Endovascular Repair of Abdominal Aortic Aneurysms With Concomitant Common Iliac Artery Aneurysm:<b>Outcome Analysis of the EUROSTAR Experience</b>

Hobo, Roel; Sybrandy, J.E.; Harris, Peter L.; Buth, Jacob

doi:10.1583/07-2217.1

Cited by 161 publications

(113 citation statements)

References 34 publications

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“…2 Previously, Falkensammer et al had shown that dilatation was more pronounced in patients with previously existing iliac dilatation, 9 and both Hobo et al and Albertini et al reported a higher risk of complications in patients requiring bellbottom (!24 mm) iliac limbs, a finding corroborated by the present study. 6,10 Similarly, Schanzer et al reported a greater chance of sac enlargement in patients with larger (20 mm or greater) iliac diameter endografts. 11 In the present study, although iliac arteries receiving a bell-bottom endograft did not dilate more than the remaining cases, significantly more limb retraction was observed among this group, which is, in the authors' opinion, the preceding step to development of a seal complication.…”

Section: Discussionmentioning

confidence: 95%

Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair

Gonçalves

Oliveira

Rijn³

et al. 2017

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS Failure after EVAR is most often associated with loss of seal and consequent re-pressurisation of the aneurysm sac. This study explores the evolution of the iliac seal zones after implantation, showing that progressive dilatation and retraction are very common occurrences, which in turn have clinical consequences. Careful attention to planning to take full advantage of the potential iliac seal, avoidance of "bell-bottom" limbs whenever possible, and attention to signs of excessive dilatation and/or retraction over the course of follow-up are practical recommendations derived from the conclusions of this study that may improve outcomes.Objective: To evaluate the dynamics of the iliac attachment zone after EVAR, and the association with clinical events. Methods: A tertiary institution's prospective EVAR database was searched to identify common iliac arteries at risk. Internally validated measurements were made, using centre lumen line reconstructions. Iliac dilatation and endograft limb retraction were the main endpoints. Associations between dilatation, retraction, oversizing, and distal seal length were investigated. Association with clinical events (sealing or occlusion) was also explored. Results: Of 452 primary EVAR patients treated from 2004 to 2012, 341 were included (mean age 72 years, 12% female, 597 common iliac arteries). Median follow-up was 4.7 years. At 30 days, the mean iliac diameter increased from 14 mm to 15 mm (p < .001). Over follow-up, it increased to 18 mm (p < .001). Iliac dilatation !20% occurred in 295 cases (49.4%) and exceeded the implanted endograft diameter in 170 (28.7%). Limb retraction !5 mm was identified in 54 patients (9.1%) and was associated with iliac seal complications (p < 0.001). Iliac endograft extension diameter !24 mm (OR 3.3, 95% CI 1.7e6.4) and iliac artery dilatation beyond the endograft (OR 2.1, 95% CI 1.2e3.8) were independent risk factors. Overall, there were 34 (5.7%) iliac seal complications. Retraction of the iliac endograft (OR 1.17 per mm, 95% CI 1.10e1.24) and baseline AAA diameter (1.04 per mm, 95% CI 1.01e1.07) were independent risk factors for seal related complications. Greater initial post-operative iliac seal length was protective (OR 0.94 per mm, 95% CI 0.90e0.97). Conclusions: Iliac dilatation and endograft retraction are common findings during follow-up, potentially leading to adverse clinical events. Optimisation of the iliac seal zone providing a long distal seal length and added attention to patients with large aneurysms or receiving !24 mm diameter iliac extensions are recommended. Also, long-term surveillance including CTA is advised to reveal and correct loss of seal at the iliac attachments before adverse clinical events occur. Ó

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Section: Discussionmentioning

confidence: 95%

Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair

Gonçalves

Oliveira

Rijn³

et al. 2017

European Journal of Vascular and Endovascular Surgery

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“…1,2 Concurrent iliac aneurysm with an abdominal aortic aneurysm (AAA) is present in 15% to 44% of subjects and can occur in isolation in 2% of patients. [3][4][5][6] The definition of an iliac artery aneurysm is typically described by a vessel diameter 1.5 times the normal adjacent reference vessel diameter. 7 Alternatively, reporting standards have suggested an absolute diameter ≥18 mm in men (≥15 mm for women) for classification of common iliac artery (CIA) aneurysm.…”

Section: Introductionmentioning

confidence: 99%

“…Some series have demonstrated good short and midterm outcomes, while larger registry data suggest that the presence of an iliac aneurysm can lead to a higher risk of type Ib leak, limb occlusion, secondary intervention, or aneurysm rupture after EVAR. 3,18 The purpose of this study was to examine the natural history of aCIAs that are used as landing sites for aortic stent-grafts.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2015

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Purpose: To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR). Methods: This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality. Results: The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak. Conclusion: Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

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“…[18][19][20] There is thus a potential for using chimneys in relining with proximal protrusion. Indeed, there is the possibility to extend the proximal According to EUROSTAR data, 21,22 the incidence of late type III endoleak after successful EVAR is reported to be ~2% to 3%, and it has been reported with 3 commercially available endoprostheses. [23][24][25] The source of these endoleaks is difficult to identify and often requires multimodal imaging, as demonstrated in the illustrated case ( Figure 2A).…”

Section: Discussionmentioning

confidence: 99%

Type IIIb Endoleak and Relining

et al. 2016

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Purpose: To examine the changes in distraction force following relining of a conventional abdominal aortic stent-graft with a type IIIb endoleak using the Nellix endovascular sealing device compared to a unilateral stent-graft. Methods:Relining is often used to repair type IIIb endoleaks, but the consequences to graft stability are unknown. A mathematical model was constructed based on pressure and volume flow through the stent-grafts, incorporating recognized distraction force equations. Steady flow was presumed at peak systolic pressures to calculate the maximum distraction force, with gravity ignored. Distraction forces for 28-to 36-mmdiameter stent-graft bodies with 16-mm limbs were calculated and compared to forces following relining with single and double Nellix devices or the Renu unilateral device.Results: Distraction forces for the 28-, 32-, and 36-mm stent-grafts prior to relining were 5.99, 10.21, and 14.99 N, respectively. Similar forces were reported after relining with bilateral Nellix devices (5.86, 10.08, and 14.86 N, respectively). However, use of a unilateral Nellix increased the distraction forces to 9.92, 14.14, and 18.92 N, respectively. These were comparable to the increase observed after relining with a Renu unilateral stent-graft (9.87, 14.09, and 18.86 N, respectively). The proportional increase in distraction force for a unilateral relining ranged from 26% to 66%, with the greatest increase noted in the smaller diameter main bodies. Conclusion:Relining a stent-graft with a type IIIb endoleak using bilateral Nellix devices does not increase the distraction force. However, a unilateral Nellix device or the Renu system could theoretically increase the distraction force by up to 66%, potentially risking migration and type Ia endoleak. In clinical practice, these results suggest that a relining with bilateral Nellix may have benefits over the Renu unilateral stent-graft.

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Endovascular Repair of Abdominal Aortic Aneurysms With Concomitant Common Iliac Artery Aneurysm:Outcome Analysis of the EUROSTAR Experience

Cited by 161 publications

References 34 publications

Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair

Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair

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

Type IIIb Endoleak and Relining

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