A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation

Abstract

Introduction A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. Methods Patients who underwent EVAR with CIAA were identified in two teaching hospitals. Bell-bottom technique (iliac limb ≥ 20mm) (BBT) or internal iliac artery embolization and limb extension to the external iliac artery (IIE+EE) were used. Outcome between these two approaches are compared. Results One hundred and eighty five patients were identified. . Indication for EVAR included asymptomatic AAA (n=157), symptomatic or ruptured aneurysm (n=19), and common iliac artery aneurysm (n=9). Mean AAA diameter was 59 mm. A total of 260 large CIAAs were treated. One hundred and sixty six CIAA limbs were treated with BBT, 94 limbs underwent IIE+EE. Total reintervention rates were similar for BBT (n=19, 11%) and IIE+EE (n=18, 19.1%) (p=0.149). Similar rates of reintervention for type 1b or 3 endoleak are reported, BBT (n=7, 4%) versus IIE+EE (n=4, 4%) (p=1.0). There was no significant difference in limb patency rates. Thirty-day mortality was 1%. Median follow-up was 22 months. While there was no significant difference in complications between the two groups the combined incidence of perioperative complications and reinterventions was higher in the IIE+EE group (49% versus 22%, p-0.002). Conclusion The combined incidence of perioperative complications and reinterventions is significantly higher in the IIE+EE when compared with the BB technique. Therefore, when feasible, BB is desirable..

Fate of Aneurysmal Common Iliac Artery Landing Zones Used for Endovascular Aneurysm Repair

“…27 Earlier studies assessing the feasibility of the bell-bottom technique included larger caliber vessels in their cohorts, but the numbers are very small and the follow-up is short. 6,20,28 Naughton et al 19 published a series on the management of aCIA LZs using either bell-bottom or flared limb techniques compared with IIA embolization with distal external iliac artery LZ extension. These authors demonstrated that there was no significant difference in type Ib endoleak or iliac limb patency; in fact, the overall rate of complications and reintervention was lower in the bell-bottom group.…”

“…If a bell-bottom 19 or flared stent-graft limb technique was employed, patients received either a flared limb from the manufacturer of the main body stent-graft, an aortic extension cuff, or an aortouni-iliac conversion device using methods previously described. 17,19,20 All overlapping graft segments were molded with a compliant balloon, and completion digital subtraction angiography was obtained to Postoperative CT surveillance with arterial and delayedphase venous imaging was typically obtained at 1, 6, and 12 months and annually thereafter unless radiographic findings dictated otherwise. Timing and need for any reintervention was based on the attending surgeon's judgment.…”

Results of Repair of Iliac Artery Aneurysms with the Sandwich Technique

“…Th is meant occluding the ipsilateral IIA (with a plug or coils) and extending the end of the endograft into the EIA ( 5 ). Th is type of approach has been referred to as occlude and extend ( 14 ). Unfortunately, this leaves a signifi cant number of patients with limiting buttock claudication.…”

“…Th e limitations of this technique are that the iliac artery cannot be larger than 32 mm and that an adequate length of CIA must be available to accommodate the devices needed and allow for seal. Th e advantage of the bell-bottom technique versus exclude and extend is a lower complication rate of 6% vs 38% ( 14 ). However, the bell-bottom technique has also been shown to lead to a higher incidence of reintervention in the follow-up period (14% vs 2%) ( 13 ).…”

Endovascular management of iliac aneurysmal disease with hypogastric artery preservation

“…Torsello et al reported their 5-year data on bell-bottom extensions in 89 patients showing no change in CIAA diameter at last follow-up (18). When compared with embolization of the HA and extension of the endograft into the EIA versus placement of a bell-bottom graft, the combined incidence of perioperative complications and reintervention favors bell-bottom treatment (19).…”