Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery Outcomes of endovascular repair of isolated iliac artery aneurysms A. Stella
Isolated iliac artery aneurysms treated by either open or, preferentially, endovascular techniques intervention should be considered when the iliac diameter exceeds 3 cm Moll FL, Eur J Vasc Endovasc Surg 2010
Isolated iliac artery aneurysm Repairs over times TOTAL ENDO OPEN Buck DB, J Vasc Surg 2015
Isolated iliac artery aneurysm Hospital Mortality (elective & urgent procedures) OPEN TOTAL ENDO Buck DB, J Vasc Surg 2015
Isolated iliac artery aneurysm 2000-2011 13.949 elective cases OPEN 35% ENDO 65% ENDO OPEN p Hospital mortality (%) 0.5 1.8 <.001 Post-operative complications (%) 6.7 17.9 <.001 Hospitalization (days) 2.3 6.7 <.001 Buck DB, J Vasc Surg 2015
Isolated iliac artery aneurysm F-up outcomes Author Journal Year Cases Mean follow-up (months) Boules T JVS 2006 61 22 Pitoulias G JVS 2007 33 35 Chaer R JVS 2008 52 17 Power A JVS 2009 11 12 Patel V Vasc 2009 31 36 Chemelli A JET 2010 91 45 Mid & long term follow up
Isolated iliac artery aneurysm F-up outcomes Author Redo (%) Complication related to hypogastric artery coverage (%) EL (%) Sac Shrinkage (%) Boules T 12 20 13 87 Pitoulias G - 12 0 72 Chaer R 19 4 6 86 Power A 0-8 ns Patel V - 19 3 67 Chemelli A 13 6 12 - Acceptable reinterventions rate
Isolated iliac artery aneurysm F-up outcomes Author Redo (%) Complication related to hypogastric artery coverage (%) EL (%) Sac Shrinkage (%) Boules T 12 20 13 87 Pitoulias G - 12 0 72 Chaer R 19 4 6 86 Power A 0-8 ns Patel V - 19 3 67 Chemelli A 13 6 12 - Symptoms related to HA interruption 4-20%
Isolated iliac artery aneurysm F-up outcomes Author Redo (%) Complication related to hypogastric artery coverage (%) EL (%) Sac Shrinkage (%) Boules T 12 20 13 87 Pitoulias G - 12 0 72 Chaer R 19 4 6 86 Power A 0-8 ns Patel V - 19 3 67 Chemelli A 13 6 12 - Any type of Endoleak 0-13%
Isolated iliac artery aneurysm F-up outcomes Author Redo (%) Complication related to hypogastric artery coverage (%) EL (%) Sac Shrinkage (%) Boules T 12 20 13 87 Pitoulias G - 12 0 72 Chaer R 19 4 6 86 Power A 0-8 ns Patel V - 19 3 67 Chemelli A 13 6 12 - High rate of sac shrinkage
Endovascular repair of isolated iliac artery aneurysm Goals Aneurysm exclusion Iliac Leg, Converter Hypogastric management Revascularization Embolization
Endovascular repair of isolated iliac artery aneurysm How Technique depends on the iliac anatomy Proximal neck Distal neck Hypogastric patency
# 1 Anatomical Feasibility CEB 23 12 10 HGB 16 12 07
1 st option Isolated Iliac Branch
1 Lungh ezza 1 33.0 m m Lu n gh ezza v aso # 2 2 Lungh ezza 2 91.1 m m Lu n gh ezza v aso Severe Iliac Angulation Length 25 mm Diameter 17 mm HA patency 5. Assiale ( MPR)
Isolated Iliac Branch CEB 23 12 14 Viabahn 8 x 50 mm HBG 16 10 07
# 3 After previous aortic repair 45 mm ZBIS 12 45 41
# 3
# 4 No Iliac branch feasibility Narrow & calcific Iliac bifurcation 45mm
# 4 1. Proximal hypogastric embolization Vascular plug 2. Iliac endograft Gore Excluder leg 16 x 12 x 120
# 5 Hypogastric Aneurysm 80mm
Distal Hypogastric Embolization Vascular Plug
Aneurysm Embolization M-Rey Coils
Proximal Hypogastric Embolization Vascular Plug
Iliac Leg Endograft Gore Excluder Leg 16 x 12 x 120)
Annals of Vascular Surgery The International Journal of Vascular Surgery and Endovascular Therapies Perioperative and Late Outcomes after Endovascular Treatment for Isolated Iliac Artery Aneurysms Claudio Bianchini Massoni, Antonio Freyrie, Mauro Gargiulo, Tiziano Tecchio, Chiara Mascoli, Enrico Gallitto, Gianluca Faggioli, Rodolfo Pini, Matteo Azzarone, Paolo Perini, Andrea Stella October 2017 vol 44, 83-93
Aim of study To report perioperative & late outcomes of the endovascular treatment for isolated iliac artery aneurysms (IIAA)
Methods Retrospective (2005-2015) Multi-center Vascular Surgery University of Bologna Vascular Surgery University of Parma Bologna CTV Building Parma
Methods Inclusion Criteria Endovascular repair Primary / para-anastomotic IIAA Elective procedure Anatomical feasibility Proximal & distal sealing zone Diameter Length 9-18mm 10mm
Methods Primary Endpoints Technical success (TS) Clinical success (CS) freedom from iliac aneurysm-related mortality, type I or III EL, endograft infection, endograft thrombosis or >50%-stenosis, iliac aneurysm growth 5mm or rupture, surgical conversion, pelvic complications (buttock claudication, bowel ischemia, sexual impotence) Freedom from reintervention (FFR) Overall and aneurysm-related mortality
Methods Secondary Endpoints Evolution of Sac Diameter Evolution of Endoleak (EL)
Results 30 Patients 32 AAII Characteristics n (%) Male 29 (97) Age (mean±sd) 74 ±8 year Hypertension 29 (96) Diabetes mellitus 4 (13) Coronary artery disease 15 (50) COPD 15 (50) Dyslipidemia 18 (60) Cerebro-vascular insufficiency 2 (7) Chronic renal failure 6 (20) ASA classification - 3 14 (47) - 4 5 (16)
Results 30 Patients 32 AAII Characteristics n (%) Para-anastomotic 11 (34) Diameter (mean±sd) Contralateral hypogastric artery occlusion 43 ±16 mm 2 (6) Inferior mesenteric artery occlusion 9 (28)
Results 30 Patients 32 AAII
Endograft Results
Results Hypogastric Artery Management Sealing above HA Isolated Iliac Branch Proximal Embolization Simple Coverage Surgical Revascularization n 3 2 8 17 2 % 9.4 6.3 25.0 53.0 6.3
Results Primary outcomes Technical success 100% Clinical success 97% (31/32) FFR* 94% (30/32) Mortality 0% Reinterventions* -1 transluminal angioplasty performed for iliac endograft stenosis (on the 1 st post-operative day) -1 femoral arteriotomy with correction of an intimal flap (on the 1 st post-operative day)
Results Clinical Success @ mean F-up medio 48±24 mesi 1 month 96.9% Late - endograft limb thrombosis - endograft limb stenosis - sac enlargement ( 5mm) for type II EL from hypogastric artery
Results Freedom from Reinterventions 1 month 94% Late -fibrinolytic therapy and kissing iliac stenting -transluminal angioplasty and stenting - surgical ligation of the hypogastric artery
Results Survival 100% Death -1 myocardial infarction -3 cancer No IIAA-related deaths
Results Secondary Outcomes Sac diameter Shrinkage 19 (59.4%) Unchanged 12 (37.5%) Increase 1 (3.1%) Type of aneurysm Diameter Hypogastric coverage Emboliz. Iliac aneurysm evolution FU (m) Reintervention III 54 X - Increase (6mm) 50 Surgical ligation of hypogastric artery Type II EL from hypogastric a.
Endoleak Results Secondary Outcomes Type I 0 Type II from hyp.a. 3 (9.4%) Type III 0 Type of aneurysm Diameter Hypogastric coverage Embolization Iliac aneurysm evolution FU (m) Reintervention III 54 X - Increase (6mm) 50 Surgical ligation III 35 X X Shrinkage (5mm) 36 - II 48 X - Unchanged 10 -
Isolated Iliac Artery Aneurysm (IIAA) Follow-up outcomes First author Year of publication Number of patients Mean follow-up (months) Reinterventions (%) Complication related with HA coverage (%) EL (%) Sac shrinkage (%) Boules T 2006 61 22 11.9 (2y) 20 13 87 Pitoulias G 2007 33 35 ns 12 0 72 Chaer R 2008 52 17 19 (2y) 3.8 5.8 86 Power A 2009 11 12 0 (1y) ns 8.3 ns Patel V 2009 31 36 ns 19 3.2 67 Chemelli A 2010 91 45 13 (ns) 5.5 12 - Present series 2016 30 48 15 (3y) 0 9.5 59.4
Conclusions If anatomical parameters are respected, endovascular iliac repair for IIAA is a safe, effective and durable procedure If possible, hypogastric patency should be maintained ( less common than during EVAR ) If hypogastric artery must be sacrificed, a proximal embolization should be perform to evoid EL type II A proximal hypogastric artery exclusion has not high rate of pelvic complications in case of contralateral hypogastric and inferior mesenteric arteries patency
Conclusions Endograft stenosis and thrombosis represent the main complications and are mostly re-treated successfully with endovascular approach A careful preoperative planning and intraoperative stenosis/kinking treatment is mandatory to improve results