Experience With Unfavorable Iliac Access When Performing Fenestrated/Branched Endovascular Aneurysm Repair

Abstract

Purpose:

To review a single-center experience with fenestrated and branched endovascular aneurysm repair (f/bEVAR) in patients with challenging iliac anatomies.

Materials and Methods:

A retrospective review of the department’s database identified 398 consecutive patients who underwent complex endovascular repair f/bEVAR between January 2010 and June 2018; of these, 67 had challenging accesses. The strategies implemented to overcome access issues were reviewed, using a dedicated scoring system to evaluate the access (integrating diameter, tortuosity, calcification, and previous open or endovascular repair).

Results:

In this subgroup of patients, the most common graft design was a 4-vessel fenestrated endograft (27, 40.3%). Hostile access was due to small diameter (<7 mm) in 25 patients (37.3%) and/or concentric calcifications in 19 patients (26.9%). Mean iliac diameter was 5.5±2.6 mm on the right side and 6.0±2.5 mm on the left side. Previous open or endovascular aortoiliac repair had been performed in 15 patients (22.4%), and 20 patients (29.9%) had a stent previously implanted in at least 1 iliac artery, resulting in the inability to perform standard fenestrated repair with access from both sides. Five patients (7.5%) had a single patent iliac access. Eight distinctive strategies were identified to overcome these access issues, including the use of preloaded renal catheters in the endograft delivery system, angioplasty, graft modification (branches instead of fenestrations or 4 preloaded fenestrations), a conduit via a retroperitoneal approach, iliac artery recanalization, and/or the multiple puncture technique. Technical success was achieved in 62 cases (92.5%). Four patients had access complications and 1 died in the early postoperative period of multiorgan failure. Median follow-up was 24.6 months (IQR 7.2, 41.3). Clinical success at the end of follow-up was achieved in 57 patients (85.1%). During follow-up, 14 patients died, including 4 from an aorta-related cause.

Conclusion:

Dedicated strategies can be implemented to overcome hostile iliac access in patients with complex aneurysms when f/bEVAR is required. Typically, these maneuvers are associated with favorable outcomes.

Keywords

aortic aneurysm branched endograft common iliac artery endovascular aneurysm repair fenestrated endograft hostile anatomy iliac artery occlusion stent-graft vascular access

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References

Jones

Waduud

Walker

, et al. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open. 2019;3:572–584.

Varkevisser

RRB

O’Donnell

TFX

Swerdlow

, et al. Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms. J Vasc Surg. 2019;69:1670–1678.

Gallitto

Gargiulo

Faggioli

, et al. Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair. J Vasc Surg. 2017;66(6):1659–1667.

Maudet

Daoudal

Cardon

, et al. Endovascular treatment of infrarenal aneurysms: comparison of the results of second- and third-generation stent grafts. Ann Vasc Surg. 2016;34:95–105.

Sobocinski

Briffa

Holt

, et al. Evaluation of the Zenith low-profile abdominal aortic aneurysm stent graft. J Vasc Surg. 2015;62:841–847.

Maurel

Resch

Spear

, et al. Early experience with a modified preloaded system for fenestrated endovascular aortic repair. J Vasc Surg. 2017;65:972–980.

Spear

Sobocinski

Hertault

, et al. One year outcomes of 101 BeGraft stent grafts used as bridging stents in fenestrated endovascular repairs. Eur J Vasc Endovasc Surg. 2018;55:504–510.

Mafeld

Annamalai

Lindsay

, et al. Initial experience with Viabahn VBX as the bridging stent graft for branched and fenestrated endovascular aneurysm repair. Vasc Endovascular Surg. 2019;53:395–400.

Chaikof

Fillinger

Matsumura

, et al. Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair. J Vasc Surg. 2002;35:1061–1066.

10.

Kristmundsson

Sonesson

Resch

A novel method to estimate iliac tortuosity in evaluating EVAR access. J Endovasc Ther. 2012;19:157–164.

11.

Taudorf

Jensen

Vogt

, et al. Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA. Eur J Vasc Endovasc Surg. 2014;48:527–533.

12.

Wanhainen

Verzini

Van Herzeele

, et al. Editor’s Choice. European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2019;57:8–93.

13.

Kontopodis

Papadopoulos

Galanakis

, et al. Improvement of patient eligibility with the use of new generation endografts for the treatment of abdominal aortic aneurysms. A comparison study among currently used endografts and literature review. Expert Rev Med Devices. 2017;14:245–250.

14.

Hinchliffe

Ivancev

Sonesson

, et al. “Paving and cracking”: an endovascular technique to facilitate the introduction of aortic stent-grafts through stenosed iliac arteries. J Endovasc Ther. 2007;14:630–633.

15.

Rowse

Morrow

Bena

, et al. Iliac conduits remain safe in complex endovascular aortic repair. J Vasc Surg. 2019;70:424–431.

16.

Batt

Haulon

Bouillanne

, et al. Iliac conduit for renal and visceral artery access during endovascular repair of a pararenal aneurysm with a fenestrated stent-graft. J Endovasc Ther. 2007;14:416–420.

17.

Takeuchi

Morikage

Mizoguchi

, et al. Using bifurcated endoprosthesis after iliac artery recanalization for concomitant abdominal aortic aneurysm and chronic total occlusions of access routes. J Vasc Surg. 2019;70:117–122.

18.

Watkins

Avramenko

Soler

, et al. A novel all-retrograde approach for t-Branch implantation in ruptured thoracoabdominal aneurysm. J Vasc Surg Cases Innov Tech. 2018;4:301–304.

19.

Katsargyris

Marques

Marino

Mufty

, et al. Early experience with the use of inner branches in endovascular repair of complex abdominal and thoraco-abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2018;55:640–646.

20.

Mirza

Tenorio

Kärkkäinen

, et al. Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent graft. J Vasc Surg. 2019;69:296–302.e1.

21.

Van Calster

Bianchini

Elias

, et al. Risk factors for early and late mortality after fenestrated and branched endovascular repair of complex aneurysms. J Vasc Surg. 2019;69: 1342–1355.