusion without coil embolization during endovascular abdominal aortic aneurysm repair. J Vasc Surg 2002 Dec;36(6):1138-1145.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
(23) Tefera G, Turnipseed WD, Carr SC, Pulfer KA, Hoch JR, Acher CW. Is coil embolization of hypogastric artery necessary during endovascular treatment of aortoiliac aneurysms? Ann Vasc Surg 2004 Mar;18(2):143-146. (24) Mell M, Tefera G, Schwarze M, Carr S, Acher C, Hoch J, et al. Absence of buttock claudication following stent-graft coverage of the hypogastric artery without coil embolization in endovascular aneurysm repair. J Endovasc Ther 2006 Jun;13(3):415-419. (25) Papazoglou KO, Sfyroeras GS, Zambas N, Konstantinidis K, Kakkos SK, Mitka M. Outcomes of endovascular aneurysm repair with selective internal iliac artery coverage without coil embolization. J Vasc Surg 2012 Aug;56(2):298-303. (26) Worcester S. Sandwich bests coil embolization for complex AAA. Vascular Specialist, May 2013. Synopses pf Dr. AC Lobato et al ISIT 2013 presentation. (27) Casey K, Al-Khatib WK, Zhou W. Hypogastric artery preservation during aortoiliac aneurysm repair. Ann Vasc Surg 2011 Jan;25(1):133.e1-133.e8. (28) Minion DJ, Xenos E, Sorial E, Saha S, Endean ED. The trifurcated endograft technique for hypogastric preservation during endovascular aneurysm repair. J Vasc Surg 2008 Mar;47(3):658661. (29) Zander T, Baldi S, Rabellino M, Kirsch D, Llorens R, Zerolo I, et al. Bifurcated endograft (Excluder) in the treatment of isolated iliac artery aneurysm: preliminary report. Cardiovasc Intervent Radiol 2009 Sep;32(5):928-936. (30) Ricci C, Ceccherini C, Cini M, Vigni F, Leonini S, Tommasino G, et al. Single-center experience and 1-year follow-up results of "sandwich technique" in the management of common iliac artery aneurysms during EVAR. Cardiovasc Intervent Radiol 2012 Oct;35(5):1195-1200. (31) Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex aortoiliac or isolated iliac aneurysms: results of midterm follow-up. J Vasc Surg 2013 Feb;57(2 Suppl):26S34S. (32) Lobato AC. A Prospective Comparison Study Between Hypogastric Artery EndoRevascularization with "Sandwich Technique" versus Coil Embolization in Complex Aortoiliac Aneurysms. ISET 2013. (33) Kasirajan K, Gupta N. Technical tips for successful outcomes using adjunctive procedures during endovascular aortic aneurysm repair. Semin Vasc Surg 2012 Sep;25(3):161-166. (34) Voelker D, Sharma R, Pipkin N, Dod H, Sharma R. Snorkeling and EVAR of Five Aneurysms in a Single Patient. Endovascular Today 2011. (35) Diethrich EB. Novel sealing concept in the Endologix AFX unibody stent-graft. J Cardiovasc Surg (Torino) 2014 Feb;55(1):93-102. (36) Welborn MB,3rd, McDaniel HB, Johnson RC, Kennedy RE, Knott A, Mundinger GH, et al. Clinical outcome of an extended proximal seal zone with the AFX endovascular aortic aneurysm system. J Vasc Surg 2014 Oct;60(4):876-884.
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
(37) Lobato AC. Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther 2011 Feb;18(1):106-111. (38) Alvarez Marcos F, Garcia de la Torre A, Alonso Perez M, Llaneza Coto JM, Camblor Santervas LA, Zanabili Al Sibbai AA, et al. Use of aortic extension cuffs for preserving hypogastric blood flow in endovascular aneurysm repair with aneurysmal involvement of common iliac arteries. Ann Vasc Surg 2013 Feb;27(2):139-145. (39) Torsello G, Schonefeld E, Osada N, Austermann M, Pennekamp C, Donas KP. Endovascular treatment of common iliac artery aneurysms using the bell-bottom technique: long-term results. J Endovasc Ther 2010 Aug;17(4):504-509. (40) Kritpracha B, Pigott JP, Russell TE, Corbey MJ, Whalen RC, DiSalle RS, et al. Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow. J Vasc Surg 2002 May;35(5):874-881. (41) Karthikesalingam A, Hinchliffe RJ, Holt PJ, Boyle JR, Loftus IM, Thompson MM. Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device. Eur J Vasc Endovasc Surg 2010 Mar;39(3):285-294. (42) Parlani G, Verzini F, De Rango P, Brambilla D, Coscarella C, Ferrer C, et al. Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur J Vasc Endovasc Surg 2012 Mar;43(3):287-292. (43) Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Erz K, Stelter WJ. Branched iliac bifurcation: 6 years experience with endovascular preservation of internal iliac artery flow. J Vasc Surg 2007 Aug;46(2):204-210. (44) Karthikesalingam A, Hinchliffe RJ, Malkawi AH, Holt PJ, Loftus IM, Thompson MM. Morphological suitability of patients with aortoiliac aneurysms for endovascular preservation of the internal iliac artery using commercially available iliac branch graft devices. J Endovasc Ther 2010 Apr;17(2):163-171. (45) Ehsan O, Murray D, Farquharson F, Serracino-Inglott F. Endovascular repair of complex aortic aneurysms. Ann Vasc Surg 2011 Jul;25(5):716-725.
Figure Legends
AC C
Figure 1: Trifurcation technique. Parallel stent graft deployment concept with the use of multiple main body bifurcated endografts. Brachial and femoral artery access is required.
Figure 2: Trifurcation technique angiographic images. Casey K, et al. Ann Vasc Surg.
ACCEPTED MANUSCRIPT
RI PT
Figure 3: The snorkeling technique utilizing the Powerlink unibody endograft. (Endologix, Inc. Irvine, CA) Only femoral artery access is required
Figure 4: Angiographic images of femoral access only Snorkel with Unibody device.
SC
Voelker DJ, et al. EVT Oct 2011
Figure 5: The Brazilian “sandwich” technique. Parallel stent grafts using femoral and
M AN U
brachial artery access
Figure 6: Angiographic images of the Brazilian Technique. Dietzek Et al. Figure 7: Angiographic images of the Bell Bottom Technique. Dietzek Et al. Figure 8: Iliac Branched Endoprosthesis. A. Atrium, B. Medtronic, C. GORE, D. JoMed.
AC C
EP
Ther. June 2008.
TE D
Figure 9: Homemade Iliac Branched device. Ricotta et al. Perspect Vasc Surg Endovasc
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT