Large Iliac Arteries: A High-Risk Group for Endovascular Aortic Aneurysm Repair

Abstract

Purpose:

To examine if the presence of large iliac arteries is a potential risk factor for the development of a type Ib endoleak (iliac sealing zone) or need for iliac artery—related secondary intervention in patients undergoing endovascular abdominal aortic aneurysm repair.

Methods:

The medical notes and all preoperative and postoperative plain abdominal radiographs and computer tomographic scans were reviewed for a consecutive series of 100 patients (89 men; mean age 75 years, range 56–91) with large iliac arteries (mean 19.7 mm, range 16–22) who had Zenith endovascular stent-grafts inserted for management of aortoiliac aneurysmal disease from January 1999 until September 2002. Endpoints were all-cause mortality, aneurysm-related death, endoleak, secondary intervention, secondary interventions, and stent-graft migration.

Results:

Mean follow-up was 30.1±8.3 months; at the last follow-up, 30% of patients were dead, 3% were aneurysm-related. Seven (7%) patients developed a type Ib endoleak, with the remainder being type II (29%), type Ia (2%), type III (1%), and type V (endotension, 1%). Eight (27.5%) type II endoleaks persisted, with the remainder closing spontaneously with sac shrinkage. The iliac artery—related secondary intervention rate was 10%, and the overall secondary intervention rate was 16%.

Conclusion:

Iliac arteries between 16 and 22 mm in diameter may be treated with a cuff to the iliac limb with an expectation of 90% efficacy. Surveillance is required, with a high index of suspicion for type 1b endoleaks. Early secondary iliac intervention with extension to the external iliac artery is recommended if there is an increase in sac size after 6 months.

Keywords

abdominal aortic aneurysm endovascular aneurysm repair stent-graft iliac arteries ectatic iliac arteries endoleak mortality secondary intervention

Get full access to this article

View all access options for this article.

References

Greenhalgh

Brown

Kwong

. 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: 843–848.

Prinssen

Buskens

, Blankensteijn JD. on behalf of the DREAM trial participants. Quality of life after endovascular and open AAA repair. Results of a randomized trial. Eur J Vasc Endovasc Surg. 2004; 27: 121–127.

Fearn

Lawrence-Brown

MMD

Semmens

. Follow-up after endovascular aortic aneurysm repair: The plain radiograph has an essential role in surveillance. J Endovasc Ther. 2003; 10: 894–902.

Lawrence-Brown

Semmens

Hartley

. How is durability related to patient selection and graft design with endoluminal grafting for abdominal aortic aneurysm? In: Greenhalgh

ed, Durability of Vascular and Endovascular Surgery. London, WB Saunders; 1999: 375–385.

Stanley

Semmens

Mai

. Evaluation of patient selection guidelines for endoluminal AAA repair with the Zenith stent-graft: The Australasian experience. J Endovasc Ther. 2001; 8: 457–464.

Sternbergh

Money

Greenberg

. Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: Results from the Zenith Multicenter Trial. J Vasc Surg. 2004; 39: 20–26.

Semmens

Lawrence-Brown

Hartley

. Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997–2004). J Endovasc Ther. 2006; 13: 320–329.

Elkouri

Martelli

Gloviczki

. Most patients with abdominal aortic aneurysm are not suitable for endovascular repair using currently approved bifurcated stent-grafts. Vasc Endovascular Surg. 2004; 38: 401–412.

Halak

McDonnell

. Rupture of an abdominal aortic aneurysm previously repaired with an endovascular stent-graft: Successful management using an endovascular approach. Ir J Med Sci. 2006; 8: 221–222.

10.

Timaran

Lipsitz

Veith

. Endovascular aortic aneurysm repair with the Zenith endograft in patients with ectatic iliac arteries. Ann Vasc Surg. 2005; 19: 161–166.

11.

Summary of Safety and Effectiveness Data for Zenith AAA Endovascular Graft with the H & L-B One-Short Introduction System. PMA Application No. P020018. US Food and Drug Administration. May 2003.

12.

van Marrewijk

Fransen

Laheij

. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up. Eur J Vasc Endovasc Surg. 2004; 27: 128–137.

13.

Tureff

Rockman

Lamparello

. Are type II (branch vessel) endoleaks really benign? Ann Vasc Surg. 2002; 16: 50–54.

14.

Karch

Hodgson

Mattos

. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2000; 32: 676–683.

15.

Karch

Hodgson

Mattos

. Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair. J Vasc Surg. 2001; 33: S33–38.

16.

Arko

Lee

Hill

. Hypogastric artery bypass to preserve pelvic circulation: Improved outcome after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2004; 39: 404–408.

17.

Sivamurthy

Schneider

Reilly

. Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: Implications for limb patency. J Vasc Surg. 2006; 43: 662–670.

18.

Greenberg

West

Pfaff

. Beyond the aortic bifurcation: Branched endovascular grafts for thoracoabdominal and aortoiliac aneurysms. J Vasc Surg. 2006; 43: 879–887.

19.

Cheng

Ting

. Aortic aneurysm morphology in Asians: Features affecting stent-graft application and design. J Endovasc Ther. 2004; 11: 605–612.

20.

Moise

Woo

Velazquez

. Barriers to endovascular aneurysm repair: Past experience and implications for future device development. Vasc Endovascular Surg. 2006; 40: 197–203.