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Patient-tailored strategies for hostile iliac artery during EVAR
Jin Hyun Joh
Kyung Hee University Hospital at Gangdong, Seoul, Korea
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Disclosure
Speaker name: Jin Hyun Joh
.................................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
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Hostile Iliac Artery
One of major limitation for successful EVAR
Increase risk of intraproceduralcomplications and worse long-term outcome
Tortuosity, stenosis/occlusion, calcification, aneurysmal dilatation
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Tortuosity
Advancing super-stiff wire to straighten the tortuous portion
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M/70, AAA and right CIA aneurysm with tortuous iliac artery/left iliac artery occlusion
End-to-end anastomosis- Segmental excision- EIA to IIA bypass
- Crossover iliofem bypass
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Stenosis
Use the low profile devices
(Hussain SM et al. Endovascular Today 2015)
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M/57, AAA with short segment, tight stenosis on EIA
- 8mm Viabahn
- Artificially rupture
“Internal
Endoconduit”
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F/73, AAA with diffuse calcified stenosis on EIA, S/P. kidney transplantation
Surgical
iliac conduit
Brachial
access
Body through
technique
Transplanted
kidney
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Aneurysmal change
20-30% of patients with AAA, at least one iliac artery is also affected by aneurysmal dilatation.
Possible approaches
- Extension of limb endograft to EIA with IIA
embolization
- Bell bottom technique
- Use the iliac branched device (IBD)
- Parallel graft technique (“Sandwich technique”)
- Hypogastric artery bypass
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M/66, AAA with bilateral CIA aneurysm
Physician
modified endograft
8mm ePTFE
Viabahn
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Male/89, AAA with bilateral CIA aneurysm, hypertension, hematuria
16mm limb
endograft
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Experience
N = 115 patients (229 iliac arteries)
45/115 (39.1%) patients; additional procedures due to
hostile iliac anatomy
6/115 (5.2%) patients; bilateral additional procedures
Additional procedures
Hostile anatomy Procedures No. (%)
Tortuosity
(tortuosity index ≥ 2)
Segmental excision + end-to-end anastomosis
Body through technique via brachial access
1 (0.9)
3 (2.6)
Calcification,
stenosis or
occlusion
Stent placement
Surgical conduit
Internal endoconduit
5 (4.3)
2 (1.7)
1 (0.9)
Aneurysmal change
Extension of limb endograft & IIA embolization
Bell bottom technique
Iliac branched device
Physician-modified iliac branched device
Parallel graft technique
Parallel limb endograft technique
Hypogastric artery bypass
28 (24.3)
1 (0.9)
2 (1.7)
2 (1.7)
1 (0.9)
2 (1.7)
3 (2.6)
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Outcomes with/without additional procedures
Characteristics
Number
Mean Age
(range, years)
Sex (male)
Rupture
Operation time (median)
(range, minutes)
ICU stay (median)
(range, days)
Complication
In-hospital mortality
ICU = intensive care unit; aIndependant t-test, bChi-square test
P value
.273a
.806b
.382b
<.001a
.069a
.076b
.076b
Yes
45 (39.1)
74.5 ± 8.6
(52-98)
36 (80.0)
3 (6.7)
347
(150-528)
1
(1-5)
4 (8.9)
4 (8.9)
No
70 (60.9)
72.6 ± 9.2
(51-91)
58 (82.9)
2 (2.9)
154
(60-419)
1
(0-10)
1 (1.4)
1 (1.4)
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Hostile Iliac Artery
Summary
Tortuosity Calcification, Stenosis Aneurysmal change
Straightening
with
Super- stiff wire
Hybrid :
Segmental
excision with
end-to-end
anastomosis
Sequential
dilation with
a dilator
Surgical
conduit
Internal
endoconduit
Extension of
limb enograft &
IIA embolization
Bell bottom
technique
Iliac branched
device (IBD)
Physician
modified IBD
Parallel graft
technique
Parallel limb
endograft
Hypogastric
artery bypass
(-) Ballooning
or Stenting
Focal,
short
segment
Long
segment(-)
Unilateral (+) Bilateral (+)
High
risk
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Patient-tailored strategies for hostile iliac artery during EVAR
Jin Hyun Joh
Kyung Hee University Hospital at Gangdong, Seoul, Korea