Open vs endovascular repair of abdominal aortic aneurysm involving the iliac bifurcation

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1 Open vs endovascular repair of abdominal aortic aneurysm involving the iliac bifurcation Frédéric Cochennec, MD, Jean Marzelle, MD, Eric Allaire, MD, PhD, Pascal Desgranges, MD, PhD, and Jean-Pierre Becquemin, MD, Créteil, France Introduction: Aneurysmal involvement of the iliac bifurcation increases the level of difficulty during surgery for abdominal aortic aneurysm (AAA) repair, potentially increasing the risk of early postoperative complications. Three previous randomized trials comparing endovascular aneurysm repair (EVAR) and open repair (OR) for AAAs showed that EVAR is associated with a lower early mortality rate. However, whether these results are valid for AAA involving the iliac bifurcation (AAAIB) remains unclear. The aim of this study was to evaluate early and late results after OR and EVAR for patients with AAA involving the iliac bifurcation. Methods: Of 1116 patients treated for elective AAA repair between January 1998 and January 2008, 131 presented with AAAIB as detected by computed tomography (CT) scan. Sixty-eight patients were treated by EVAR and 63 by OR. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. The median duration of follow-up was 38 months for both groups. Results: Patients in the EVAR group (72 10 years) were older than those in the OR group (64 8 years; P <.0001), but there were no differences in cardiac, renal, or pulmonary comorbidities between the two groups. Inhospital mortality rates were 2.9% vs 6.3% for EVAR and OR groups, respectively (P.43). Systemic postoperative complications occurred in 7.4% vs 9.5% (P.76) and postoperative colonic ischemia in 0% vs 6.3% (P.051) of patients with EVAR and OR, respectively. Survival rates by Kaplan-Meier analysis were 91 7% for patients with EVAR and 90 8% for patients with OR at 2 years, and 61% 15 for EVAR and 79% 13 for OR at 5 years. All-cause reoperation rates were 25% with EVAR and 22% with OR (P.83). Patients with EVAR were more likely to develop buttock claudication (33.3% vs 3.6%; P <.0001), whereas patients with OR were more prone to develop abdominal wall complications (19.6% vs 0%; P <.001). Conclusion: In this series, the postoperative mortality and systemic complication rates after either EVAR or OR for AAAIB were not statistically different. In the OR group, there were more abdominal wall complications and a trend toward a higher rate of colonic ischemia. In the EVAR group, buttock claudication was more frequent. (J Vasc Surg 2010;51: ) About 20% of abdominal aortic aneurysms (AAAs) extend to the iliac bifurcation (AAAIB). 1 In comparison to aneurysms limited to the aorta or proximal common iliac arteries (CIA), treatment of AAAIB is more challenging. Open repair (OR) is technically challenging due to the deep pelvic location and due to the fact that hypogastric artery (HA) repair is more difficult, especially for aneurysmal lesions. This may lead to an increased risk of ureteric and iliac vein injury and may result in the internal iliac flow being compromised when the repair is not feasible. The intervention is all the more challenging in obese patients or in cases of previous abdominal surgery. This may account for the higher mortality rate associated with OR of AAAIB in comparison to OR of isolated AAAs. 2-4 Endovascular repair (EVAR) is a widely accepted and currently used option for AAA treatment. For AAAIBs, additional procedures are deemed necessary. Exclusion of From the Department of Vascular Surgery, Henri Mondor Hospital, Créteil. Competition of interest: none. Reprint requests: Frédéric Cochennec, Henri Mondor Hospital, 51 av De Lattre de Tassigny, Créteil, France ( cochennecf@gmail. com). 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 competition of interest /$36.00 Copyright 2010 by the Society for Vascular Surgery. doi: /j.jvs the HA with or without coil embolization and extension of the graft limb into the external iliac artery (EIA) is the most common and easiest choice Although still a matter of debate, the risk of pelvic ischemia does exist. More recent technological advances using branched grafts offer an attractive option. However, this method remains limited to a small subset of patients with favorable anatomy. A hybrid technique combining open and endovascular repair represents another option. However, the procedure carries greater risk and benefits of using this technique have not been demonstrated. In patients with AAAIB, studies comparing EVAR and OR are scarce and no randomized trials have been published. Thus, whether open or endovascular repair should be chosen, especially in patients with AAAIB with low or moderate risk, has not been clearly established. The aim of this study was to review the data for patients treated for AAAIB to evaluate short-term and long-term mortality, morbidity, and reintervention rates with both techniques. METHODS Over a period of 10 years ( ), 1116 patients were treated for an AAA in a single institution. Retrospective analysis of data from a prospectively maintained database was performed to identify patients who had undergone either EVAR or OR. For the purpose of this study,

2 JOURNAL OF VASCULAR SURGERY Volume 51, Number 6 Cochennec et al 1361 patients with aortoiliac aneurysms extending close to or as far as the iliac bifurcation (AAAIB) were selected. The patients were included in the series when the iliac aneurysmal disease in the EVAR group had no zone in the distal common iliac artery and in the OR when the anastomosis could not be done on the distal CIA. Patients with ectatic CIA who were treated either by endovascular procedure, by fixation of a large diameter limb above the iliac bifurcation, or by OR with implantation of the graft at the end of the CIA, were not included. Patients with ruptured or juxtarenal aneurysms, those with prior AAA repair, or with mycotic aneurysms were also excluded from the study. Treatment selection was influenced by anatomic factors, surgical risk, and surgeons and patients preferences, as long as it was in agreement with the French regulation. Preoperative, intraoperative, and follow-up data obtained from the database were reviewed by a vascular surgeon (F.C.), with missing data collected by examination of medical records. Where necessary (2 patients), telephone interviews were conducted to obtain up-to-date information on patient clinical status. We used a standard preoperative workup that included spiral computed tomography (CT) angiography. Until recently, patients with chronic renal insufficiency were subjected to a magnetic resonance scan, which is no longer the case given the increased recognition of gadolinium-associated nephrogenic systemic fibrosis. Follow-up after EVAR consisted of physical examination, CT scan, duplex scan, and plain x-ray at 1 month, 6 months, 12 months, and yearly thereafter, depending upon the size of the aneurysm. Patients with type II endoleaks and patients with increasing size of the aneurysmal sac had a CT scan every 3 to 6 months. Follow-up after OR consisted of physical examination and duplex scan at 1 month and yearly thereafter. A CT scan was not routinely performed, but was used for particular clinical situations or when the duplex scan disclosed an abnormality. Early and midterm outcomes were compared between the two treatment groups. Complications were classified and graded according to the reporting standards of the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery/International Society for Cardiovascular Surgery. 13,14 Three classes of complications (systemic, localnonvascular and local-vascular, or implant-related) and three grades of severity (mild, moderate, and severe) were used. Diagnosis of myocardial infarction was established based on electrocardiogram changes and troponin values. Acute renal insufficiency was defined as an increase of plasmatic creatinine levels greater than 50% of the patient s baseline. Colonic ischemia was documented by colonoscopy and/or operation. Pulmonary complications were defined as any pulmonary abnormalities that were clinically significant. Hemorrhagic complications were defined as postoperative bleeding, wherever it came from, including bleeding from surgical sites and from gastroduodenal origin. Surgical technique. In the EVAR group, device selection was made on the basis of anatomic suitability and surgeon preference. We used preferentially bifurcated stent grafts. Aortomonoiliac grafts were used in cases of unilateral excessive iliac tortuosity or unilateral iliac occlusion. For patients with unilateral AAAIB, treatment consisted in hypogastric embolization and placement of the limb into the EIA. In cases of bilateral AAAIB or unilateral AAAIB associated with controlateral HA occlusion, the flow in at least one hypogastric artery was usually preserved by performing an EIA to HA bypass. The bypass was performed at the beginning of the procedure through a retroperitoneal approach and using an 8 cm Dacron graft (Datascope, La Ciotat, France or Edwards, Maurepas, France). However, in cases of hypogastric aneurysmal or extensive stenotic disease, patients deemed unsuitable for hypogastric revascularization underwent exclusion of both HA. Occlusions of HAs were performed the day before the stent graft implantation when the procedure was expected to be time-consuming or at the beginning of the procedure for the technically easy cases. When bilateral embolization was deemed necessary, staged embolization was performed with a period of a few months between each embolization and EVAR. Hypogastric occlusions where performed with either coils (Nester or Tornado embolization coils, Cook Medical Inc, Bloomington, Ind) or Amplatzer plugs (AVP; AGA Medical, Golden Valley, Minn). To preserve the pelvic collateral flow, we preferentially embolized the proximal HA. For patients with hypogastric aneurysm, coil embolization of primary branch vessels was carried out. We did not use branched stent grafts in this series. In the OR group, transperitoneal or retroperitoneal approaches were used depending on surgeon preference. Inferior mesenteric arteries were selectively reimplanted where backflow was poor or when intraoperative Doppler scan assessment of the colonic arcade failed to demonstrate pulsatile flow. Three types of iliac reconstruction were used to treat aneurysms involving the iliac bifurcation: end-toend prosthetic limb placement on the EIA/common femoral artery (CFA) with HA ligation/aneurysmorrhaphy (type 1); end-to-end prosthetic limb placement on the HA with EIA reimplantation/bypass on the CFA (type 2); and end-to-side prosthetic limb placement on the EIA/CFA associated with ligation of the distal CIA (type 3). Statistical analysis. Proportions and categorical variables were compared using a chi-square test or a Fisher exact test when appropriate. Continuous data were compared using a t test. All tests were two-sided. A P value.05 was considered to indicate statistical significance. Patient survival and freedom from secondary procedures were determined by the Kaplan-Meier method and compared using the log-rank test. We used the GraphPad Prism version 5.0 software (GraphPad Inc, San Diego, Calif) for the survival analysis and the R software (R Development Core Team, Vienna, Austria) for the other statistical tests. RESULTS A total of 131 patients with AAAIB were included. EVAR was performed for 68 of 131 of these patients (56 unilateral iliac aneurysms and 12 bilateral) and OR was

3 1362 Cochennec et al JOURNAL OF VASCULAR SURGERY June 2010 Table I. Demographic and anatomic characteristics of patients with AAAIB EVAR group (n 68) OR group (n 63) P value Mean age (y) SD Men, no. (%) 65 (96) 60 (95).747 Cardiac failure, No. (%) 3 (4) 0 (0).245 Coronary artery disease, No. (%) 24 (35) 19 (30).661 Arrhythmia, No. (%) 6 (9) 5 (8) 1 Chronic obstructive pulmonary disease, No. (%) 14 (21) 6 (10).129 Renal insufficiency, No. (%) 10 (15) 4 (6).160 Patients under dialysis, No. (%) 4 (6) 0 (0).120 Dyslipidemia, No. (%) 21 (31) 14 (22).357 Tobacco use, No. (%) 34 (50) 23 (36).168 Hypertension, No. (%) 30 (44) 25 (40).736 Diabetes, No. (%) 9 (13) 8 (13).866 Mean maximal diameter of aneurysm (mm) SD Eurostar aneurysm morphology class, No. (%) D (extends into one iliac bifurcation) 56 (82) 40 (63).025 E (extends into both iliac bifurcations) 12 (18) 23 (37).025 Hypogastric aneurysms a Bilateral 1 (1) 4 (6).195 Unilateral 17 (25) 19 (30).642 Overall Symptomatic aneurysms, No. (%) 4 (6) 7 (11).352 AAAIB, Abdominal aortic aneurysm iliac bifurcation; EVAR, endovascular aneurysm repair; No., number of patients; OR, open repair. a Eighty aneurysmal iliac bifurcations in the EVAR group, 86 in the OR group. performed for 63 of 131 patients (40 unilateral iliac aneurysms and 23 bilateral). In the EVAR group, a variety of stent grafts were used, including Zenith (Cook Medical Inc; n 54), AneuRx/ Talent (Medtronic Vascular, Santa Rosa, Calif; n 7), Excluder (W. L. Gore & Associates, Flagstaff, Ariz; n 3), Vanguard (Boston Scientific, Natick, Mass; n 4). There were 53 bifurcated devices and 15 aortouniiliac devices. In 6 cases of unilateral AAAIB (2 at the start of the procedure and 4 the day before the procedure), the embolization was not technically feasible due to major tortuosity of the iliac arteries. Therefore, we simply covered the HA with the stenograph. A subsequent type II endoleak occurred in 3 of these patients but had resolved spontaneously on the control CT scan at 6 months in all cases. Two patients with unilateral AAAIB underwent an ipsilateral EIA to HA bypass because of controlateral HA occlusion. Various operations were performed in patients having bilateral AAAIB (n 12). A bifurcated device extending to both EIA was used in 8 patients and HA were managed as follows: bilateral HA embolization (n 3), unilateral embolization of an HA aneurysm on one side and covering of an occluded HA on the other side (n 1), covering of two occluded HA (n 1), HA embolization on one side and EIA to HA bypass on the other side (n 3). In the 4 remaining patients, we used an aortouniiliac device with either ipsilateral HA embolization and contralateral EIA to HA bypass (n 2) or ipsilateral embolization and contralateral EIA ligation (n 2). In the OR group, a transperitoneal approach was used in 42 cases and a retroperitoneal approach in 21. Of 86 aneurysms involving the iliac bifurcation, 45 (52%) were repaired with type 1 iliac reconstruction, 23 (27%) with type 2, and 18 (21%) with type 3. All patients underwent infrarenal clamping. The inferior mesenteric artery was transposed to the prosthetic graft in 4 cases. Five patients underwent bilateral interruption of the HA flow: 4 had bilateral HA aneurysm that required bilateral aneurysmorrhaphy and 1 had an HA aneurysm on one side that required aneurysmorrhaphy and a calcified controlateral HA that was ligated. Three patients required interruption of one HA whilst the controlateral HA was occluded. Patient demographics and characteristics of aneurysms are summarized in Table I. Short-term outcomes. The technical success rate immediately after EVAR was 100%. There were two (2.9%) inhospital deaths in the EVAR group and four (6.4 %) in the OR group (P.43). In the EVAR group, deaths were related to myocardial infarction in 1 case and cholesterol crystal embolism leading to multiorgan failure in the second case. In the OR group, intraoperative iliac vein injury occurred in 1 case, responsible for severe hemorrhagic shock and death a few hours after the intervention. Three patients died of multiorgan failure due to colonic ischemia despite early colonic resection. There was a marked trend toward higher rate of postoperative colonic ischemia in the OR group (EVAR, n 0 vs OR, n 4; [6.3%]; P.051). Among the 4 patients with OR that developed colonic ischemia, none had inferior mesenteric artery reimplantation and all had at least one HA sacrified (type 1 iliac reconstruction). One patient with bilateral HA aneurysms underwent bilateral hypogastric aneurysmorrhaphy and end-to-end distal anastomosis to both common femoral arteries. One patient had a preoperative occlusion of the left HA and an aneurysm of the right HA that required aneurysmorrhaphy and end-to-end distal anastomosis to the left CIA and the right EIA. Two

4 JOURNAL OF VASCULAR SURGERY Volume 51, Number 6 Cochennec et al 1363 Table II. Early postoperative complications in patients with AAAIB treated either by EVAR or OR Variables EVAR group (n 68) No. (%) OR group (n 63) No. (%) P value In-hospital deaths 2 (2.9) 4 (6.3).427 Moderate and severe overall complications 9 (13.2) 9 (14.3).937 Moderate and severe systemic complications 5 (7.4) 6 (9.5).758 Cardiac 2 (2.9) 1 (1.6) 1 Pulmonary 1 (1.5) 0 (0) 1 Renal 1 (1.5) 0 (0) 1 Cerebrovascular or spinal cord 1 (1.5) 0 (0) 1 Colonic ischemia 0 (0) 4 (6.3).051 Moderate and severe local-vascular or implant-related complications 0 (0) 2 (3.2).230 Hemorrhage 0 (0) 1 (1.6).481 Graft infection 0 (0) 0 (0) 1 Thromboembolic complications 0 (0) 1 (1.6).481 Moderate and severe local-nonvascular complications 4 (5.9) 2 (3.2).682 AAAIB, Abdominal aortic aneurysm iliac bifurcation; EVAR, endovascular aneurysm repair; No., number of patients; OR, open repair. Table III. Midterm and late adverse events in patients with AAAIB treated either by EVAR or OR Late complications EVAR group (n 66) No. (%) OR group (N 56) a N (%) P value Rupture 1 (1.5) 0 (0) 1 Graft infection 2 (0) b 0 (0).50 Limb graft thrombosis 2 (3) c 3 (5.4) c.66 Buttock claudication 22 (33.3) 2 (3.6).0001 Sexual dysfunction 3 (4.5) 2 (3.6) 1 Incisional hernia 0 (0) 11 (19.6).001 Fig 1. Kaplan-Meier estimates of survival in patients with endovascular aneurysm repair (EVAR) and open repair (OR) with abdominal aortic aneurysm iliac bifurcation (AAAIB). AAAIB, Abdominal aortic aneurysm iliac bifurcation; EVAR, endovascular aneurysm repair; No., number of patients; OR, open repair. a Three patients lost to follow-up after discharge. b Two femoro-femoral bypass sepsis but no infection of the endograft. c One asymptomatic patient. patients had a unilateral AAAIB with an ipsilateral hypogastric aneurysm and a patent contralateral HA. They underwent unilateral hypogastric aneurysmorrhaphy with endto-end distal anastomosis to the ipsilateral EIA and to the contralateral CIA. Rates of early postoperative complications in both groups are summarized in Table II. Midterm results. No patient in the EVAR group and 3 in the OR group were lost to follow-up. Median duration of follow-up was 38.5 months (range, ) in the EVAR group and 38.0 months (range, ) in the OR group. Of the patients who were alive at discharge, 17 from the EVAR group and 11 from the OR group died during the follow-up. Survival rates estimated by Kaplan- Meier analysis (Fig 1) were: 91% 7 with EVAR and 90% 8 with OR at 2 years, and 61% 15 with EVAR and 79% 13 with OR at 5 years (log-rank test, P.39). One patient suffered rupture of his aneurysm 41 months after EVAR. Rupture was related to disconnection between two graft components. This patient was successfully treated by graft limb placement between the two components. In the open group, no aneurysm-related or graft-related complications occurred. Abdominal wall complications (incisional hernias or abdominal wall palsy) were more likely to occur in the OR group (EVAR, 0% vs OR, 19.6%; P.001). True hernias occurred after transperitoneal incisions and abdominal wall palsy after retroperitoneal incisions. Buttock claudication occurred more frequently in the EVAR group (EVAR, 33.3% vs OR, 3.6%; P.0001). Of 22 patients with EVAR presenting with postoperative buttock claudication, 12 (54%) were still suffering debilitating symptoms after 1 year. Bilateral claudication occurred in only 1 patient who had bilateral HA embolization. His symptoms resolved spontaneously in 6 months on one side but persisted on the other side. Among patients with EVAR that underwent EIA to HA bypass, none developed ipsilateral buttock claudication. The 2 patients with OR presenting with buttock claudication had type 1 iliac reconstructions and resolved their symptoms 6 months after surgery. One of them had both HA aneurysmal and required bilateral aneurysmorrhaphy. He subsequently presented with bilateral claudication. The other patient presented with left buttock claudication after left HA aneurysmorrhaphy. Types and rates of late complications are shown in Table III.

5 1364 Cochennec et al JOURNAL OF VASCULAR SURGERY June 2010 Fig 2. Kaplan-Meier estimates of freedom from reintervention among patients with endovascular aneurysm repair (EVAR) and open repair (OR) with abdominal aortic aneurysm iliac bifurcation (AAAIB). Freedom from secondary intervention is indicated for both groups in Fig 2. There was no significant difference between the two groups. Reinterventions in the OR group were total colectomy (n 2) and left colectomy (n 2) for colonic ischemia, negative laparotomy for suspected colonic ischemia (n 1), incisional hernia repairs (n 5), femoro-femoral bypass for graft limb thrombosis (n 2), and plasty for anastomotic stenosis (n 1). In the EVAR group, reinterventions were: endoconversion for proximal type I endoleak (n 2), placement of a left graft limb extension for distal type I endoleak, urgent graft limb interposition between the body of the graft and the graft right limb for disconnection and type III endoleak (n 1), embolizations for type II endoleaks (n 5), stent placement for graft limb stenosis (n 1), femoro-femoral bypass for graft limb thrombosis (n 1), allograft (n 1), superficial femoral vein (n 1), and femoro-femoral bypasses for prosthetic femoro-femoral bypass sepsis and surgical repair of pseudoaneurysms of the common femoral artery (n 3). DISCUSSION Our study of AAA involving the iliac bifurcation, treated by either EVAR or OR, showed a trend toward higher inhospital mortality and higher risk of systemic complications in the OR group, although this difference did not reach statistical significance. This is consistent with findings from the EVAR 1, Dutch Randomized Endovascular Aneurysm Management (DREAM), and Open Versus Endovascular Repair (OVER) trials showing better short-term survival in the EVAR group Neither the EVAR 1 nor the DREAM study specifically investigated the effect of aneurysmal involvement of the iliac arteries. Previous studies have compared EVAR and OR for the treatment of isolated iliac aneurysms but have not addressed their use for treatment of AAAIB, which is associated with different technical difficulties Furthermore, such studies have reported contradictory results and conclusions on the best procedure to use. It remains unclear whether OR or endovascular repair of AAAs provide better results in terms of colonic ischemia. Similar results were obtained in the DREAM trial 16 (EVAR, 0%; OR, 1.1%). Retrospective studies comparing EVAR and OR for the treatment of isolated iliac aneurysms have shown contradictory results In our study, there was a marked trend toward a higher incidence of colonic ischemia after OR (EVAR, 0% vs OR, 6.3%; P.031) and colonic ischemia was responsible for three of four deaths in this group. Furthermore, the incidence of colonic ischemia in the OR group (6.3%) was higher than in previous series of AAA repair. It was present in 1% of 1420 patients in the Brewster series, % of 2930 patients in the Swedish Vascular Registry (SEDVASC) 24 and 4% of 682 in a previous study from our group. 25 This suggests that aneurysmal involvement of one or both iliac bifurcations increases the risk of colonic complications in patients subjected to OR but not in patients subjected to EVAR. Even though all cases of colonic ischemia occurred in patients that required at least one HA to be sacrificed (type 1 reconstruction), HA occlusion during EVAR did not have any significant impact on colonic perfusion. This observation tends to confirm that colonic ischemia is more of a multifactorial adverse event rather than only due to the type of iliac reconstruction. Therefore, the higher rate of colonic ischemia associated with OR in this series may be due to several possible explanations: (1) aneurysms of both iliac bifurcations were significantly more frequent in the OR group (Table I); (2) the open operation is associated with greater blood loss and a longer clamping time, which are likely to affect the rate of colonic ischemia; and (3) micro embolization from the external manipulation of the sac may be an aggravating factor. Buttock claudication was more common in the EVAR group, it occurred in one-third of patients with EVAR, with symptoms resolved in half of these patients within the first year after the operation. Previous studies comparing EVAR and OR for isolated iliac aneurysms reported similar results, with rates of buttock claudication varying between 12% and 45% for EVAR and between 0% and 5% for OR In our series, endovascular management of aneurysmal iliac bifurcations mostly involved preliminary coil embolization of the HA and extension of the graft into the EIA. This strategy provides good results in terms of patency and endoleak, but is associated with significant morbidity, including mainly buttock claudication, 5-12 but also erectile dysfunction, 5,26,27 colonic and pelvic ischemia, 25,28,29 lower limb neurological deficits, 30 and gluteal compartment syndrome. 31 Other methods have been proposed to preserve the pelvic flow. Relocation of the iliac bifurcation with HA bypass and transposition onto the distal EIA may be used. These procedures are associated with good patency rates but increase the complexity of EVAR and may extend the duration of hospital stay In our series, patients with EVAR that underwent EIA to HA bypass had neither postoperative ipsilateral buttock claudication nor complications related to the procedure. However, the number of bypasses was too small and the postoperative assessment of the patency was too poor to determine if they

6 JOURNAL OF VASCULAR SURGERY Volume 51, Number 6 Cochennec et al 1365 could prevent buttock claudication efficiently. Another less invasive method uses large components or aortic cuffs to anchor the device within the CIA ( bell bottom technique) Despite concerns about longer-term durability, this technique seems reasonable for patients with CIA ectasia 25 mm in diameter. However, it has limited benefit for patients with larger aneurysms or with hypogastric aneurysms. Branched stent grafts that maintain anterograde perfusion of hypogastric arteries are currently under clinical evaluation. Early reports have demonstrated a good level of safety and encouraging short-term results Unfortunately, the use of these devices is limited to favorable anatomic conditions, which are not frequently encountered. As compared to other reports, 46 the rates of postoperative sexual dysfunction were low in both groups. This study was not specifically designed to assess sexual function. We mainly asked the patients if they had retrograde ejaculation or erectile dysfunction. Other aspects of sexual function such as interest, pleasure, engagement, and orgasm were not evaluated. Some patients may have denied or simply misjudged sexual problems. In particular, we did not use questionnaires as Prinssen et al 46 did in their prospective study. In addition, preoperative sexual function was not assessed accurately. Finally, due to bias inherent to the retrospective design of this study, sexual dysfunction rates may have been underestimated. The main limitations of our study are due to the relatively small number of cases included and the lack of randomization. Bilateral AAAIBs in particular were more common in the OR, which constitute a significant selection bias as there were more patients with a complicated anatomy in the OR group. The choice of the procedure depended on the decision of the attending surgeon after discussion with the patient. Thanks to ongoing improvement of EVAR technology, graft limbs as large as 24 mm in diameter are now available. This will allow more patients with large aneurysm of the CIA extending down to the bifurcation to be treated without the need for closing the hypogastric artery. Despite these limitations, this study is the first to compare EVAR and OR for AAAIB. We were able to demonstrate that the postoperative mortality and complications after either EVAR or OR for AAAIB were not statistically different. In the OR group, there were more abdominal wall complications and a trend toward a higher rate of colonic ischemia. In the EVAR group, buttock complications were more frequent. Further comparative studies are needed to determine whether EVAR should be the first choice in these patients. We thank Manj S. Gohel for his helpful advice and critical review of this manuscript. 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