HYPOGASTRIC ARTERY PRESERVATION DURING EVAR: SURGICAL AND ENDOVASCULAR TECHNIQUES Single Centre Experience Ilaria Ficarelli Service of Vascular Surgery Cardarelli Hospital Naples Chief: Carlo Ruotolo, MD
Disclosure Speaker name: Ilaria Ficarelli I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
HYPOGASTRIC ARTERIES PRESERVATION Background Abdominal aorta aneurysms Associated iliac aneurysms (20-30%) Short common iliac arteries Isolated common iliac aneurysms Iliac bifurcation involvement Hypogastric arteries
HYPOGASTRIC ARTERY OCCLUSION Clinical consequences Serious, life-threatening Colonic ischemia Buttock necrosis Spinal cord injury Impredictable, underreported, and disabling Buttock claudication Erectile dysfunction
Geraghty PJ. J Vasc Surg 2004;40:413-8 Becquemin JP, JVS 2008; 47:258-63 Eagleton MJ. J Vasc Surg 2014;59:89-95
HYPOGASTRIC ARTERY OCCLUSION Clinical consequences Serious, life-threatening Colonic ischemia Buttock necrosis Spinal cord injury Impredictable, underreported, and disabling Buttock claudication Erectile dysfunction
Jean-Baptiste E. J Vasc Surg 2014;60:40-9 Patients 71 Procedures 75 Acute pelvic ischemia 2 (2.8%) 30-day mortality 3 (4.3%) Buttock claudication 25.3% - persistent @ 18 months 85%
Buttock claudication Jean-Baptiste E. J Vasc Surg 2014;60:40-9 WIQ score p= Persistent 35.4.001 Regressive 76.5.02 No experience 65.34 <.0003 Patients 71 Procedures 75 Acute pelvic ischemia 2 (2.8%) 30-day mortality 3 (4.3%) Buttock claudication 25.3% - persistent @ 18 months 85%
HYPOGASTRIC ARTERY PRESERVATION May 2004-September 2018 Patients N=58 Hypogastric artery 66 Surgical revascularization 22 Endovascular techniques 44
HYPOGASTRIC ARTERY PRESERVATION Surgical revascularization Patients N=17 Hypogastric artery 22 External-to hypogastric artery bypass 9 Hypogastric artery transposition 13
Short common iliac arteries
Hypogastric artery-to-external iliac artery transposition
HYPOGASTRIC ARTERY PRESERVATION Endovascular techniques Patients N=41 Hypogastric artery 44 Reversed U stent graft technique 1 Nellix EVAS System 2 Bell-bottom technique 8 Double barrell technique 3 Branched devices 30
84 years Ectatic right common iliac artery Left common iliac artery aneurysm Bell-bottom technique (2009)
24 mm
81 years 19 mm Left CIA 18 mm Right CIA
Nellix EVAS System
Right hypogastric artery occlusion 2010
Reverse-U stent graft (Fluency 12 X 56 mm)
DEDICATED BRANCHED DEVICES Dicember 2012-September 2018 Branched devices 30 Cook IBD 6 Gore IBE 24
Aneurisma mesenterica superiore 66 years F.E. 30% CIA aneurysms
Cook Zenith branched Advanta stent graft
Cook bifurcated endograft
@ 2 years
18 mm 17 mm
18 mm
@ 1 year
HYPOGASTRIC ARTERY PRESERVATION Early results 30d Mortality 1/58 (1.7%) Surgical revascularization 22 MI 1/22 (4.5%) EIA dissection/thrombosis 2/22 (9%) Endovascular techniques 44 Technical success 42/44 (95%) MI 1/44 (2.3%) Renal bleeding+cfa occlusion 1/44 (2.3%) Intraoperative hypogastric occlusion 1/44 (2.3%)
60 years 2014: AAA open repair (Dacron bifurcated graft) Bilateral double barrell technique @ 2 years
EIA: Viabhan 13 mm x 10 cm IIA: Viabhan 7 mm x 15 cm
EIA: Viabhan 13 mm x 10 cm IIA: Viabhan 7 mm x 15 cm Everflex 7x60 mm
FOLLOW UP Median follow-up 38 months Patients 58 Survival 50/58 (86%) Hypogastric artery 66 Primary patency 63/66 (95.5%) Hypogastric artery occlusion 3/66 (4.5%)
HYPOGASTRIC ARTERY PRESERVATION Conclusions Hypogastric artery occlusion not always benign Hypogastric artery preservation should be considered Younger and more active patients Endovascular techniques First line option Surgical revascularization Fit for surgery Not suitable for endovascular solution
HYPOGASTRIC ARTERY PRESERVATION DURING EVAR: SURGICAL AND ENDOVASCULAR TECHNIQUES Single Centre Experience Ilaria Ficarelli Service of Vascular Surgery Cardarelli Hospital Naples Chief: Carlo Ruotolo, MD