Hypogastric Preservation Using Retrograde Endovascular Bypass
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1 Hypogastric Preservation Using Retrograde Endovascular Bypass Mathew Wooster MD, Adam Tanious MD, Brad Johnson MD, Murray Shames MD, Paul Armstrong MD, Martin Back MD Florida Vascular Society 30 th Annual
2 CONFLICTS OF INTEREST No financial conflicts
3 Background Complications of Hypogastric Occlusion Buttock claudication: 13-55% Erectile dysfunction: 5-45% Colonic ischemia: 1-2%?Bowel/bladder dysfunction?spinal cord ischemia
4 Background AUI, fem-fem, EIA-IIA covered stent AUI, fem-fem, fem-iia bypass Off label device use Bifurcated stentgraft with limb to IIA, fem-fem Trifurcation Mainbody into mainbody Mainbody into bellbottom limb Double Barrel Snorkel 88% technical success, 3 early limb occlusions 6 month primary patency 95% (EIA), 88% (IIA)
5 Background Bifurcated Iliac Devices
6 Background One method we have used regularly is the external to internal iliac artery endovascular bypass combined with cross femoral artery bypass
7 Objective To evaluate the mid to late follow up of hypogastric artery preservation by means of endovascular external to internal artery bypass
8 Methods Retrospective review All patients treated from Anatomic inclusion criteria Unilateral iliac artery aneurysm with contralateral hypogastric occlusion Bilateral iliac artery aneurysms External-internal iliac artery angle >45
9 Methods Bilateral open femoral artery exposure Aorto-uni-iliac device deployment +/- ipsilateral hypogastric embolization with limb extension to the external iliac artery Cross-femoral artery bypass Contralateral hypogastric artery cannulation Deployment of covered stentgraft from hypogastric artery to external iliac artery Post delivery angioplasty Completion angiography
10 Methods Technical description with pictures
11 Methods Technical description with pictures
12 Methods Technical description with pictures
13 Methods Surveillance Protocol Duplex ultrasound at 1 month and 6 months postoperatively, then annually thereafter CT scan (with selective contrast use) 1 month postoperatively, then annually thereafter
14 Results Demographics N 17 Age, years /- 6.8 Male 93% Hypertension 15 (93%) Hyperlipidemia 15 (93%) Diabetes 5 (33%) Prior CVA 1 (7%) Smoking 16 (100%) Coronary artery disease 6 (36%) Obesity 4 (27%) COPD 5 (33%)
15 Results Aneurysm Information Iliac Aneurysm Size, cm 4.0 +/ Indication Primary Disease 11 (64%) Prior Open Repair 4 (24%) Prior Endovascular Repair 2 (12%) Morphology Unilateral Iliac 7 (41%) Bilateral Common Iliac 9 (53%) Bilateral Internal Iliac 1 (6%) External-Internal Iliac Angle, degrees 71.4 (51-102)
16 Results Operative Details Technical Success 100% Length of Surgery, minutes 168 (50-300) Blood Loss, ml 412 ( ) Contrast, ml 75.5 (25-150)
17 Results Operative Details Contralateral Hypogastric Embolization 6 Proximal Extension (Snorkel/Fenestration) 5 Devices Bard Fluency 1 Gore Excluder Limb 3 Gore Viabahn 13
18 Results Median ICU stay: 2 days Median hospital stay: 3 days No major complications All discharged home
19 Results Mean follow up 25.7 months (range 3-56) Primary patency: 94.1% One occlusion Fluency stentgraft Asymptomatic One reinterventions Type II endoleak No aneurysm sac growth
20 Results Mean follow up 25.7 months (range 3-56) No bowel/bladder dysfunction No buttock claudication No bowel ischemia No spinal cord ischemia No new erectile dysfunction
21 Results
22 Discussion Zenith (Ziegler et al 2007) Excluder (van Sterkenburg et al 2016 ) EIA-IIA Bypass (Current study) N Technical Success 69% 93.5% 100% Follow Up 24 months 6 months 25.7 months Patency 87% 94% 94.1%
23 Conclusion Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation
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