- Email: [email protected]
Endovascular treatment of hypogastric artery aneurysms
Endovascular treatment of hypogastric artery aneurysms Miriam Kliewer, MD,a Markus Plimon, MD,a Fadi Taher, MD,a Corinna Walter, MD,a Kornelia Hirsch, MD,a Jürgen Falkensammer, MD,a,b and Afshin Assadian, MD,a Vienna, Austria
ABSTRACT Objective: Internal iliac artery aneurysm (IIAA) is a rare entity. Its treatment can be technically challenging. The aim of this study was to evaluate the treatment possibilities in an era of advanced endovascular techniques and their potential to preserve iliac blood flow while reliably excluding the aneurysm. Methods: A retrospective analysis of 46 consecutive patients with endovascularly treated IIAA was performed. Data were collected from a single-institution aortoiliac database. The following end points were recorded: technique of aneurysm exclusion, technical success rates, perioperative morbidity and mortality, primary patency, and midterm follow-up. Results: Between September 2009 and May 2016, a total of 46 patients with 55 IIAAs were identified. The majority of patients (n ¼ 39 [84.8%]) had aortoiliac aneurysms and seven had isolated IIAAs (15.2%). The following surgical techniques were used: implantation of iliac branch devices (IBDs; n ¼ 29), occlusion of the internal iliac artery (IIA) by ostium coverage with or without prior coil embolization (n ¼ 23), and other endovascular techniques (n ¼ 3). Primary assisted technical success was achieved in 93.1% of IBD implantations and in 100% of occlusions by ostium coverage and other techniques. Overall 30-day mortality was 4.3% (n ¼ 2) and 0% in electively treated patients. Assisted midterm patency after IBD implantation was 93.1%. Gluteal claudication occurred in seven patients (15.2%) who had undergone intentional or accidental occlusion of the IIA or the superior gluteal artery. Reintervention rates within the midterm follow-up were 13.8% (n ¼ 4) after IBD implantation and 4.3% (n ¼ 1) after coverage of the IIA ostium. No ruptures were observed during follow-up, and no complications occurred during reinterventions. Conclusions: Implantation of IBD devices for the treatment of hypogastric artery aneurysms shows good technical results with a high primary patency and a low rate of perioperative complications. Although successful aneurysm exclusion while preserving pelvic blood flow is associated with a higher rate of reinterventions during midterm follow-up, it should be taken into consideration, especially in complex endovascular aortoiliac aneurysm repair. (J Vasc Surg 2019;-:1-8.) Keywords: Internal iliac artery aneurysm; Endovascular techniques; Iliac branch device; Gluteal claudication
The internal iliac artery (IIA) is a rare location for aneurysmatic degeneration. There are few data on the incidence of IIA aneurysms (IIAAs), which may occur in isolation or along with other aortoiliac disease. Kasulke et al1 estimated the incidence of isolated IIAAs with 0.4% of all intra-abdominal aneurysms, whereas the incidence seems to be higher among patients with aortoiliac disease.2 An incidence of 5% of IIAAs associated with abdominal aortic aneurysm and 29% with common iliac artery aneurysms has been described.3-5 As a consequence of the location in the minor pelvis, open surgical repair is technically challenging.6 With the advent of endovascular aneurysm repair (EVAR), an increasing willingness to treat the hypogastric arteries as dispensable can be observed. Occlusion of the IIA ostium by coil embolization or
extension of the endograft into the external iliac artery has been recommended for these cases. Although potentially lethal complications, including colon ischemia, gluteal necrosis, and spinal cord ischemia, are rare, incidences of 30% to 50% for buttock claudication and 20% to 50% for erectile dysfunction have been described.7-10 Conventional open reconstruction and endovascular occlusion have recently been supplemented by novel endovascular techniques that provide means of aneurysm exclusion while also preserving internal iliac blood flow. Especially in complex endovascular cases with occlusion of the inferior mesenteric artery during EVAR, the treatment of a concomitant hypogastric aneurysm with preservation of the pelvic blood flow seems to be favorable to avoid ischemic symptoms. The aim of this study was to assess the technical and clinical feasibility of different endovascular techniques to exclude IIAAs.
From the Department of Vascular and Endovascular Surgery, Wilhelminenhospitala; and the Sigmund Freud Private University, Medical School.b Author conflict of interest: none.
METHODS
Correspondence: Jürgen Falkensammer, MD, Department of Vascular and Endovascular Surgery, Wilhelminenhospital, Montleartstreet 37, Pavillion 30B, A-1160 Vienna, Austria (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2018.12.048
Study design A retrospective evaluation of 46 consecutive patients treated endovascularly for isolated or combined IIAAs during a period of 7 years (September 2009-August 2016) was performed. All included patients were unfit for open surgery. Data were collected from a single-institution aortoiliac aneurysm database and completed with 1
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information from paper-based and electronic health records. All patients showing dilation of the IIA $16 mm were included for retrospective evaluation. Aneurysms limited to the iliac bifurcation were not defined as IIAAs. The IIA diameter of $16 mm was in no case the indication for surgery but a defined study inclusion criterion as a representation of the diagnosis of IIAA.3,11 Postoperatively, all patients received computed tomography angiography (CTA) during the hospital stay and were seen afterward within 3 months and in 12-month intervals thereafter. Data on mortality were collected from electronic health records. Furthermore, outpatient visits were documented, and control computed tomography scans were screened for each patient. The course or development of ischemic symptoms, wound complications, and any adverse events were documented, as were secondary interventions, endoleaks, thrombosis of the iliac branch device (IBD), or other stent graft complications. The patients were routinely questioned about claudication of the lower extremity during each follow-up examination after aortoiliac repair. The review board of the City of Vienna approved the study and waived informed consent of the patients. The following end points were recorded: technique of aneurysm exclusion, technical success rates, 30-day morbidity and mortality, and midterm follow-up. Aneurysm anatomy The preoperative CTA image of each patient was analyzed using centerline reconstructions for aneurysm configuration and size (OsiriX 7.0 software; Pixmeo SARL, Geneva, Switzerland). In case of combined aortoiliac aneurysms, the maximum diameter of the infrarenal aorta, the common iliac artery, and the IIA was measured. A dilation of the abdominal aorta $30 mm and the common iliac artery $20 mm was defined as aneurysm.12,13 The same surgeon did all retrospective measurements. The anatomic location of aneurysms was then classified into combined aortoiliac aneurysms and isolated IIAAs (Fig 1). Surgical technique In general, the aim of case planning was to preserve iliac blood flow to at least one and if reasonably feasible both IIAs to avoid ischemic complications. The selection of the endovascular technique depended on the patient’s fitness and age, the clinical estimation of the development and quality of life impact of ischemic symptoms, and the anatomic suitability for IBD implantation or other techniques. The IBD devices used are listed in Table I. Patients routinely received 5000 units of heparin perioperatively and lifelong antiplatelet therapy (aspirin 100 mg once a day) postoperatively. Patients treated with IBD implantation additionally took clopidogrel (75 mg once a day) for 6 weeks after surgery. There were basically three alternatives to endovascular IIAA exclusion in the department.
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ARTICLE HIGHLIGHTS d
d
d
Type of Research: Single-center retrospective study of prospectively collected data Key Findings: The use of iliac branch devices (IBDs) for treatment of 29 of 55 hypogastric artery aneurysms showed good technical success rates (primary assisted success, 93.1%) combined with a 93.1% patency at a mean follow-up of 14.9 months. No ruptures were observed, and patients were treated successfully with IBDs without ischemic complications. Take Home Message: The treatment of internal iliac artery aneurysms with IBDs was technically feasible, safe, and effective in excluding the aneurysm while preserving the pelvic blood flow.
Implantation of an IBD. Implantations of IBDs were performed according to common protocols.14-16 The selection of IBD manufacturer (Cook, JOTEC, Gore, Bolton custom-made) was made because of anatomic feasibility. The distal sealing zone of IBD connecting stent grafts in the IIA was evaluated preoperatively. At least 10 mm in length and 5 mm in diameter of healthy artery were required to provide a safe distal sealing zone.15 To connect the IBD into a healthy hypogastric artery segment, balloon-expandable and self-expanding stent grafts were used. We relined balloon-expandable covered stent grafts with nitinol stents (Luminexx; Bard, Covington, Ga), exceeding it with 5 mm into the healthy segment to increase fixation of the reconstruction and to avoid secondary stent graft compression and migration.14 There were three options: sealing in the main branch, in the superior gluteal artery, or in the visceral branch of the IIA (Fig 2, A and B). Coils (Interlock 6- to 12-mm coils; Boston Scientific, Marlborough, Mass) were used to occlude branches that were likely to result in a type II endoleak (>6 mm in diameter14). Coils were placed through a microcatheter and through the released IBD. Endovascular coverage of the IIA ostium. Coverage of the ostium with a stent graft to exclude the aneurysm from antegrade blood flow was predominantly performed in combination with the implantation of an infrarenal bifurcated graft. Therefore, the iliac limb was chosen long enough to cover the ostium and to seal in a healthy zone of at least 20-mm length in the external iliac artery. Before coverage, the IIA outlet was occluded by either coil embolization (Interlock 6- to 12-mm coils) or plug implantation (Amplatzer Vascular Plug II; St. Jude Medical, St. Paul, Minn), depending on anatomy and the surgeon’s preference. Each device was inserted by crossover technique using a hydrophilic guidewire (HiWire, 0.035 inch; Cook Medical, Bloomington, Ind) and support catheter to cannulate the IIA.
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Fig 1. Anatomic aneurysm data.
Table I. Technical details of 29 iliac branch device (IBD) cases No. of devices used (%) Manufacturer of IBD Cook Zenith branch (ZBIS)
12 (41.4)
JOTEC E-iliac
11 (37.9)
Gore Excluder iliac component
4 (13.8)
Bolton custom-made
2 (6.9)
Type of BECS/self-expanding stent combination Advanta V12 (Maquet)/Luminexx (Bard) Eventus (JOTEC)/Luminexx (Bard)
26 (89.7) 3 (10.3)
BECS, Balloon-expandable covered stent graft.
A crossover 7F sheath (Flexor introducer sheath, 45-cm length, G09810; Cook) was usually placed in the main branch of the IIA and served as save path for plug or coil insertion (Fig 2, C). Exclusion of aneurysms limited to the IIA: Other techniques. Isolated aneurysms limited to the IIA excursions were excluded with local application of a covered stent (Advanta V12 [Maquet, Rastatt, Germany], Viabahn [W. L. Gore & Associates, Flagstaff, Ariz], Fluency [Bard]) anddif necessary and anatomically possibled prior coiling of the aneurysm lumen. This technique required healthy proximal and distal sealing zones of at least 15-mm length and 5-mm diameter in the main branch or the superior gluteal artery. Access was gained through crossover cannulation of the IIA, followed by insertion of a 7F sheath to protect stent graft run-through (Fig 2, D).
Technical success and follow-up Technical success was defined as effective exclusion of the aneurysm and, when intended, successful preservation of the pelvic blood flow. Occlusion of the IBD branch was considered technical failure. This was documented by angiography at the end of the intervention and by CTA during the postoperative hospital stay. Because of described graft porosities of IBD devices, which may impair intraoperative differentiation of type IV and types I, II, and III endoleaks, we consider CTA a few days after surgery important. Type II endoleak was not considered a technical failure. Statistics All demographics, baseline characteristics, and postoperative and follow-up data were evaluated descriptively. Kaplan-Meier analysis was performed, estimating survival functions from data on overall survival, IBD patency, combined type IB and type III endoleaks, and clinical outcome. All statistical calculations were performed using Microsoft Excel for Windows (Microsoft, Redmond, Wash) and SPSS Statistics for Windows (version 21.0; IBM Corp, Armonk, NY).
RESULTS Patients’ demographics. Within the database, 55 IIAAs were identified in 46 patients. Mean age was 72.2 years (range, 46-91 years), and 41 patients were male. The cardiovascular risk factors are presented in Table II. Most patients (n ¼ 39 [84.8%]) had coexisting aneurysms of the aorta (n ¼ 9), common iliac arteries (n ¼ 11), or both (n ¼ 19). In the remaining seven patients (n ¼ 7 [15.2%]), a total of nine isolated IIAAs with a mean diameter of 38.2 mm were found (Fig 1). There
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Table II. Patients’ demographics and cardiovascular risk factors No. or mean % or SD No. of patients
46
100
Age, years
72.2
69.2
Male
41
89.1
Hypertension
39
84.8
Smoking
29
63.0
Hyperlipidemia
25
54.3
Diabetes mellitus
10
21.7
Coronary artery disease
16
34.8
Prior myocardial infarction
6
13.0
Congestive heart failure
5
10.9
Atrial fibrillation
4
8.7
Chronic obstructive pulmonary disease
9
19.6
Renal insufficiency (serum creatinine $1.4 mg/dL)
11
23.9
Obesity (body mass index >30 kg/m2)
8
17.4
SD, Standard deviation.
Fig 2. Variations of endovascular internal iliac artery aneurysm (IIAA) exclusion. A, Iliac branch device (IBD) implantation sealing in the main hypogastric branch. B, IBD implantation sealing in the superior gluteal artery with coiling of possible feeding branches. C, Coverage of the internal iliac artery (IIA) ostium with coiling or plug implantation of possible feeding branches. D, Exclusion of hypogastric aneurysm with covered stent within the excursion of the artery itself and preservation of the pelvic blood flow.
were six (13.0%) urgent (symptomatic or ruptured) patients. In 40 patients, the treatment was elective (nonurgent). Surgery methods. The numbers of differently used methods are listed in Table III and are defined as numbers of treated IIAAs. Different methods may be used in the same patient with unilateral sacrifice of the IIA and contralateral preservation. This was the case in four patients; none received planned bilateral occlusion, and in five patients, bilateral hypogastric aneurysms were treated with preservation of both IIAs. The results of the different endovascular methods in detail are as follows: Twenty-nine IIAAs (52.7 %) were excluded using an IBD with graft extension into the superior gluteal artery
(n ¼ 12 [41.4%]), the main branch of the IIA (n ¼ 16 [55.2%]), or the visceral branch (n ¼ 1 [3.4%]). The IBD devices used and connecting stents are listed in Table I. The majority of IBD implantations was performed after 2013 and replaced the former coverage of the IIA ostium in patients with suitable anatomy (Fig 3). In 23 cases (41.8%) of IIAAs, the ostium was covered by either extension of the ipsilateral iliac limb during EVAR (n ¼ 20) or selective stent graft implantation into the common iliac artery and external iliac artery across the IIA origin (n ¼ 3). Before coverage, an Amplatzer plug was placed in seven IIAAs; in two cases, coils were applied in aneurysm feeding branches; and in one case, coils and a plug were inserted before coverage of the IIA ostium. In three patients (5.5%), an isolated IIAA was excluded using covered stent graft implantation limited to the IIA. Therefore, an Advanta V12 or Viabahn in combination with a nitinol stent (Luminexx) was used in all cases (Fig 2, D). Technical success and early reinterventions. Primary technical success was achieved in 89.7% (93.1% assisted) of IBD implantations and in 100% of IIA ostium coverages. The following technical failures occurred: disconnection of an IBD with the connecting Advanta stent graft in a case of 3-cm IIAA with tortuous IIA excursion, resulting in a type III endoleak and need for early reintervention with extension into the superior gluteal artery; endoleak type IB on the postoperative computed tomography scan with failing distal attachment in the main branch of the IIA, resulting in reintervention with extension of the sealing zone into the superior gluteal
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Table III. Perioperative and midterm results in 55 internal iliac artery aneurysm (IIAA) cases IBD implantation No. of IIAAs treated Diameter of treated IIAAs, mm Primary technical success Early reinterventions (within 30 days)
29 (52.7)
Othera
Coverage of IIAA ostium 23 (41.8)
3 (5.5)
Total 55 (100)
29.04 (8.89)
30.35 (13.72)
35.67 (11.02)
29.94 (11.02)
89.7%
100%
100%
94.5%
2 (6.9)
0 (0)
0 (0)
2 (3.6)
1 (3.4)
N/A
N/A
1 (1.8)
1 (3.4)
N/A
N/A
1 (1.8)
4 (13.8)
1 (4.3)
1 (33.3)
6 (10.9)
1 (33.3)
1 (1.8)
Reason for early reintervention Type III endoleak Type IB endoleak Reinterventions during midterm follow-upb Reason for late reinterventions Type IA endoleak
0 (0)
0 (0)
Type IB endoleak
2 (6.9)
0 (0)
Type II endoleak
0 (0)
Type III endoleak
0 (0)
1 (4.3)
0 (0) 0 (0)
0 (0)
0 (0)
2 (3.6) 1 (1.8) 0 (0)
IIA thrombosis
1 (3.4)
0 (0)
0 (0)
1 (1.8)
External iliac limb and IIA occlusion
1 (3.4)
0 (0)
0 (0)
1 (1.8)
IBD, Iliac branch device; N/A, not applicable. Categorical variables are presented as number (%). Continuous variables are presented as mean (standard deviation). a Exclusion of aneurysms limited to the IIA using covered stent grafts (Fig 2, D). b Mean follow-up period of 14.9 (0.4-51.8) months.
surgery. The patient was treated with thoracic endograft implantation (thoracic endovascular aortic repair). One or several minor postoperative complications were observed in seven patients (Table IV). The minor complications could not be related to a specific endovascular treatment method because the same patient may receive unilateral ostium coverage and contralateral IBD implantation.
Fig 3. Type of endovascular internal iliac artery aneurysm (IIAA) exclusions per year. IBD, Iliac branch device.
artery; and intraoperative thrombosis of the IIA after IBD implantation with ipsilateral occlusion of the pelvic blood flow, which was left under conservative treatment. The first control CTA was performed on day 2 to 13 after surgery. Five patients showed type II iliac endoleaks after IIA coverage (n ¼ 3/23 [13.04%]) and IBD implantation (n ¼ 2/29 [6.9%]). Thirty-day morbidity and mortality. No major adverse events occurred during surgery. The overall 30-day mortality was 4.3% and 0% in elective patients. Postoperatively, one type B dissection after EVAR and right-sided IBD implantation was detected on day 5 after
Midterm follow-up. The mean follow-up period was 14.9 months (0.4-51.8 months). Kaplan-Meier analysis on the overall survival after treatment estimated a 4-year overall survival of 81% of the patients (Fig 4). Six patients needed reintervention after endovascular treatment: 1 type IA endoleak after local IIAA exclusion (Fig 2, D), 2 type IB endoleaks after IBD in tortuous anatomy, 1 occlusion of the IIA after IBD, 1 external iliac limb and IIA occlusion after EVAR and IBD, and 1 progressive type IIB endoleak after coverage of the IIA ostium. The combined type IB/III endoleak rate after IBD was 10.3%. None of the patients had technical or clinical complications during reintervention. No severe ischemic symptoms were recorded during follow-up. The evaluation of erectile dysfunction was not possible because of a lack of documentation on this specific question. Seven patients (15.2%) developed gluteal claudication during follow-up: two patients after unilateral ostium coverage (8.7%), one after IBD with sealing in the visceral branch and coiling of the calcified superior gluteal artery, and four patients with thrombosis of the IIA after IBD. Two patients underwent successful recanalization of the IIA. No patient with successful
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Table IV. Clinical follow-up of 46 patients Type of complication
No. of patients (%)
Major intraoperative adverse events
0 (0)
Major postoperative adverse events
3 (6.5)
Type B aortic dissection
1 (2.2)
30-Day mortality
2 (4.3)
Minor postoperative adverse events
7 (15.2)
Fever
2 (4.3)
Pneumonia
2 (4.3)
Urinary tract infection
1 (2.2)
Femoral pseudoaneurysm
1 (2.2)
Seroma of the groin
1 (2.2)
Prolonged wound healing
1 (2.2)
Fig 5. Estimated iliac branch device (IBD) thrombosis-free survival of 89.7% after 24 months (unassisted). CI, Confidence interval.
Fig 4. Kaplan-Meier analysis of overall survival after treatment estimated a 4-year overall survival of 81%. CI, Confidence interval.
preservation of the pelvic and gluteal blood flow reported gluteal claudication. Assisted midterm patency of IBDs was 93.1%. Kaplan-Meier analyses of IBD thrombosis-free survival, gluteal claudication-free survival, and probability for combined type IB and type III endoleaks are provided in Figs 5 to 7.
DISCUSSION IIAA is a rare entity, and its treatment can be challenging. The occlusion of the hypogastric artery ostium with prior coil or Amplatzer plug application is the most established and investigated endovascular treatment option in cases of common iliac artery aneurysm or IIAA.15 Whereas severe ischemic symptoms are reported rarely, one-quarter of the patients who receive unilateral IIA interruption suffer from gluteal claudication. Moreover, a review by Kouvelos et al17
showed that bilateral vs unilateral IIA interruption is associated with a significantly higher rate of gluteal claudication. With the advent of EVAR, hybrid solutions with open reconstruction of IIA continuity are performed to reduce ischemic symptoms. This technique shows good results, considering long-term patency, but increases the perioperative morbidity and might not be suitable in patients with concurrent large IIAAs.18,19 Therefore, an endovascular solution to preserve the pelvic blood flow and reliably exclude isolated or combined IIAAs seems worthwhile. Between 2009 and the beginning of 2013, the majority of patients were treated with coverage of the IIA ostium using iliac limb devices (Fig 3). This method was associated with a relatively higher rate of ischemic symptoms but a lower rate of reinterventions compared with IBD implantation. Therefore, careful selection of patients is required in an elective setting. In old patients with a low activity level and high perioperative risk, unilateral IIA ostium coverage is arguably safe, but younger patients with a longer life expectancy and good mobility may substantially benefit from bilateral preservation of the pelvic blood flow.17 The occurrence of buttock claudication in the study group was associated with occlusion of the IIA (ostium coverage, thrombosis of the IBD) or coiling of the superior gluteal artery in one case. There was no case of claudication after successful IBD implantation sealing in the main or gluteal IIA branch. These results combined with a low rate of complications and good technical success rates support IIAA exclusion using IBDs. Since 2013, a clear trend from primary intentional occlusion of the IIA toward anatomic endovascular reconstruction using IBDs can be observed at our institution (Fig 3).
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Clinical Outcome (Gluteal Claudication Survival Curve) 1,0
0,8
Cum. Survival
n=44, mean estimate=20.51 months, 95% CI =18.1 to 22.9
0,6
0,4
0,2
0,0 ,00
Number at risk: 44
6,00
12,00
18,00
24,00
Follow-Up (months) 38
37
37
37
Fig 6. Calculations on clinical outcome resulted in an 84.1% estimate for claudication-free survival after 2 years. Claudication-free survival is defined as having no signs of buttock claudication after treatment using iliac branch device (IBD) or ostium coverage. CI, Confidence interval.
Before 2010, IIAA was widely considered a limitation of IBD implantation,20 but Austermann et al14 reported good results in 16 patients treated with IBDs in combined aneurysms of the internal and aortoiliac arteries. The authors recommended the creation of a landing zone of at least 2 cm in the superior gluteal artery and sealing with a combination of covered stent grafts (Advanta V12/ Viabahn) and self-expanding nitinol stents for sufficient lining. A 0% rate of gluteal claudication or of type I and type III endoleaks during a 2-year follow-up was reported, and only one patient developed mild erectile dysfunction.14 To date, there is no validation of anatomic criteria for the use of IBD in patients with IIAAs, but general recommendations for IBD implantation mention a healthy sealing zone in the IIA of at least 10 mm.15,21 In this series, a healthy sealing zone of at least 10 mm or more in the IIA or one of its major branches was accepted. However, in our series, the combined type IB and type III endoleak rate was 10.3% compared with 0% in the 16 cases published by Austermann et al.14 In retrospect, the available distal sealing zone of at least 10 mm may be too short, especially in patients with tortuous anatomies. Therein may lie a relevant finding of this series, which may indicate a 2-cm sealing zone in the superior gluteal artery to perhaps be more adequate. Because large common iliac aneurysms grow in length and diameter,21,22 considerable tortuosity of the IIA may follow and aggravate complexity of creating a sufficient sealing zone in the IIA. This should also be considered in ongoing discussions about the threshold of common iliac artery aneurysms and IIAAs indicating
Fig 7. Combined type IB and type III endoleak-free survival of 89.7% (3/29 cases, unassisted) after treatment with iliac branch device (IBD) and 100% (0/23 cases) after treatment with ostium coverage (OC). CI, Confidence interval.
treatment. Whereas the critical size for isolated IIAAs is considered to be 3 to 4 cm,2,3,23 we also treated smaller IIAAs in patients undergoing EVAR for aorta-common iliac aneurysm disease to avoid the need for secondary interventions. For the same reason, we prefer IBD implantation to “bell-bottom” technique, which is associated with a higher frequency of secondary interventions because of disease progression and development of endoleaks.22,24 However, this should not be considered a general recommendation to exclude IIAAs smaller than 3 cm using IBDs but a suitable possibility in the portfolio of sufficient minimally invasive aortoiliac aneurysm repair.
CONCLUSIONS There is a clear trend toward functional endovascular treatment of isolated or combined IIAAs using IBD devices in the study institute. This technique shows good primary results concerning successful aneurysm exclusion and preservation of pelvic blood flow, combined with a low rate of perioperative complications and good long-term patency. Considering the reintervention rate, careful assessment of patients in terms of suitable distal sealing zone in the hypogastric artery and the quality of life impact of preserving the pelvic blood flow is required.
AUTHOR CONTRIBUTIONS Conception and design: MK, MP, JF, AA Analysis and interpretation: MK, MP, FT, CW, JF, AA Data collection: MK, MP, KH Writing the article: MK, FT, CW, JF Critical revision of the article: MK, MP, FT, CW, KH, JF, AA
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Final approval of the article: MK, MP, FT, CW, KH, JF, AA Statistical analysis: MK, MP, CW, JF Obtained funding: Not applicable Overall responsibility: AA
13.
14.
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guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018;67:2-77.e2. Farivar BS, Abbasi MN, Dias AP, Kuramochi Y, Brier CS, Parodi FE, et al. Durability of iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms. J Vasc Surg 2017;66:1028-36.e18. Austermann M, Bisdas T, Torsello G, Bosiers MJ, Lazaridis K, Donas KP. Outcomes of a novel technique of endovascular repair of aneurysmal internal iliac arteries using iliac branch devices. J Vasc Surg 2013;58:1186-91. Duvnjak S. Endovascular treatment of aortoiliac aneurysms: from intentional occlusion of the internal iliac artery to branch iliac stent graft. World J Radiol 2016;8:275-80. Donas KP, Bisdas T, Torsello G, Austermann M. Technical considerations and performance of bridging stent-grafts for iliac side branched devices based on a pooled analysis of single-center experiences. J Endovasc Ther 2012;19:667-71. Kouvelos GN, Katsargyris A, Antoniou GA, Oikonomou K, Verhoeven EL. Outcome after interruption or preservation of internal iliac artery flow during endovascular repair of abdominal aorto-iliac aneurysms. Eur J Vasc Endovasc Surg 2016;52:621-34. Lee WA, Nelson PR, Berceli SA, Seeger JM, Huber TS. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. J Vasc Surg 2006;44: 1162-8; discussion: 1168-9. Ghosh J, Murray D, Paravastu S, Farquharson F, Walker MG, Serracino-Inglott F. Contemporary management of aortoiliac aneurysms in the endovascular era. Eur J Vasc Endovasc Surg 2009;37:182-8. 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;17:163-71. Oderich GS, Greenberg RK. Endovascular iliac branch devices for iliac aneurysms. Perspect Vasc Surg Endovasc Ther 2011;23:166-72. Falkensammer J, Hakaim AG, Andrew Oldenburg W, Neuhauser B, Paz-Fumagalli R, McKinney JM, et al. Natural history of the iliac arteries after endovascular abdominal aortic aneurysm repair and suitability of ectatic iliac arteries as a distal sealing zone. J Endovasc Ther 2007;14:619-24. Laine MT, Björck M, Beiles CB, Szeberin Z, Thomson I, Altreuther M, et al. Few internal iliac artery aneurysms rupture under 4 cm. J Vasc Surg 2017;65:76-81. McDonnell CO, Semmens JB, Allen YB, Jansen SJ, Brooks DM, Lawrence-Brown MM. Large iliac arteries: a highrisk group for endovascular aortic aneurysm repair. J Endovasc Ther 2007;14:625-9.
Submitted May 13, 2018; accepted Dec 18, 2018.
ABSTRACT Objective: Internal iliac artery aneurysm (IIAA) is a rare entity. Its treatment can be technically challenging. The aim of this study was to evaluate the treatment possibilities in an era of advanced endovascular techniques and their potential to preserve iliac blood flow while reliably excluding the aneurysm. Methods: A retrospective analysis of 46 consecutive patients with endovascularly treated IIAA was performed. Data were collected from a single-institution aortoiliac database. The following end points were recorded: technique of aneurysm exclusion, technical success rates, perioperative morbidity and mortality, primary patency, and midterm follow-up. Results: Between September 2009 and May 2016, a total of 46 patients with 55 IIAAs were identified. The majority of patients (n ¼ 39 [84.8%]) had aortoiliac aneurysms and seven had isolated IIAAs (15.2%). The following surgical techniques were used: implantation of iliac branch devices (IBDs; n ¼ 29), occlusion of the internal iliac artery (IIA) by ostium coverage with or without prior coil embolization (n ¼ 23), and other endovascular techniques (n ¼ 3). Primary assisted technical success was achieved in 93.1% of IBD implantations and in 100% of occlusions by ostium coverage and other techniques. Overall 30-day mortality was 4.3% (n ¼ 2) and 0% in electively treated patients. Assisted midterm patency after IBD implantation was 93.1%. Gluteal claudication occurred in seven patients (15.2%) who had undergone intentional or accidental occlusion of the IIA or the superior gluteal artery. Reintervention rates within the midterm follow-up were 13.8% (n ¼ 4) after IBD implantation and 4.3% (n ¼ 1) after coverage of the IIA ostium. No ruptures were observed during follow-up, and no complications occurred during reinterventions. Conclusions: Implantation of IBD devices for the treatment of hypogastric artery aneurysms shows good technical results with a high primary patency and a low rate of perioperative complications. Although successful aneurysm exclusion while preserving pelvic blood flow is associated with a higher rate of reinterventions during midterm follow-up, it should be taken into consideration, especially in complex endovascular aortoiliac aneurysm repair. (J Vasc Surg 2019;-:1-8.) Keywords: Internal iliac artery aneurysm; Endovascular techniques; Iliac branch device; Gluteal claudication
The internal iliac artery (IIA) is a rare location for aneurysmatic degeneration. There are few data on the incidence of IIA aneurysms (IIAAs), which may occur in isolation or along with other aortoiliac disease. Kasulke et al1 estimated the incidence of isolated IIAAs with 0.4% of all intra-abdominal aneurysms, whereas the incidence seems to be higher among patients with aortoiliac disease.2 An incidence of 5% of IIAAs associated with abdominal aortic aneurysm and 29% with common iliac artery aneurysms has been described.3-5 As a consequence of the location in the minor pelvis, open surgical repair is technically challenging.6 With the advent of endovascular aneurysm repair (EVAR), an increasing willingness to treat the hypogastric arteries as dispensable can be observed. Occlusion of the IIA ostium by coil embolization or
extension of the endograft into the external iliac artery has been recommended for these cases. Although potentially lethal complications, including colon ischemia, gluteal necrosis, and spinal cord ischemia, are rare, incidences of 30% to 50% for buttock claudication and 20% to 50% for erectile dysfunction have been described.7-10 Conventional open reconstruction and endovascular occlusion have recently been supplemented by novel endovascular techniques that provide means of aneurysm exclusion while also preserving internal iliac blood flow. Especially in complex endovascular cases with occlusion of the inferior mesenteric artery during EVAR, the treatment of a concomitant hypogastric aneurysm with preservation of the pelvic blood flow seems to be favorable to avoid ischemic symptoms. The aim of this study was to assess the technical and clinical feasibility of different endovascular techniques to exclude IIAAs.
From the Department of Vascular and Endovascular Surgery, Wilhelminenhospitala; and the Sigmund Freud Private University, Medical School.b Author conflict of interest: none.
METHODS
Correspondence: Jürgen Falkensammer, MD, Department of Vascular and Endovascular Surgery, Wilhelminenhospital, Montleartstreet 37, Pavillion 30B, A-1160 Vienna, Austria (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2018.12.048
Study design A retrospective evaluation of 46 consecutive patients treated endovascularly for isolated or combined IIAAs during a period of 7 years (September 2009-August 2016) was performed. All included patients were unfit for open surgery. Data were collected from a single-institution aortoiliac aneurysm database and completed with 1
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information from paper-based and electronic health records. All patients showing dilation of the IIA $16 mm were included for retrospective evaluation. Aneurysms limited to the iliac bifurcation were not defined as IIAAs. The IIA diameter of $16 mm was in no case the indication for surgery but a defined study inclusion criterion as a representation of the diagnosis of IIAA.3,11 Postoperatively, all patients received computed tomography angiography (CTA) during the hospital stay and were seen afterward within 3 months and in 12-month intervals thereafter. Data on mortality were collected from electronic health records. Furthermore, outpatient visits were documented, and control computed tomography scans were screened for each patient. The course or development of ischemic symptoms, wound complications, and any adverse events were documented, as were secondary interventions, endoleaks, thrombosis of the iliac branch device (IBD), or other stent graft complications. The patients were routinely questioned about claudication of the lower extremity during each follow-up examination after aortoiliac repair. The review board of the City of Vienna approved the study and waived informed consent of the patients. The following end points were recorded: technique of aneurysm exclusion, technical success rates, 30-day morbidity and mortality, and midterm follow-up. Aneurysm anatomy The preoperative CTA image of each patient was analyzed using centerline reconstructions for aneurysm configuration and size (OsiriX 7.0 software; Pixmeo SARL, Geneva, Switzerland). In case of combined aortoiliac aneurysms, the maximum diameter of the infrarenal aorta, the common iliac artery, and the IIA was measured. A dilation of the abdominal aorta $30 mm and the common iliac artery $20 mm was defined as aneurysm.12,13 The same surgeon did all retrospective measurements. The anatomic location of aneurysms was then classified into combined aortoiliac aneurysms and isolated IIAAs (Fig 1). Surgical technique In general, the aim of case planning was to preserve iliac blood flow to at least one and if reasonably feasible both IIAs to avoid ischemic complications. The selection of the endovascular technique depended on the patient’s fitness and age, the clinical estimation of the development and quality of life impact of ischemic symptoms, and the anatomic suitability for IBD implantation or other techniques. The IBD devices used are listed in Table I. Patients routinely received 5000 units of heparin perioperatively and lifelong antiplatelet therapy (aspirin 100 mg once a day) postoperatively. Patients treated with IBD implantation additionally took clopidogrel (75 mg once a day) for 6 weeks after surgery. There were basically three alternatives to endovascular IIAA exclusion in the department.
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ARTICLE HIGHLIGHTS d
d
d
Type of Research: Single-center retrospective study of prospectively collected data Key Findings: The use of iliac branch devices (IBDs) for treatment of 29 of 55 hypogastric artery aneurysms showed good technical success rates (primary assisted success, 93.1%) combined with a 93.1% patency at a mean follow-up of 14.9 months. No ruptures were observed, and patients were treated successfully with IBDs without ischemic complications. Take Home Message: The treatment of internal iliac artery aneurysms with IBDs was technically feasible, safe, and effective in excluding the aneurysm while preserving the pelvic blood flow.
Implantation of an IBD. Implantations of IBDs were performed according to common protocols.14-16 The selection of IBD manufacturer (Cook, JOTEC, Gore, Bolton custom-made) was made because of anatomic feasibility. The distal sealing zone of IBD connecting stent grafts in the IIA was evaluated preoperatively. At least 10 mm in length and 5 mm in diameter of healthy artery were required to provide a safe distal sealing zone.15 To connect the IBD into a healthy hypogastric artery segment, balloon-expandable and self-expanding stent grafts were used. We relined balloon-expandable covered stent grafts with nitinol stents (Luminexx; Bard, Covington, Ga), exceeding it with 5 mm into the healthy segment to increase fixation of the reconstruction and to avoid secondary stent graft compression and migration.14 There were three options: sealing in the main branch, in the superior gluteal artery, or in the visceral branch of the IIA (Fig 2, A and B). Coils (Interlock 6- to 12-mm coils; Boston Scientific, Marlborough, Mass) were used to occlude branches that were likely to result in a type II endoleak (>6 mm in diameter14). Coils were placed through a microcatheter and through the released IBD. Endovascular coverage of the IIA ostium. Coverage of the ostium with a stent graft to exclude the aneurysm from antegrade blood flow was predominantly performed in combination with the implantation of an infrarenal bifurcated graft. Therefore, the iliac limb was chosen long enough to cover the ostium and to seal in a healthy zone of at least 20-mm length in the external iliac artery. Before coverage, the IIA outlet was occluded by either coil embolization (Interlock 6- to 12-mm coils) or plug implantation (Amplatzer Vascular Plug II; St. Jude Medical, St. Paul, Minn), depending on anatomy and the surgeon’s preference. Each device was inserted by crossover technique using a hydrophilic guidewire (HiWire, 0.035 inch; Cook Medical, Bloomington, Ind) and support catheter to cannulate the IIA.
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Fig 1. Anatomic aneurysm data.
Table I. Technical details of 29 iliac branch device (IBD) cases No. of devices used (%) Manufacturer of IBD Cook Zenith branch (ZBIS)
12 (41.4)
JOTEC E-iliac
11 (37.9)
Gore Excluder iliac component
4 (13.8)
Bolton custom-made
2 (6.9)
Type of BECS/self-expanding stent combination Advanta V12 (Maquet)/Luminexx (Bard) Eventus (JOTEC)/Luminexx (Bard)
26 (89.7) 3 (10.3)
BECS, Balloon-expandable covered stent graft.
A crossover 7F sheath (Flexor introducer sheath, 45-cm length, G09810; Cook) was usually placed in the main branch of the IIA and served as save path for plug or coil insertion (Fig 2, C). Exclusion of aneurysms limited to the IIA: Other techniques. Isolated aneurysms limited to the IIA excursions were excluded with local application of a covered stent (Advanta V12 [Maquet, Rastatt, Germany], Viabahn [W. L. Gore & Associates, Flagstaff, Ariz], Fluency [Bard]) anddif necessary and anatomically possibled prior coiling of the aneurysm lumen. This technique required healthy proximal and distal sealing zones of at least 15-mm length and 5-mm diameter in the main branch or the superior gluteal artery. Access was gained through crossover cannulation of the IIA, followed by insertion of a 7F sheath to protect stent graft run-through (Fig 2, D).
Technical success and follow-up Technical success was defined as effective exclusion of the aneurysm and, when intended, successful preservation of the pelvic blood flow. Occlusion of the IBD branch was considered technical failure. This was documented by angiography at the end of the intervention and by CTA during the postoperative hospital stay. Because of described graft porosities of IBD devices, which may impair intraoperative differentiation of type IV and types I, II, and III endoleaks, we consider CTA a few days after surgery important. Type II endoleak was not considered a technical failure. Statistics All demographics, baseline characteristics, and postoperative and follow-up data were evaluated descriptively. Kaplan-Meier analysis was performed, estimating survival functions from data on overall survival, IBD patency, combined type IB and type III endoleaks, and clinical outcome. All statistical calculations were performed using Microsoft Excel for Windows (Microsoft, Redmond, Wash) and SPSS Statistics for Windows (version 21.0; IBM Corp, Armonk, NY).
RESULTS Patients’ demographics. Within the database, 55 IIAAs were identified in 46 patients. Mean age was 72.2 years (range, 46-91 years), and 41 patients were male. The cardiovascular risk factors are presented in Table II. Most patients (n ¼ 39 [84.8%]) had coexisting aneurysms of the aorta (n ¼ 9), common iliac arteries (n ¼ 11), or both (n ¼ 19). In the remaining seven patients (n ¼ 7 [15.2%]), a total of nine isolated IIAAs with a mean diameter of 38.2 mm were found (Fig 1). There
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Table II. Patients’ demographics and cardiovascular risk factors No. or mean % or SD No. of patients
46
100
Age, years
72.2
69.2
Male
41
89.1
Hypertension
39
84.8
Smoking
29
63.0
Hyperlipidemia
25
54.3
Diabetes mellitus
10
21.7
Coronary artery disease
16
34.8
Prior myocardial infarction
6
13.0
Congestive heart failure
5
10.9
Atrial fibrillation
4
8.7
Chronic obstructive pulmonary disease
9
19.6
Renal insufficiency (serum creatinine $1.4 mg/dL)
11
23.9
Obesity (body mass index >30 kg/m2)
8
17.4
SD, Standard deviation.
Fig 2. Variations of endovascular internal iliac artery aneurysm (IIAA) exclusion. A, Iliac branch device (IBD) implantation sealing in the main hypogastric branch. B, IBD implantation sealing in the superior gluteal artery with coiling of possible feeding branches. C, Coverage of the internal iliac artery (IIA) ostium with coiling or plug implantation of possible feeding branches. D, Exclusion of hypogastric aneurysm with covered stent within the excursion of the artery itself and preservation of the pelvic blood flow.
were six (13.0%) urgent (symptomatic or ruptured) patients. In 40 patients, the treatment was elective (nonurgent). Surgery methods. The numbers of differently used methods are listed in Table III and are defined as numbers of treated IIAAs. Different methods may be used in the same patient with unilateral sacrifice of the IIA and contralateral preservation. This was the case in four patients; none received planned bilateral occlusion, and in five patients, bilateral hypogastric aneurysms were treated with preservation of both IIAs. The results of the different endovascular methods in detail are as follows: Twenty-nine IIAAs (52.7 %) were excluded using an IBD with graft extension into the superior gluteal artery
(n ¼ 12 [41.4%]), the main branch of the IIA (n ¼ 16 [55.2%]), or the visceral branch (n ¼ 1 [3.4%]). The IBD devices used and connecting stents are listed in Table I. The majority of IBD implantations was performed after 2013 and replaced the former coverage of the IIA ostium in patients with suitable anatomy (Fig 3). In 23 cases (41.8%) of IIAAs, the ostium was covered by either extension of the ipsilateral iliac limb during EVAR (n ¼ 20) or selective stent graft implantation into the common iliac artery and external iliac artery across the IIA origin (n ¼ 3). Before coverage, an Amplatzer plug was placed in seven IIAAs; in two cases, coils were applied in aneurysm feeding branches; and in one case, coils and a plug were inserted before coverage of the IIA ostium. In three patients (5.5%), an isolated IIAA was excluded using covered stent graft implantation limited to the IIA. Therefore, an Advanta V12 or Viabahn in combination with a nitinol stent (Luminexx) was used in all cases (Fig 2, D). Technical success and early reinterventions. Primary technical success was achieved in 89.7% (93.1% assisted) of IBD implantations and in 100% of IIA ostium coverages. The following technical failures occurred: disconnection of an IBD with the connecting Advanta stent graft in a case of 3-cm IIAA with tortuous IIA excursion, resulting in a type III endoleak and need for early reintervention with extension into the superior gluteal artery; endoleak type IB on the postoperative computed tomography scan with failing distal attachment in the main branch of the IIA, resulting in reintervention with extension of the sealing zone into the superior gluteal
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Table III. Perioperative and midterm results in 55 internal iliac artery aneurysm (IIAA) cases IBD implantation No. of IIAAs treated Diameter of treated IIAAs, mm Primary technical success Early reinterventions (within 30 days)
29 (52.7)
Othera
Coverage of IIAA ostium 23 (41.8)
3 (5.5)
Total 55 (100)
29.04 (8.89)
30.35 (13.72)
35.67 (11.02)
29.94 (11.02)
89.7%
100%
100%
94.5%
2 (6.9)
0 (0)
0 (0)
2 (3.6)
1 (3.4)
N/A
N/A
1 (1.8)
1 (3.4)
N/A
N/A
1 (1.8)
4 (13.8)
1 (4.3)
1 (33.3)
6 (10.9)
1 (33.3)
1 (1.8)
Reason for early reintervention Type III endoleak Type IB endoleak Reinterventions during midterm follow-upb Reason for late reinterventions Type IA endoleak
0 (0)
0 (0)
Type IB endoleak
2 (6.9)
0 (0)
Type II endoleak
0 (0)
Type III endoleak
0 (0)
1 (4.3)
0 (0) 0 (0)
0 (0)
0 (0)
2 (3.6) 1 (1.8) 0 (0)
IIA thrombosis
1 (3.4)
0 (0)
0 (0)
1 (1.8)
External iliac limb and IIA occlusion
1 (3.4)
0 (0)
0 (0)
1 (1.8)
IBD, Iliac branch device; N/A, not applicable. Categorical variables are presented as number (%). Continuous variables are presented as mean (standard deviation). a Exclusion of aneurysms limited to the IIA using covered stent grafts (Fig 2, D). b Mean follow-up period of 14.9 (0.4-51.8) months.
surgery. The patient was treated with thoracic endograft implantation (thoracic endovascular aortic repair). One or several minor postoperative complications were observed in seven patients (Table IV). The minor complications could not be related to a specific endovascular treatment method because the same patient may receive unilateral ostium coverage and contralateral IBD implantation.
Fig 3. Type of endovascular internal iliac artery aneurysm (IIAA) exclusions per year. IBD, Iliac branch device.
artery; and intraoperative thrombosis of the IIA after IBD implantation with ipsilateral occlusion of the pelvic blood flow, which was left under conservative treatment. The first control CTA was performed on day 2 to 13 after surgery. Five patients showed type II iliac endoleaks after IIA coverage (n ¼ 3/23 [13.04%]) and IBD implantation (n ¼ 2/29 [6.9%]). Thirty-day morbidity and mortality. No major adverse events occurred during surgery. The overall 30-day mortality was 4.3% and 0% in elective patients. Postoperatively, one type B dissection after EVAR and right-sided IBD implantation was detected on day 5 after
Midterm follow-up. The mean follow-up period was 14.9 months (0.4-51.8 months). Kaplan-Meier analysis on the overall survival after treatment estimated a 4-year overall survival of 81% of the patients (Fig 4). Six patients needed reintervention after endovascular treatment: 1 type IA endoleak after local IIAA exclusion (Fig 2, D), 2 type IB endoleaks after IBD in tortuous anatomy, 1 occlusion of the IIA after IBD, 1 external iliac limb and IIA occlusion after EVAR and IBD, and 1 progressive type IIB endoleak after coverage of the IIA ostium. The combined type IB/III endoleak rate after IBD was 10.3%. None of the patients had technical or clinical complications during reintervention. No severe ischemic symptoms were recorded during follow-up. The evaluation of erectile dysfunction was not possible because of a lack of documentation on this specific question. Seven patients (15.2%) developed gluteal claudication during follow-up: two patients after unilateral ostium coverage (8.7%), one after IBD with sealing in the visceral branch and coiling of the calcified superior gluteal artery, and four patients with thrombosis of the IIA after IBD. Two patients underwent successful recanalization of the IIA. No patient with successful
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Table IV. Clinical follow-up of 46 patients Type of complication
No. of patients (%)
Major intraoperative adverse events
0 (0)
Major postoperative adverse events
3 (6.5)
Type B aortic dissection
1 (2.2)
30-Day mortality
2 (4.3)
Minor postoperative adverse events
7 (15.2)
Fever
2 (4.3)
Pneumonia
2 (4.3)
Urinary tract infection
1 (2.2)
Femoral pseudoaneurysm
1 (2.2)
Seroma of the groin
1 (2.2)
Prolonged wound healing
1 (2.2)
Fig 5. Estimated iliac branch device (IBD) thrombosis-free survival of 89.7% after 24 months (unassisted). CI, Confidence interval.
Fig 4. Kaplan-Meier analysis of overall survival after treatment estimated a 4-year overall survival of 81%. CI, Confidence interval.
preservation of the pelvic and gluteal blood flow reported gluteal claudication. Assisted midterm patency of IBDs was 93.1%. Kaplan-Meier analyses of IBD thrombosis-free survival, gluteal claudication-free survival, and probability for combined type IB and type III endoleaks are provided in Figs 5 to 7.
DISCUSSION IIAA is a rare entity, and its treatment can be challenging. The occlusion of the hypogastric artery ostium with prior coil or Amplatzer plug application is the most established and investigated endovascular treatment option in cases of common iliac artery aneurysm or IIAA.15 Whereas severe ischemic symptoms are reported rarely, one-quarter of the patients who receive unilateral IIA interruption suffer from gluteal claudication. Moreover, a review by Kouvelos et al17
showed that bilateral vs unilateral IIA interruption is associated with a significantly higher rate of gluteal claudication. With the advent of EVAR, hybrid solutions with open reconstruction of IIA continuity are performed to reduce ischemic symptoms. This technique shows good results, considering long-term patency, but increases the perioperative morbidity and might not be suitable in patients with concurrent large IIAAs.18,19 Therefore, an endovascular solution to preserve the pelvic blood flow and reliably exclude isolated or combined IIAAs seems worthwhile. Between 2009 and the beginning of 2013, the majority of patients were treated with coverage of the IIA ostium using iliac limb devices (Fig 3). This method was associated with a relatively higher rate of ischemic symptoms but a lower rate of reinterventions compared with IBD implantation. Therefore, careful selection of patients is required in an elective setting. In old patients with a low activity level and high perioperative risk, unilateral IIA ostium coverage is arguably safe, but younger patients with a longer life expectancy and good mobility may substantially benefit from bilateral preservation of the pelvic blood flow.17 The occurrence of buttock claudication in the study group was associated with occlusion of the IIA (ostium coverage, thrombosis of the IBD) or coiling of the superior gluteal artery in one case. There was no case of claudication after successful IBD implantation sealing in the main or gluteal IIA branch. These results combined with a low rate of complications and good technical success rates support IIAA exclusion using IBDs. Since 2013, a clear trend from primary intentional occlusion of the IIA toward anatomic endovascular reconstruction using IBDs can be observed at our institution (Fig 3).
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Clinical Outcome (Gluteal Claudication Survival Curve) 1,0
0,8
Cum. Survival
n=44, mean estimate=20.51 months, 95% CI =18.1 to 22.9
0,6
0,4
0,2
0,0 ,00
Number at risk: 44
6,00
12,00
18,00
24,00
Follow-Up (months) 38
37
37
37
Fig 6. Calculations on clinical outcome resulted in an 84.1% estimate for claudication-free survival after 2 years. Claudication-free survival is defined as having no signs of buttock claudication after treatment using iliac branch device (IBD) or ostium coverage. CI, Confidence interval.
Before 2010, IIAA was widely considered a limitation of IBD implantation,20 but Austermann et al14 reported good results in 16 patients treated with IBDs in combined aneurysms of the internal and aortoiliac arteries. The authors recommended the creation of a landing zone of at least 2 cm in the superior gluteal artery and sealing with a combination of covered stent grafts (Advanta V12/ Viabahn) and self-expanding nitinol stents for sufficient lining. A 0% rate of gluteal claudication or of type I and type III endoleaks during a 2-year follow-up was reported, and only one patient developed mild erectile dysfunction.14 To date, there is no validation of anatomic criteria for the use of IBD in patients with IIAAs, but general recommendations for IBD implantation mention a healthy sealing zone in the IIA of at least 10 mm.15,21 In this series, a healthy sealing zone of at least 10 mm or more in the IIA or one of its major branches was accepted. However, in our series, the combined type IB and type III endoleak rate was 10.3% compared with 0% in the 16 cases published by Austermann et al.14 In retrospect, the available distal sealing zone of at least 10 mm may be too short, especially in patients with tortuous anatomies. Therein may lie a relevant finding of this series, which may indicate a 2-cm sealing zone in the superior gluteal artery to perhaps be more adequate. Because large common iliac aneurysms grow in length and diameter,21,22 considerable tortuosity of the IIA may follow and aggravate complexity of creating a sufficient sealing zone in the IIA. This should also be considered in ongoing discussions about the threshold of common iliac artery aneurysms and IIAAs indicating
Fig 7. Combined type IB and type III endoleak-free survival of 89.7% (3/29 cases, unassisted) after treatment with iliac branch device (IBD) and 100% (0/23 cases) after treatment with ostium coverage (OC). CI, Confidence interval.
treatment. Whereas the critical size for isolated IIAAs is considered to be 3 to 4 cm,2,3,23 we also treated smaller IIAAs in patients undergoing EVAR for aorta-common iliac aneurysm disease to avoid the need for secondary interventions. For the same reason, we prefer IBD implantation to “bell-bottom” technique, which is associated with a higher frequency of secondary interventions because of disease progression and development of endoleaks.22,24 However, this should not be considered a general recommendation to exclude IIAAs smaller than 3 cm using IBDs but a suitable possibility in the portfolio of sufficient minimally invasive aortoiliac aneurysm repair.
CONCLUSIONS There is a clear trend toward functional endovascular treatment of isolated or combined IIAAs using IBD devices in the study institute. This technique shows good primary results concerning successful aneurysm exclusion and preservation of pelvic blood flow, combined with a low rate of perioperative complications and good long-term patency. Considering the reintervention rate, careful assessment of patients in terms of suitable distal sealing zone in the hypogastric artery and the quality of life impact of preserving the pelvic blood flow is required.
AUTHOR CONTRIBUTIONS Conception and design: MK, MP, JF, AA Analysis and interpretation: MK, MP, FT, CW, JF, AA Data collection: MK, MP, KH Writing the article: MK, FT, CW, JF Critical revision of the article: MK, MP, FT, CW, KH, JF, AA
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Final approval of the article: MK, MP, FT, CW, KH, JF, AA Statistical analysis: MK, MP, CW, JF Obtained funding: Not applicable Overall responsibility: AA
13.
14.
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Submitted May 13, 2018; accepted Dec 18, 2018.