IP047. IFU Violation and Anatomic Factors Are Strongest Predictors of Clinically Significant Type II Endoleaks

Abstract

Objectives: Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass.Methods: All patients undergoing retrograde EIA-IIA endovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle >45 . Procedures were performed using aortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, and annually thereafter with computed tomography CT scan (with selective contrast usage) 1 month postoperatively and annually thereafter.Results: Seventeen patients (mean age, 70 years; 93% male) were treated over the period. Most were treated for primary disease (n ¼ 11), while the remainder underwent secondary interventions following open repair (n ¼ 4) or endovascular repair (n ¼ 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac, n ¼ 8; left iliac, n ¼ 9). Retrograde bypasses were performed using Fluency (n ¼ 1), Viabahn (n ¼ 13), or Gore Excluder (n ¼ 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71 (range, 51 -102 ). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series.Conclusions: Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.