Management of the hypogastric artery during EVAR. Francesco Torella Liverpool Vascular & Endovascular Service
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1 Management of the hypogastric artery during EVAR Francesco Torella Liverpool Vascular & Endovascular Service
2 Disclosure of interest Professional fees Educational grants Research grant
3 Case selection Hypogastric coverage with embolisation without embolisation Hypogastric preservation Surgery CIA landing Branched iliac devices What is the evidence?
4 Hypogastric coverage Advantages (Almost) universally feasible Technically simple in most cases Cheap Disadvantages (Usually) irreversible Complications Buttock claudication Sexual dysfunction Type II endoleak Colonic ischaemia Buttock necrosis Ischaemic lumbar plexopathy Spinal cord ischaemia
5 Rayt et al., 2008 Buttock claudication After hypogastric coverage
6 Claudication after hypogastric coverage publications sample size: Early (n. = 729) 201 (28% - 95%CI = 25-31% ) Persistent (n. = 741) 126 (17% - 95%CI = 14-20% ) No difference between: No QoL data coverage vs embolisation coils vs vascular plugs unilateral vs bilateral coverage
7 Hypogastric coverage To embolise or not to embolise? No need to embolise if Distal CIA landing zone Diseased hypogastric artery Ostial hypogastric stenosis Sealing ring at CIA origin Using Nellix
8 Hypogastric coverage Nellix
9 Hypogastric preservation External iliac to hypogastric bypass or transposition Invasive Universally available Alternative to IBD/IBE Not of historical interest only JVS, 2011
10 Hypogastric preservation CIA landing Easy and quick On IFU for up to 35 mm CIA Ø (Nellix) Increased risk of type Ib endoleak Secondary intervention SGVI score: CIA diameter significant predictor of poor outcome Karthikesalingam et al. BJS 2013 Hobo et al. JEVT, 2008
11 Hypogastric preservation CIA landing A deliberate compromise
12 Hypogastric preservation Branched grafts
13 Hypogastric preservation Iliac branched devices Anatomical limitations Narrow CIA lumen Lack of hypogastric landing zone Short CIA Tortuous EIAs Only 20-60% of patients are suitable 12 GORE IBE may have wider applicability than Cook ZBIS 2 1 Gray et al., EJVES, Pearce et al., Ann Vasc Surg 2015
14 Hypogastric preservation ZBIS iliac branched device (IBD) EJVES, studies 196 cases Variable clinical and anatomical criteria Technical success: % Buttock claudication prevented in all but 1 3 endoleaks 5 EIA occlusions 12/24 late IBD occlusion (50% claudication)
15 Hypogastric preservation ZBIS iliac branched device (IBD) EJVES, isolated iliac aneurysms Technical success: 95% No perioperative deaths Follow up 1-60 months Buttock claudicatio in 4 3 iliac endoleaks 2 x Ib 1 x III
16 Hypogastric preservation Straight and helical iliac branched devices (IBD) JVS, patients 51% during FEVAR Technical success: 94% 5/9 failures: IIA ostial stenosis 1 perioperative death (MI) Follow up 1-72 months Branch patency: 81.8% at 5 y Claudication in 5/7 late occlusions 4 iliac endoleaks
17 Hypogastric preservation IBE device 4 studies 81 cases No deaths 1 failure of deployment 2 type Ib endoleaks 2/51 early claudication No persistent claudication
18 IBD vs hypogastric coverage 1 year outcome 23 x IBD 37 x coverage Verzini et al., JVS, 2008
19 IBD vs hypogastric coverage 3 month outcome Claudicants Unilateral hypogastric occlusion (n. = 77) 27 (35%) Unilateral IBD (n. = 4) 0 Bilateral hypogastric occlusion (n. = 6) 2 (33%) Unilateral hypogastric occlusion + contralateral IBD (n. = 20) 11 (55%)* *all ipsilateral to hypogastric occlusion Taudorf et al, JVIR, 2014
20 My take on the evidence Hypogastric coverage results in a 15-20% risk of persistent buttock claudication The risk of sexual dysfunction due to hypogastric coverage is unknown Patients with suitable anatomy can be safely treated with iliac branched devices EIA-IIA bypass/transposition is a potential alternative to iliac branched devices Comparative data on iliac preservation vs coverage is poor I would offer unilateral or bilateral iliac preservation, if feasible, to active patients, who want to minimise the risk of post-evar buttock claudication
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