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INTRODUCTION: The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique. METHODS: This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate. RESULTS: Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB. CONCLUSION: The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability. CLINICAL IMPACT: The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.
RESUMO
BACKGROUND: Endovascular aneurysm repair (EVAR) is recommended as the first option for both elective and ruptured abdominal aortic aneurysms (rAAAs) with suitable anatomy. The aim of this study was to evaluate the outcomes of the gradual adoption of ruptured EVAR (rEVAR) as first option in the management of rAAAs in a reference tertiary center over a 16 year-period. METHODS: A retrospective analysis of prospectively collected clinical data was undertaken, including all patients that were treated for rAAA infrarenal or juxtarenal either with open surgical repair (OSR) or EVAR from 2006-2023. Three periods were identified and analyzed: Initial (2006-2011); intermediate (2012-2017); and current (2018-2023). The primary outcomes were the 30-day mortality rate in relation to the changing pattern of treatment. Secondary outcomes were re-intervention and mortality during the follow up period. RESULTS: Two hundred patients were treated for rAAA; 52% by endovascular means [EVAR (94), Ch-EVAR (9), and branched endovascular aneurysm repair (1)] and 48% by OSR (96). In the initial period, 61 patients were treated for rAAA (21% EVAR vs. 79% OSR), 68 in intermediate patients (47% EVAR vs. 53% OSR), and 71 in current period (83% EVAR vs. 17% OSR). Only in the current period juxta -renal rAAAs were treated by endovascular means (14%). The 30-day mortality rate was 46% in initial period (31% for EVAR vs. 50% for OSR), 64% in second period (46% in EVAR vs. 80% for OSR), and 35% in third period (25% for EVAR vs. 83% for OSR). The mean follow up did not differ between the groups, (EVAR 28.3 ± 2 months, vs. OSR 33.1 ± 3 months, P = 0.56). The survival rate did not differ between the groups; in rEVAR was 82% (SE 5%), 74% (SE 6%), 68% (SE 6.5%), and 63% (SE 7.7%) at 12, 24, 36, and 48 months, respectively, and in OSR was 76% (SE 7%), 66% (SE 8%), and 56% (SE 9.5%) at 6, 24, and 48 months, respectively (P = 0.544). CONCLUSIONS: Through a 16-year period, the implementation of EVAR as treatment of choice for rAAAs over OSR resulted in a noticeable reduction in the 30-day mortality. rEVAR was feasible in over 80% of rAAA patients.