O-066 - ILIAC BRANCH DEVICES IN THE REPAIR OF RUPTURED AORTO-ILIAC ANEURYSMS. A MULTICENTER STUDY.

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Karelis A. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden) , Sonesson B. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden) , Gallito E. (Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Italy ~ Bologna ~ Italy) , Tsilimparis N. (German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany ~ Hamburg ~ Germany) , Forsell C. (Department of Cardiothoracic and Vascular Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden ~ Linköping ~ Sweden) , Leone N. (Department of Vascular Surgery, University of Modena and Reggio Emilia, Modena, Italy ~ Modena ~ Italy) , Silingardi R. (Department of Vascular Surgery, University of Modena and Reggio Emilia, Modena, Italy ~ Modena ~ Italy) , Mesnard T. (CHU Lille, Aortic Centre, Vascular Surgery, Lille, France; Université Lille, INSERM U1008, CHU Lille, Lille, France ~ Lille ~ France) , Sobocinski J. (CHU Lille, Aortic Centre, Vascular Surgery, Lille, France; Université Lille, INSERM U1008, CHU Lille, Lille, France ~ Lille ~ France) , Isernia G. (Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy ~ Perugia ~ Italy) , Resch T. (Copenhagen University Hospital, Department of Vascular Surgery and University of Copenhagen, Faculty of Health and Medical Sciences, Denmark ~ Copenhagen ~ Denmark) , Gargiulo M. (Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Italy ~ Bologna ~ Italy) , Dias N. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden)
Introduction:
Endovascular aortic aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) is a well-established treatment showing favorable results with decreased blood loss, operative time, hospital stay, morbidity and mortality rates compared to open surgical repair.(1-2) The extension of the AAA into the iliac artery has been associated with worse outcome especially in ruptures.(3) This occurs in approximately 40% of the patients leading to inadequate landing zones in the common iliac arteries.(4, 5) Initially EVAR was done with sacrifice of one or both IIAs and extension of the stent graft to the external iliac artery. However, this has been associated with pelvic ischemic complications in the elective setting of up to 45 % of patients who undergo unilateral IIA occlusion. The rates are even higher in those who undergo bilateral IIA occlusion or are treated for rAAA. (6) Iliac branch devices (IBD) are a technical alternative that preserve one or both IIA during EVAR. Good results have been repeatedly reported in the elective setting.(7) More recently we have reported the feasibility of this technology in the acute setting of ruptured aneurysms in a small cohort study.(8)
Methods:
A multicenter retrospective review of all consecutive patients undergoing acute endovascular repair of ruptured aortoiliac aneurysm with IBD at 8 aortic centers. The main outcome measures were 30-day mortality, major adverse events, technical and clinical success. Secondary outcomes were buttock claudication, primary, primary assisted and secondary patency of the IBD, occurrence of types I/III endoleaks and re-intervention.
Results:
Some 24 patients receiving 28 IBDs were included in the study, 20 (83%) of which were hemodynamically stable during the procedure. Technical success was achieved in all cases with a procedure time of 180 (133 - 254) minutes, 45 (23 -65) of which were from IBD. There were two (8%) deaths during first 30-days, both in patients that became hemodynamically unstable intraoperatively. Two (8%) major complications occurred, both unrelated to the IBD, Figure 1. Median follow-up was 17 months (2 - 39) with a primary patency of 60 ± 14 % at 3 years that went up to 92 ± 8 % with 8 reinterventions in 6 patients (25 %), Figure 2.
Conclusion:
IBD is a valid alternative for maintaining the pelvic circulation for EVAR of ruptured aorto-iliac aneurysms. The technical success and mid-term outcomes are very satisfactory in hemodynamically stable patients, but the re-intervention rate is considerable mandating continuous follow-up. Further studies are needed to refine patient selection and evaluate long-term outcomes.
References:
1. Boyle JR, Mao J, Beck AW, Venermo M, Sedrakyan A, Behrendt CA, et al. Editor's Choice - Variation in Intact Abdominal Aortic Aneurysm Repair Outcomes by Country: Analysis of International Consortium of Vascular Registries 2010 - 2016. Eur J Vasc Endovasc Surg. 2021;62(1):16-24. 2. D'Oria M, Hanson KT, Shermerhorn M, Bower TC, Mendes BC, Shuja F, et al. Editor's Choice - Short Term and Long Term Outcomes After Endovascular or Open Repair for Ruptured Infrarenal Abdominal Aortic Aneurysms in the Vascular Quality Initiative. Eur J Vasc Endovasc Surg. 2020;59(5):703-16. 3. Jalalzadeh H, Indrakusuma R, Koelemay MJW, Balm R, Collaborators, Van den Akker LH, et al. Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands. Eur J Vasc Endovasc Surg. 2020;60(1):49-55. 4. Karthikesalingam A, Hinchliffe RJ, Holt PJ, Boyle JR, Loftus IM, Thompson MM. Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device. Eur J Vasc Endovasc Surg. 2010;39(3):285-94. 5. Hobo R, Sybrandy JE, Harris PL, Buth J, Collaborators E. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther. 2008;15(1):12-22. 6. Lee WA, Nelson PR, Berceli SA, Seeger JM, Huber TS. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. J Vasc Surg. 2006;44(6):1162-8; discussion 8-9. 7. Fargion AT, Masciello F, Pratesi C, Pratesi G, Torsello G, Donas KP, et al. Results of the multicenter pELVIS Registry for isolated common iliac aneurysms treated by the iliac branch device. J Vasc Surg. 2018;68(5):1367-73 e1. 8. Karelis A, Dijkstra ML, Singh B, Vaccarino R, Sonesson B, Dias NV. The Use of Iliac Branched Devices in the Acute Endovascular Repair of Ruptured Aortoiliac Aneurysms. Ann Vasc Surg. 2020;67:171-7.
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