Endovascular Treatment of Aorta-Iliac Aneurysms with a Flared Iliac Limb
02 March 2019 (online)
Endovascular abdominal aneurysm repair (EVAR) relies on the quality of the proximal and distal landing zone. Reinterventions are higher in patients with suboptimal landing zone. The study aimed to evaluate reintervention rate after endovascular treatment of an aorta-iliac aneurysm using the flared iliac limbs.
The retrospective study included 179 patients treated with EVAR at a single university hospital institution from January 2011 to January 2014 of which 75 patients (42%) were treated with flared iliac limb stent graft and 104 patients (58%) were treated with a nonflared iliac limb stent graft. There were 165 male patients (92%), mean age was 75.8 ± 6.6 years.
Thirty-six patients underwent secondary treatment accounting for overall reintervention rate of 20%. Endoleak type 1b occurred in 13 patients (7%), followed by endoleak type 1a in six patients (3%). Endoleak type 2 occurred in seven patients (4%) requiring the treatment due to abdominal aortic aneurysm (AAA) enlargement, endoleak type 3 in three patients (2%), and leg stent graft thrombosis in seven patients (4%). In 143 patients (80%), there were no secondary interventions during the follow-up period. Reintervention due to endoleak type 1b was statistically significantly higher in a flared iliac limb group (p < 0.02) with the rate of 7.2% compared with 1.9% rate in nonflared iliac limb group. The mean follow-up was 44.3 ± 20.4. Overall mortality was 33%.
Flared iliac limb with a distal diameter of ≥ 20 mm, show a higher rate of iliac limb reintervention in a follow-up period due to endoleak type 1b.
- 1 Prinssen M, Verhoeven EL, Buth J. , et al; Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351 (16) 1607-1618
- 2 Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. ; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364 (9437): 843-848
- 3 Lederle FA, Freischlag JA, Kyriakides TC. , et al; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302 (14) 1535-1542
- 4 Armon MP, Wenham PW, Whitaker SC, Gregson RHS, Hopkinson BR. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1998; 15 (03) 255-257
- 5 Duvnjak S. Endovascular treatment of aortoiliac aneurysms: From intentional occlusion of the internal iliac artery to branch iliac stent graft. World J Radiol 2016; 8 (03) 275-280
- 6 Donas KP, Inchingolo M, Cao P. , et al; pELVIS Registry collaborators; Martin Austermann; Kristin Weiss; Michel Bosiers; Matteo Barbante; Gioele Simonte; Aaron Fargion and Fabrizio Masciello. Secondary procedures following iliac branch device treatment of aneurysms involving the iliac bifurcation: the pELVIS registry. J Endovasc Ther 2017; 24 (03) 405-410
- 7 Lobato AC. Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther 2011; 18 (01) 106-111
- 8 Naughton PA, Park MS, Kheirelseid EA. , et al. A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation. J Vasc Surg 2012; 55 (04) 956-962
- 9 Kritpracha B, Pigott JP, Russell TE. , et al. Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow. J Vasc Surg 2002; 35 (05) 874-881
- 10 McDonnell CO, Semmens JB, Allen YB, Jansen SJ, Brooks DM, Lawrence-Brown MM. Large iliac arteries: a high-risk group for endovascular aortic aneurysm repair. J Endovasc Ther 2007; 14 (05) 625-629
- 11 Ballotta E, Da Giau G, Gruppo M, Mazzalai F, Toniato A. Natural history of common iliac arteries after aorto-aortic graft insertion during elective open abdominal aortic aneurysm repair: a prospective study. Surgery 2008; 144 (05) 822-826
- 12 Richards T, Dharmadasa A, Davies R, Murphy M, Perera R, Walton J. Natural history of the common iliac artery in the presence of an abdominal aortic aneurysm. J Vasc Surg 2009; 49 (04) 881-885
- 13 Falkensammer J, Hakaim AG, Andrew Oldenburg W. , et al. Natural history of the iliac arteries after endovascular abdominal aortic aneurysm repair and suitability of ectatic iliac arteries as a distal sealing zone. J Endovasc Ther 2007; 14 (05) 619-624
- 14 Gray D, Shahverdyan R, Reifferscheid V, Gawenda M, Brunkwall JS. EVAR with flared iliac limbs has a high risk of late type 1b endoleak. Eur J Vasc Endovasc Surg 2017; 54 (02) 170-176
- 15 Hobo R, Sybrandy JE, Harris PL, Buth J. ; EUROSTAR Collaborators. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther 2008; 15 (01) 12-22
- 16 Torsello G, Schönefeld E, Osada N, Austermann M, Pennekamp C, Donas KP. Endovascular treatment of common iliac artery aneurysms using the bell-bottom technique: long-term results. J Endovasc Ther 2010; 17 (04) 504-509
- 17 Kirkwood ML, Saunders A, Jackson BM, Wang GJ, Fairman RM, Woo EY. Aneurysmal iliac arteries do not portend future iliac aneurysmal enlargement after endovascular aneurysm repair for abdominal aortic aneurysm. J Vasc Surg 2011; 53 (02) 269-273
- 18 Telles GJ, Razuk Filho Á, Karakhanian WK. , et al. Dilatation of common iliac arteries after endovascular infrarenal abdominal aortic repair with bell-bottom extension. Rev Bras Cir Cardiovasc 2016; 31 (02) 145-150
- 19 Adiseshiah M, Boardley D, Raphael MJ. Late iliac artery aneurysm formation: implications for the lower landing site after EVAR. J Endovasc Ther 2008; 15 (02) 246-247
- 20 Agu O, Boardley D, Adiseshiah M. Another late complication after endovascular aneurysm repair: aneurysmal degeneration at the iliac artery landing site. Vascular 2008; 16 (06) 316-320
- 21 Roos H, Tokarev M, Chernoray V. , et al. Displacement forces in stent grafts: Influence of diameter variation and curvature asymmetry. Eur J Vasc Endovasc Surg 2016; 52 (02) 150-156