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Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.

ABSTRACT: Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass.Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded.The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent.Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.

SUBMITTER: Mansukhani NA

PROVIDER: S-EPMC5483202 | biostudies-other | 2017 Jul

REPOSITORIES: biostudies-other

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Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.

Mansukhani Neel A NA Havelka George E GE Helenowski Irene B IB Rodriguez Heron E HE Hoel Andrew W AW Eskandari Mark K MK

Annals of vascular surgery 20170308

<h4>Background</h4>Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ...[more]

PMID: 28286187

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Project description:ObjectiveInternal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments.MethodsBetween June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft.ResultsThe median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m2 (range, 23-26.4 kg/m2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs.ConclusionsTotal robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.

Project description:BackgroundEndovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.Case presentationA 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.ConclusionEndovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.

Project description:PurposeTo determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR).MethodsThis single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality.ResultsThe mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak.ConclusionAneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

Dataset Information

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.

Publications

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.

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