O-062 - USE OF SECONDARY ILIAC BRANCH DEVICES AFTER PREVIOUS ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR.

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Spath P. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Cardona-Gloria Y. (Vascular Surgery, St Franziskus Hospital, Münster, Germany ~ Münster ~ Germany) , Torsello G. (Vascular Surgery, St Franziskus Hospital, Münster, Germany ~ Münster ~ Germany) , Gallitto E. (Vascular Surgery, University of Bologna, DIMES, Bologna, Italy ~ Bologna ~ Italy) , Öz T. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Beropoulis E. (Vascular Surgery, St Franziskus Hospital, Münster, Germany ~ Münster ~ Germany) , Stana J. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Gargiulo M. (Vascular Surgery, University of Bologna, DIMES, Bologna, Italy ~ Bologna ~ Italy) , Tsilimparis N. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany)
Introduction:
Type 1b endoleaks might occur after endovascular aortic repair (EVAR) due to the degeneration of the distal sealing zones, with an incidence of 3.5% during follow-up.[1] Given the importance of the internal iliac artery (IIA) in maintaining pelvic perfusion, iliac branch devices (IBD) have been used to treat secondary type 1b endoleaks or even de novo IIA aneurysms. The treatment with a secondary IBD after a previous implanted EVAR may be challenging with upper extremity or complex cross-over access required to maintain the IIA. The aim of this study is to report technical aspects, early and long-term outcomes of secondary IBD after previous EVAR.
Methods:
A multicenter, retrospective, cross-sectional study was conducted in three European vascular centers. We included all consecutive patients with a previous repair of abdominal aortic aneurysm (AAA) or thoraco-abdominal aneurysm (TAAA) with bifurcated aortic endograft and sealing zone in the common iliac arteries with: a) the presence of type 1B endoleak or b) the novo aneurysm of the more distal common and/or internal iliac artery with indication for repair. All patients were treated with an IBD (ZBIS device COOK Medical or Gore Excluder Iliac Branch Endoprosthesis) with catherization of the hypogastric artery either though a transaxillary access or in an "up-and-over" technique. Primary endopoint: Technical success. Secondary endpoints: 30-day complications, early and long-term freedom from reinterventions and target vessel instability. Analysis on demographics were done using the number of patients as numerator, while technical aspects using the numbers of IBDs. Kaplan-Meier's analysis were used for follow-up outcomes. Univariate and Multivariate analyses were performed using SPSS version 24.0 (IBM Corp, Armonk, NY).
Results:
From 2005 to January 2022, 75 patients (Age 71±9 years, Male 72-96%, ASA score III-IV 55 [67%]) underwent secondary IBD procedures (74 [98%]Cook IBD and 1 [2%] Gore IBD) in three centers. Thirteen (17%) were bilateral, with overall 88 IBDs implanted. The indications for secondary repair were aneurysmatic evolution of iliac arteries in 46 (52%) cases and type Ib endoleak in 42 (48%) cases. Primary procedures were EVAR and fenestrated/branched EVAR in 64 (85%) and 11(15%) cases, respectively. The mean time between primary and secondary IBD procedures was 63±55 months. The mean operation time for IBDs was 221±71 minutes. Out of 88 internal iliac arteries (IIA) revascularized, 36 (42%) required a relining, with the catheterization of the IIA obtained through transaxillary or with "up-and-over" techniques in 82 (93%), and 6 (7%) cases, respectively. Right axillary access was used in 14 (16%) of the cases. Technical success was achieved in all cases (100%). During hospitalization, 4 (5%) major adverse events occurred (one myocardial infarction, three acute kidney injuries), 3 (4%) reinterventions (one relining for kinking of external iliac artery component, two femoral access complications) and no mortality occurred, as well as no strokes and upper access complications. Mean follow-up was 47±30 months, and survival rate at 5 years was 78±6% with no aortic related mortality. Cox's Regression analysis showed pre-operative renal function impairment (HR 3.4; 95% CI [95%CI] 1.1-10.1; p=033) and primary TAAA treatment (HR 6.1; 95%CI 1.6-22-3; p:.006) as independent factors for long-term mortality. Out of 88 IBDs implanted, 11 (12%) required reintervention (5 endoleaks, 4 IBD thrombosis, 2 stenoses) and freedom from reinterventions at 5-years was 84±6%. IIA instability was reported in 3 cases (3%) and freedom from target vessel instability was 95±3% after 60 months (Figure 1). The two different techniques in catheterization of IIA did not affect the early and follow-up results, with comparable safety and technical outcomes results (Table 1).
Conclusion:
The use of secondary IBD after endovascular aortic repair is a safe and effective procedure with high technical success and low complication rates. Choice of technique to revascularize hypogastric artery does not affect early and follow-up results. The durability of the repair with secondary iliac branch device is acceptable, long-term mortality is not affected by aorto-iliac repair and the revascularized IIAs show low rates of target vessel instability and reinterventions.
References:
1. Choi E, Lee SA, Ko GY, Kim N, Cho YP, Kwon TW. Risk Factors for Early and Late Type Ib Endoleak Following Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg. 2021;72:507-516.
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