iliac artery aneurysms - current treatment strategies
DESCRIPTION
South East Coast Vascular Network meeting with VSGBI AAAQIP September 2012TRANSCRIPT
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Iliac Aneurysms – Current Treatment StrategiesPatrick Chong
Department of Vascular Surgery,
Frimley Park Hospital NHS Foundation Trust
Surrey Vascular Group Network
South East Coast Vascular Network Inaugural MeetingKent & Canterbury Hospital26th September 2012
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The Solitary Iliac artery aneurysm> 50% increase c.f. native iliac artery diameterPrevalence of 2%-6% in autopsy seriesAsymptomaticClinically difficult to detectConsider repair > 3.5cm in good risk patientsRupture is commonElective open repair (11%)Emergency open repair (40-60%)
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Iliac artery aneurysms - Aetiology
Degenerative AtherosclerosisInfectionDissectionTraumaFibromuscular DysplasiaMarfans
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Iliac artery aneurysms – natural historyAverage rate of expansion: 0.118 +/- 0.017 cm/year
No expansion in 37.5%<3cm: 0.05-0.15cm/year>3cm: 0.25-0.28cm/yearAll IAA between 4 and 4.9cm expanded
Santilli et al. 2000
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Internal iliac artery aneurysms -AetiologyProgressive atherosclerosis 80%
Childbirth Trauma 11%Mycotic
Staphylococcus Aureus
Klebsiella spp.Pseudomonas spp.
Salmonella spp.
Previous IR-AAA repairCTDs
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Iliac artery aneurysms - complicationsRuptureExtrinsic compression
UrologicalNeuropathyDeep venous
Distal EmbolisationThrombotic occlusionFistula formation
UretericEnteric
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Internal iliac artery aneurysmsRare – incidence 0.4% Male : Female ratio 6: 1Mean age at presentation 67.2 years
Ruptured at initial presentation 33-40%Mortality from rupture 31-58%Risk of rupture >3cm 14-31%
“There is no significant correlation between size of internal iliac aneurysm and risk of rupture” r=+0.161 Spearman p=0.279De Donato 2005
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The classification of isolated iliac artery aneurysmsUberoi et al. 2011
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Endovascular options
Balloon expandable Jostent by JOMED,
Cheshire, UK Advanta by ATRIUM
Medical International
Self-expanding Fluency stent by
BARD Haemobahn by
GORE Viabahn by GORE
TECHNICAL TIPSAntibioticsHeparinPercutaneous or open cut down accessBilateral groin approachLA or Regional or GA10F sheath or larger if using EVAR limbs180mm or 260mm carriage wire
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Treatment options
Open repair Bypass Ligation
Endovascular repair
Stent Embolisation Hybrid approaches
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EVAR limb stent graft optionsCOOK spiral Z iliac limbs > 10mm landing
vessel 7.5-20mm(outer to outer wall)length 39-12mm10-15% oversize
VASCUTEK Anaconda iliac limbs
10-23mm stent diameter 60-140mm stent length
>25mm proximal>20mm distal10-15% oversize
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Technical and Clinical OutcomesTechnical Success 100%Primary Patency Rates 85-95% at 2 years
86-97% at 3 yearsRe-intervention 0-26%
for stent occlusion
For stent endoleaks
Data is not robust after 2 yearsIs your patient fit for open repair?
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Left IIAA found on diagnostic trans-femoral angiography Beware of using TFA findings alone !CT Aortogram showed no proximal neck – coil embolization
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Treatment strategy for Type A anatomy
Treatment strategy for Type B anatomy
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Large Right CIAA with no distal landing zone proximal to theRight IIA origin.Proximal coiling of Right IIA originRight iliac stent with distal landing zone in the external iliac artery
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Endovascular management Type B anatomy
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Large Right CIAA with no proximal landing zone Aorto-uni-iliac stent to Left CIAFem-Fem crossover bypass
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Treatment strategy for Type C anatomy
Treatment strategy for Type D anatomy
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Treatment strategy for Type E anatomy
Embolisation tipsContralateral approach / Ansel crossover sheath (COOK) / Terumo hydrophilic wireAmplatzer vascular plugsCoilsGlueThrombinOnyx
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Endovascular embolisation of IIA – when is it not required?
Landing zone in distal CIA availableOccluded IIAHigh grade stenosis of IIA origin
Buttock claudication reported in up to 23%Persistent symptoms in 1 in 6 up to 2 years
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SummaryRupture risk < 3cm low >5cm
significant
Surveillance <3cm yearly 3.5-4.0 cm 6 months
Consider repair when >4cm or symptomatic
Open repair may be better in patients with compressive symptoms
Endovascular therapy may be safer in co-morbid patients
Further need for long term durability comparison of open vs. endovascular repair