Endovascular options of treating iliac aneurysms Marek Majewski Department of Vascular Surgery of P. Desgranges Henri Mondor Hospital University Paris XII Créteil, France
Common Iliac Artery Aneurysms (CIAAs) The majority of CIAAs are asymptomatic, but patients may present with rupture, distal embolization, thrombosis, or symptoms of visceral or neurologic compression. Ruptured CIAAs are associated with significant perioperative mortality as high as 33% to 50%. To prevent these complications, elective repair is recommended for CIAAs with a diameter > 35mm.
There are many possible options of treating iliac aneurysms
First Traditional, surgical bypass
Alternative, endovascular procedures
The embolization of hypogastric artery and inserting a stent-graft with the risk of postop complications. - Bottock claudication (27 32%) - Erectile dysfunction (14 18%) - Colonic ischemia up to 3% - Spinal ischemia < 1%
Emphasizing the importance of preserving the IIA. * Iliac branch * Off-label endovascular techniques * Bel-bottom limb
ZBIS COOK branched stent-graft Limited by anatomical conditions: ICAL > 45mm Bif.ICA Diameter > 16mm IIA Diameter < 12mm expensive the procedure is; quite difficult and complex and of limited availability
ZBIS
EIB GORE limited by anatomical conditions: ICAL > 55mm ICA pr. Diameter > 17mm Bif.ICA Diameter > 16mm IIA Diameter 6.5 13.5mm IIAL > 10mm EIA Diameter 6.5 25mm EIAL > 10mm expensive the procedure is; quite difficult and complex and of limited availability
Mr B. B. aged 63 Bilateral Common Iliac Aneurysms. EIB *Right iliac aneurysm of 33 mm in diameter with distal neck. *Left iliac aneurysm of 45 mm in diameter Includes hypogastric bifurcation.
Sandwich iliac
Now, since september 2012 we have used a new technique; The advantages of this technique are as follows: * The material is less expensive; It can be used immediately when needed; * The procedure is simpler;
In addition, we need: 1) Precise sizing ; 2) Favorable landing zone in external iliac artery hypogastric artery.
Endurant
V12
AFX
V12 V12
Mr. LP, aged 83, AAA of 40 mm in diameter, aneurysm of the left common iliac artery 51 mm in diameter and the right common iliac artery diameter of 41 mm and bilateral hypogastric arteries aneurysms; Endurant + double iliac sandwich
Mr. BD, aged 70. Separated left common iliac aneurysm of 37 mm in diameter with a regular upper iliac neck, 3 cm in length. Placement of one Cook iliac extension just before aortic bifurcation. By cross-over, placement of the 2 covered stents in the hypogastric artery. Placement of the 2 Cook extensions to the common and external iliac arteries SANDWICH ILIAQUE Isolated CIAAs are rare with and incidence of < 1 %
AAA treated by stent-graft Endologix CT-scan shows endoleaks; left common iliac type 1B and lumbar type 2. Embolisation with the coils lumbar arteries. SANDWICH ILIAQUE By cross-over placement of the 2 covered stents in the hypogastric artery. Placement of the Cook limb to the common and external iliac arteries, with an overlap with former limb.
So far we have had 22 cases where we applied this technique with successful patency.
Comparison of sandwich and iliac branched devices for hypogastric preservation during EVAR 1) Department of vascular surgery, Henri Mondor Hospital, Paris University, Créteil, France 2) Department of thoracic and vascular surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, France
2010-2014 37 patients Isolated CIA (30%) or AAA involving iliac arteries (70%) 20 IBD 20 ST Technical success Patency Complications (Endoleaks) Exclusion: major iliac tortuosity, symptomatic / infected aneurysms
RESULTS Groups comparable: clinical / anatomical criteria Success rate: IBD = 95% - Sandwich = 100% (p=0.1) Outcomes Thrombosis n (%) Endoleak (1 and 3) n (%) Buttock claudication n (%) IBD Sandwich <30d >30d <30d >30d 0 1 (5.2) 2 (10.4) 2 (10.4) 2 (10.5) 1 (5.2) 3 (15.6) 3 (15.6) 0 1 (5.2) 0 0 Major adverse events 0 0
CONCLUSIONS Both techniques offer comparable outcomes Sandwich technique is a reliable alternative to IBD Long term follow up study
Outside IF U Nellix OUTSIDE IFU: AAA 2 Iliac Aneurysms 2 Hypogastric Ectasies
Mr B. J. aged 65, A High Surgical Risk Patient with an AAA, Bilateral Common Iliac Aneurysms, and Bilateral Hypogastric Ectasies. AAA of 63mm in diameter, upper neck, 30 mm long. 10 160 just below lowest right renal artery 10 160 just below lowest right renal artery Right iliac aneurysm of 30 mm in diameter to hypogastric bifurcation. Ectasia right hypogastric artery of 19mm in diameter. Left iliac aneurysm of 32 mm in diameter to hypogastric bifurcation. Ectasia left hypogastric artery of 16mm in diameter. to right hypogastric artery to left hypogastric artery
Conclusion Emphasizing the importance of preserving the IIA with * Iliac branch * Off-label endovascular techniques to avoid: - Bottock claudication - Erectile dysfunction - Colonic ischemia - Spinal ischemia Sandwich technique is a reliable alternative to IBD.
Thank you very much for your attention Dziękuję bardzo za uwagę Merci beaucoup pour votre attention
Mr. GF 77 aged, Right common iliac aneurysm of 33 mm in diameter without the upper and lower necks. Placement of a bifurcated AFX stent-graft. By cross-over, placement of the 3 covered stents in the hypogastric artery. Placement of the right limb proximally at the aortic bifurcation.
Endovascular options of treating iliac aneurysms Marek Majewski Department of Vascular Surgery of P. Desgranges Henri Mondor Hospital University Paris XII Créteil, France