Endovascular exclusion of abdominal aorto-iliac aneurysms with Iliac branch endoprostheses (IBE) may require additional embolisation of internal iliac artery (IIA) collateral branches, when distal landing in the IAA is not suitable. The purpose of this study is to evaluate the early and late clinical results in this particular cohort of patients, and to compare them with those submitted to standard IBE implantation.

This retrospective single-centre study included patients who underwent elective IBE implantation for abdominal aorto-iliac or isolated iliac aneurysms between 2017 and 2021. Patients were assigned to StG group if submitted to standard IBE implantation (distal landing in the IIA), and to EmbG group if submitted to IBE implantation (distal landing in a IIA branch) associated with single or multiple IIA branch embolisation. Demographics and risk factors, intra and post-operative data at 30 days and at last follow-up (FU, mean 24 +/- 19 months), were collected and analysed. Technical success was defined as successful introduction and deployment of the device in the absence of surgical conversion or mortality, type I or type III endoleak, branch occlusion, or graft limb obstruction. Early endpoints were procedure duration, dose area product (DAP), technical success, in-hospital major adverse event (MAE) rate, need of blood transfusion, length of stay (LOS), 30-day branch thrombosis and 30-day reintervention rate. Late endpoints were IBE-related endoleak, branch thrombosis, reintervention, and buttock claudication at FU. Categorical variables were compared using Fisher Exact test, continuous variables using Student T test.

A total of 88 patients (84 males; mean age, 73 +/- 8 years) were included in this study: 78 patients in the StG (88.6%) and 10 in the EmbG (11.4%). Both groups were substantially homogeneous as regards risk factors and demographics. No significant differences in procedure duration [StG, 112 +/- 55 min vs EmbG, 112 +/- 31 min; p=1.0] and DAP [StG, 146 +/- 107 Gycm2 vs EmbG, 178 +/- 46 Gycm2; p=0.354] were observed. The overall technical success rate was 98.7% in the StG and 100% in the EmbG (p=1.0). In-hospital MAE rate [StG, 12.8% vs EmbG, 0%; p=0.596] and need of blood transfusion [StG, 13 (16.7%) vs EmbG, 1 (10%); p=1.0] were similar in both groups. LOS resulted lower in the EmbG [StG, 2.91 +/- 1.36 days vs EmbG, 1.7 +/- 0.95 days; p=0.008]. Thirty-day branch thrombosis [StG, 0 (0%) vs EmbG, 1 (10%); p=0.113] and re-intervention [StG, 0 (0%) vs EmbG, 1 (10%); p=0.113] rates were not significantly different. At FU, endoprosthesis branch thrombosis was observed more frequently in the EmbG group [StG, 0 (0%) vs EmbG, 2 (20%); p=0.011]. No statistically significant difference at FU was found as regards endoleak [StG, 5 (6.4%) vs EmbG, 0 (0%); p=1.0] and reintervention [StG, 2 (2.6%) vs EmbG, 0 (0%); p=1.0] rates. In particular, 2 IBE-related endoleaks requiring reintervention were detected, both in the StG group: in both cases the endoleak was due to the loss of sealing on IAA distal landing zone (type IIIc). Both patients were treated by embolisation of a pudendal branch and IBE distal extension. Buttock claudication was reported with similar frequency in the two groups [StG, 5.2% vs EmbG, 10%; p=0.461].

According to this single-centre analysis, IBE implantation associated with IIA branches embolisation does not entail significant changes in perioperative outcomes as compared to controls (standard IBE procedures). At follow-up, increased thrombosis of the endoprosthesis iliac branch may be observed, even if this is not associated with higher reintervention rates or buttock claudication. Conversely, standard IBE implantation may be associated with development of type IIIc endoleak at follow-up due to the loss of distal sealing in the IIA. Longer assessment and larger cohort studies are needed to confirm these initial observations.