Scientific Exhibit Authors: J. M. M. Sanchis Garcia, J. Palmero da Cruz, J. Guijarro

Transcription

1 Endovascular aortic aneurysm repair (EVAR) with hypogastric branch stent graft to preserve pelvic perfusion in patients with aortoiliac aneurysms extending to the iliac bifurcation: our experience Poster No.: C-2348 Congress: ECR 2011 Type: Scientific Exhibit Authors: J. M. M. Sanchis Garcia, J. Palmero da Cruz, J. Guijarro Rosaleny, J. Gil Romero, I. Martin Gonzalez, J. I. CERVERA MIGUEL, M. Bertolo Domínguez, J. A. Bahamonde Romano ; 1 2 Valencia/ES, VALENCIA/ES Keywords: Interventional vascular, Arteries / Aorta, Vascular, CTAngiography, Catheter arteriography, Stents, Embolisation, Grafts DOI: /ecr2011/C-2348 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Page 1 of 53

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3 Purpose INTRODUCTION AND PURPOSES: Common iliac artery (CIA) aneu- rysms may prevent or complicate en- dovascular aneurysm repair (EVAR) and are found in up to 20% of patients with abdominal aortic aneurysm (AAA). CIA aneurysms frequently extend close to the iliac bifurcation, requiring distal fixation in the external iliac ar- tery (EIA), excluding the internal iliac artery (IIA). Although interruption of one or both IIAs can be performed, preservation of flow to at least one IIA artery is recommended to avoid com- plications such as paraplegia, colon ischemia, impotence, buttock claudication, bladder sphincter dysfunction, and pelvic necrosis. Recently, new endovascular approaches have been developed such as branched stent grafts or the deployment of a stent graft for EIA-to-IIA "cross-stenting" with reverse hypo- gastric artery revascularization. These procedures permit preservation of pelvic circulation in patients with aortoiliac aneurysms while avoiding the retroperitoneal approach but also require adequate landing zones. Potential complications associated with IIA occlusion include buttock claudication, sexual dysfunction, colon ischemia, distal spinal cord infarction, and gluteal necrosis. The incidence of these complications varies widely, ranging from 1.1% of gluteal claudication in patients treated with aortoiliac bypass surgery to 15%- 20% of pelvic ischemia with unilateral and bilateral IIA occlusion. Because these complications are significant, investigators encourage the preservation of at least one IIA. We show our preliminary results of this new approach. Methods and Materials In our hospital from march 2007 to november male patients were treated with a bifurcated stent graft, that include a unilateral internal iliac artery branch device (IIBD). We analyzed the duration of the procedure, fluoroscopy time, radiation dose, contrast volume, hemoglobin drop, days of hospitalization, median diameters of abdominal aortic and common iliac artery aneurysms. Postoperative endoleaks, patency rate and diameter of the vessels were determined with CT. Results Page 3 of 53

4 Fig.: Figure 24. At the 30-month CT follow-up patency of the stent-graft without complications or endoleaks is shown. Lung tumor in the right upper lobe was found as an incidental finding (d). References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 4 of 53

5 Fig.: Figure 23. At the 20-month CT follow-up patency of the stent-graft without complications or endoleaks can be seen. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 5 of 53

6 Fig.: Figure 22. Angiography shows obstruction of the right branch of the stent. Fibrinolysis was performed with r-tpa (a). In the post-fibrinolysis control (b and c) recanalization of the right branch of the stent is shown. A new stent-graft was placed in the right common iliac artery. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 6 of 53

7 Fig.: Figure 21. At the 2 month CT follow-up obstruction of the right branch stent-graft (white arrow in b) and obstrucción of the right external iliac artery (white arrow in c) with revascularization in the right common femoral artery can be seen. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 7 of 53

8 Fig.: Figure 20. Calibrated angiography showing a left common iliac artery aneurysm. A stent-graft is passed through the internal iliac artery branch to extend it (a). The final control shows little enhancement in the right branch of the stent-graft (b). References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 8 of 53

9 Fig.: Figure 19. Coronal MPR image. Aorto-iliac aneurysm is noted. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 9 of 53

10 Fig.: Figure 18. Contrast-enhanced axial CT images. Infrarenal abdominal aortic aneurysm extending to left common iliac artery. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 10 of 53

11 Fig.: Figure month CT follow-up shows patency of stent-graft without endoleaks. Resolution of left groin abscess is observed. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 11 of 53

12 Fig.: Figure month CT follow-up shows patency of the stent-graft without endoleaks. Abscess in left groin (white arrow in d) is seen. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 12 of 53

13 Fig.: Figure 15. Angiography (a) showing a stent-graft in left internal iliac artery. (b) Control angiography shows correct results without endoleaks. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 13 of 53

14 Fig.: Figure month follow-up enhanced CT scan shows gas bubbles in the aneurysm (white arrow in a) that suggest infection of the stent-graft. Obstruction of right external iliac artery (white arrow in c) and revascularization of right common femoral artery are noted. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 14 of 53

15 Fig.: Figure month follow-up unenhanced CT images show a gas bubble in the aneurysm (white arrow in b) suggesting stent-graft infection. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 15 of 53

16 Fig.: Figure month CT follow-up shows patency of the stent-graft without any endoleaks or complications. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 16 of 53

17 Fig.: Figure day CT follow-up shows patency of the stent-graft without endoleaks. Gas bubble observed in the aneurysm may be related to the releasing device (white arrow in b). Patency of stent graft in right internal iliac artery (white arrow in c) and embolization material in left internal iliac artery (black arrow in d) are seen. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 17 of 53

18 Fig.: Figure 10.- Angiography (a) showing a stent-graft in the right internal iliac artery and embolization material (black arrow). (b) Control angiography shows satisfactory results without endoleaks References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 18 of 53

19 Fig.: Figure 9. Volume-rendered image demonstrating aorto-iliac aneurysm References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 19 of 53

20 Fig.: Figure 8. Axial CT after intravenous contrast administration. Infrarenal abdominal aortic aneurysm extending to both common iliac arteries. Infraumbilical hernia is also noted References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 20 of 53

21 Fig.: Figure month CT follow-up. Permeability of the stent-graft, with no endoleaks and remodeling of the aneurysm are observed. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 21 of 53

22 Fig.: Figure 6. At the 24-month CT follow-up permeability of the stent-graft is observed, no endoleaks are seen and aneurysm size has decreased. This phenomenon is known as remodeling of the aneurysm. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 22 of 53

23 Fig.: Figure 5. 6-month CT follow-up shows patency of the stent-graft without any complications or endoleaks. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 23 of 53

24 Fig.: Figure 4. Angiography (a) showing aorto-left common iliac artery aneurism and ectatic right common iliac artery (b) A stent-graft is passed through the internal iliac artery branch. (c) Control angiography shows good results without endoleaks References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 24 of 53

25 Fig.: Figure 3. Aorto-iliac aneurysm is noted on coronal MPR image. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 25 of 53

26 Fig.: Figure 2. Axial CT following intravenous contrast administration. Infrarenal abdominal aortic aneurysm extending to the left common iliac artery. References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Page 26 of 53

27 Fig.: Table 1 References: J. M. M. Sanchis Garcia; Radiology, Hospital Clinico Universitario de Valencia (Valencia); Spain, Valencia, SPAIN Duration of procedure and fluoroscopy time was 191,72 ± 64,78 and 69,36 ± 18,18 minutes respectively, radiation dose 3443,09 ± 1257,68 mgy, contrast volume 179,81 ± 22,36 ml, hemoglobin drop 3,1 ± 1,58 g/dl. Days of hospitalization 6,27 ± 1,49. The median diameters before procedure of the abdominal aortic and common iliac artery aneurysms were 51,89 ± 21,16 mm and 30,18 ± 6,66 mm, respectively, and in postprocedural controls 50,63 ± 20,31 mm and 27,72 ± 6,00 mm. In 4 cases (19,05%) contralateral hypogastric artery was embolized. In two cases (9,52%) was observed distal iliac occlusion, the first one was, with the hipogastric embolized, was treated with fibrinolitic and remain patency; the other one the occlusion was distal to the hipogastric branch and the patient remain asymptomatic without additional treatment. At a mean follow-up of 13,6 ± 11,6 months, all branched hypogastric arteries remained patent without endoleak, migration or loss of device integrity. There were no deaths or conversión. Table 1. You can see some pacients of our serie in the next images. Page 27 of 53

28 - Images for this section: Fig. 1: Table 1 Page 28 of 53

29 Fig. 2: Figure 2. Axial CT following intravenous contrast administration. Infrarenal abdominal aortic aneurysm extending to the left common iliac artery. Page 29 of 53

30 Fig. 3: Figure 3. Aorto-iliac aneurysm is noted on coronal MPR image. Page 30 of 53

31 Fig. 4: Figure 4. Angiography (a) showing aorto-left common iliac artery aneurism and ectatic right common iliac artery (b) A stent-graft is passed through the internal iliac artery branch. (c) Control angiography shows good results without endoleaks Page 31 of 53

32 Fig. 5: Figure 5. 6-month CT follow-up shows patency of the stent-graft without any complications or endoleaks. Page 32 of 53

33 Fig. 6: Figure 6. At the 24-month CT follow-up permeability of the stent-graft is observed, no endoleaks are seen and aneurysm size has decreased. This phenomenon is known as remodeling of the aneurysm. Page 33 of 53

34 Fig. 7: Figure month CT follow-up. Permeability of the stent-graft, with no endoleaks and remodeling of the aneurysm are observed. Page 34 of 53

35 Fig. 8: Figure 8. Axial CT after intravenous contrast administration. Infrarenal abdominal aortic aneurysm extending to both common iliac arteries. Infraumbilical hernia is also noted. Page 35 of 53

36 Fig. 9: Figure 9. Volume-rendered image demonstrating aorto-iliac aneurysm Page 36 of 53

37 Fig. 10: Figure 10.- Angiography (a) showing a stent-graft in the right internal iliac artery and embolization material (black arrow). (b) Control angiography shows satisfactory results without endoleaks Page 37 of 53

38 Fig. 11: Figure day CT follow-up shows patency of the stent-graft without endoleaks. Gas bubble observed in the aneurysm may be related to the releasing device (white arrow in b). Patency of stent graft in right internal iliac artery (white arrow in c) and embolization material in left internal iliac artery (black arrow in d) are seen. Page 38 of 53

39 Fig. 12: Figure month CT follow-up shows patency of the stent-graft without any endoleaks or complications. Page 39 of 53

40 Fig. 13: Figure month follow-up unenhanced CT images show a gas bubble in the aneurysm (white arrow in b) suggesting stent-graft infection. Page 40 of 53

41 Fig. 14: Figure month follow-up enhanced CT scan shows gas bubbles in the aneurysm (white arrow in a) that suggest infection of the stent-graft. Obstruction of right external iliac artery (white arrow in c) and revascularization of right common femoral artery are noted. Page 41 of 53

42 Fig. 15: Figure 15. Angiography (a) showing a stent-graft in left internal iliac artery. (b) Control angiography shows correct results without endoleaks. Page 42 of 53

43 Fig. 16: Figure month CT follow-up shows patency of the stent-graft without endoleaks. Abscess in left groin (white arrow in d) is seen. Page 43 of 53

44 Fig. 17: Figure month CT follow-up shows patency of stent-graft without endoleaks. Resolution of left groin abscess is observed. Page 44 of 53

45 Fig. 18: Figure 18. Contrast-enhanced axial CT images. Infrarenal abdominal aortic aneurysm extending to left common iliac artery. Page 45 of 53

46 Fig. 19: Figure 19. Coronal MPR image. Aorto-iliac aneurysm is noted. Page 46 of 53

47 Fig. 20: Figure 20. Calibrated angiography showing a left common iliac artery aneurysm. A stent-graft is passed through the internal iliac artery branch to extend it (a). The final control shows little enhancement in the right branch of the stent-graft (b). Page 47 of 53

48 Fig. 21: Figure 21. At the 2 month CT follow-up obstruction of the right branch stent-graft (white arrow in b) and obstrucción of the right external iliac artery (white arrow in c) with revascularization in the right common femoral artery can be seen. Page 48 of 53

49 Fig. 22: Figure 22. Angiography shows obstruction of the right branch of the stent. Fibrinolysis was performed with r-tpa (a). In the post-fibrinolysis control (b and c) recanalization of the right branch of the stent is shown. A new stent-graft was placed in the right common iliac artery. Page 49 of 53

50 Fig. 23: Figure 23. At the 20-month CT follow-up patency of the stent-graft without complications or endoleaks can be seen. Page 50 of 53

51 Fig. 24: Figure 24. At the 30-month CT follow-up patency of the stent-graft without complications or endoleaks is shown. Lung tumor in the right upper lobe was found as an incidental finding (d). Page 51 of 53

52 Conclusion This approach is feasible and allows maintain perfusion to one or both hypogastric arteries and preserving pelvic perfusion and it helps to keep lower extremities' perfusion. References 1. Armon MP, Wenham PW, Whitaker SC, Gregson RH, Hopkinson BR. Com- mon iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1998; 15: Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, McLaf- ferty RB. Adverse consequences of intenal iliac occlusion during endovascular repair of abdominal aortic aneurysms. JVascSurg 2000; 32: Ayerdi J, McLafferty RB, Solis MM, et al. Retrograde endovascular hypogastric artery preservation (REHAP) and aortouniiliac (AUI) endografting in the management of complex aor- toiliac aneurysms. Ann Vasc Surg 2003; 17: Parodi JC, Ferreira M. Relocation of the iliac artery bifurcation to facilitate endoluminal treatment of abdominal aortic aneurysms. J Endovasc Surg 1999; 6: Yano OJ, Morrissey N, Eisen L, et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001; 34: Rhee RY, Muluk SC, Tzeng E, MissigCarroll N, Makaroun MS. Can the internal iliac artery be safely covered during endovascular repair of abdominal aortic and iliac artery aneurysms? Ann Vasc Surg 2002; 16: Kritpracha B, Pigott JP, Abraham CZ, et al. A modular multi-branched system for endovascular repair of bilateral common iliac artery aneurysms. J Endovasc Ther 2003; 10: Malina M, Dirven M, Sonesson B, Resch T, Dias N, Ivancev K. Feasibility of a branched stent-graft in common iliac artery aneurysms. J Endovasc Ther 2006; 13: Hinchliffe RJ, Hopkinson BR. A hybrid endovascular procedure to preserve internal iliac artery patency dur- ing endovascular repair of aortoiliac aneurysms. J Endovasc Ther 2002; 9: Page 52 of 53

53 10. Reyring TF, Brewster DC, Cambria RP, et al. Utility and reliability of endovascular aortouniiliac with femoro-femoral crossover graft for aortoiliac aneurysm disease. J Vasc Surg 2000; 31: Gioacchino Coppi, MD, Sebastiano Tasselli, MD, Roberto Silingardi, MD, Stefano Gennai, MD, Giuseppe Saitta, MD, and Roberto Moratto, MD. Endovascular Preservation of Full Pelvic Circulation with External Iliac-to-internal Iliac Artery "Cross-stenting" in Patients with Aorto-iliac Aneurysms. J Vasc Interv Radiol 2010; 21: Personal Information Page 53 of 53