Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Endovascular Treatment of Peripheral Vascular Blowout Syndrome in End-Stage Malignancies.

BACKGROUND: Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically. METHODS: Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications. RESULTS: Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities. CONCLUSIONS: Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.

[Open and endovascular repair of iliac artery aneurysms]. / Arteria iliaca aneurysma nyitott és endovascularis kezelése.

INTRODUCTION AND AIM: Iliac artery aneurysms make up 2% of all aneurysms. There are only a few data available on the results of surgical treatment, therefore the optimal treatment is unclear. Our objective was the retrospective analysis of the perioperative morbidity and mortality of patients who underwent iliac artery surgery as well as the comparison of elective open surgery and endovascular iliac aneurysm repair (EVIAR). METHOD: Retrospective analysis of patients who underwent surgery for iliac artery aneurysm between 1 January 2005 and 31 December 2014. RESULTS: During the 10-year period, 62 patients with a mean age of 68.9 years underwent elective surgery for iliac artery aneurysm (54 males, 87.1%). In 10 cases acute surgery was performed due to aneurysm ruptures (13.9%), 3 patients died within the perioperative period (30%). Regarding anatomical localisation, aneurysm developed mostly on the common iliac artery (80.6%). As an elective surgery, 35 patients (56.5%) underwent open surgery, 25 (40.3%) underwent EVIAR and other endovascular interventions were performed in 2 cases (3.2%). Postoperative complications (1 patient [4.0%] vs. 17 patients [48.5%]; p<0.001) and intensive care treatment (29 patients [82.8%] vs. 2 patients [8.0%]; p<0.001) were significantly rarer after EVIAR than after open surgery. Furthermore, EVIAR resulted in considerably shorter postoperative hospital stays (4.7 ± 2.3 days vs. 11.8 ± 12.2 days; p = 0.006) and significantly less blood transfusion demand (1 patient [4.0%] vs. 26 patients [74.2%]; p<0.001). There were no significant differences regarding long-term survival rates between EVIAR and open surgery (81.4% vs. 71.4%; p = 0.95). CONCLUSION: In case of the surgical treatment of iliac artery aneurysms, owing to the lower complication rates and shorter postoperative length of stay, EVIAR is primarily recommended. Orv Hetil. 2018; 159(13): 520-525.

How to overcome challenging iliac artery anatomy in endovascular repair for AAA.

Challenging iliac anatomy is a major limitation of endovascular repair for aortic aneurysms. Stenotic lesions, excessive calcification, tortuosity, and aneurysmal dilatation jeopardize technical success of device implantation and long-term success. This review addresses technical options in treating patients with stenotic or aneurysmatic iliac arteries. Endovascular solutions and hybrid procedures are included to demonstrate the wide scope of endovascular therapy that may be offered to patients with unfavorable iliac anatomy.

EVAR with Flared Iliac Limbs has a High Risk of Late Type 1b Endoleak.

INTRODUCTION: Re-interventions are still the Achilles' heel of endovascular aneurysm repair (EVAR). Ectatic common iliac arteries (CIA) can be treated with flared iliac limbs but a dilated artery used as sealing zone could increase the risk of a late type 1b endoleak. The aim of the present analysis was to evaluate the risk of late type 1b endoleak after EVAR in patients with CIA limbs ≥20 mm compared with those <20 mm. METHODS: A retrospective analysis was performed of patients treated by EVAR at the study institution between 2006 and 2012, including patients with available information about the type of iliac stent grafts and a minimum follow-up (FU) of 3 years with contrast enhanced CT, or those that had developed a type 1b endoleak earlier. The cohort was divided into two groups: Group I included iliac limbs with a distal diameter <20 mm, and Group II included all iliac limbs with a distal diameter ≥20 mm. RESULTS: Of 692 limbs (346 patients), 239 limbs (34.5%) from 129 patients were included in the analysis. Mean CT FU was 53 months, 178 had an iliac stent graft diameter <20 mm (Group I), and 61 a diameter of ≥20 mm (Group II). Mean oversizing for iliac limbs was 17.2% (IQR 14) and there was no case of immediate type 1b endoleak. For the whole group, 18 type 1b endoleaks occurred during FU (7.5%) after a mean of 37.7 months (range 4-96). Eleven of 61 (18%) iliac limbs in Group II developed a type 1b endoleak during FU in contrast to 7/178 (3.9%) in Group I (OR 5.3, 95% CI 1.98-14.59, p = 0,001). The ROC curve analysis indicated a limb diameter of 19 mm as a cutoff value for a higher probability of developing a type 1b endoleak. CONCLUSION: Patients treated with iliac limbs ≥20 mm had a fivefold higher risk of late (mean 37 months) type 1b endoleak compared with patients treated with a distal iliac limb diameter <20 mm.

Ruptured aneurysm of the external iliac vein.

Primary iliac venous aneurysm is an extremely rare vascular abnormality that is associated with the likelihood of rupture, embolism, and thrombosis. In this report, we describe the case of a ruptured aneurysm of the external iliac vein in a 63-year-old woman who was admitted to the emergency department and diagnosed by computed tomography. Computed tomography indicated a 4 × 5-cm ruptured aneurysm in the right external iliac vein that was surrounded by hematoma in the right side of the pelvis. The aneurysm was successfully treated by tangential aneurysmectomy and lateral venorrhaphy.

Single-center experience in the endovascular management of isolated iliac artery aneurysm.

BACKGROUND: Isolated iliac artery aneurysms (IAA) are relatively uncommon and represent 2-7% of all intra-abdominal aneurysms. Surgery is the gold standard treatment for IAA. However, endovascular stent-graft placement is gaining acceptance as an alternative to surgery especially in patients with high surgical risk. PURPOSE: To evaluate the effectiveness and safety of endovascular management of isolated IAA having various anatomic and pathologic bases. MATERIAL AND METHODS: Between 2008 and 2011, 31 patients who underwent endovascular treatment for isolated IAA were retrospectively analyzed. The mean aneurysm size was 43 mm (range, 30-71 mm). The age ranged from 37 to 87 years (mean, 70.0 years). Isolated IAAs were treated in one of three different ways: (i) infrarenal aortic stent-graft placement with limb extension; (ii) stent-graft placement for isolated iliac artery coverage; and (iii) embolization with a coil and a vascular plug combined with femoral-femoral bypass grafting. All patients were assessed by contrast-enhanced computed tomography (CT). The mean follow-up period was 25.1 months (range, 1-60 months). RESULTS: Common iliac artery involvement was seen in 28 patients. Ten (35.7%) of those patients also had an internal IAA. Three patients had an isolated internal IAA. Infrarenal stent-graft placement was performed in 25 patients. Stent-graft placement for coverage of the only iliac artery was performed in five patients. One patient, who had a mycotic aneurysm of the right common iliac artery underwent coil embolization of the ipsilateral common iliac artery with concurrent femoral-femoral bypass graft. Five of the 31 patients (16.1%) with stent grafts had type II endoleaks at the time of the last imaging study, one of those patients underwent percutaneous embolization with glue. None of the patients showed major procedure-related complications. CONCLUSION: Percutaneous management of IAA is effective and safe with various techniques depending on the anatomical and pathologic features of the isolated IAA.

Predicting aortic complications after endovascular aneurysm repair.

BACKGROUND: Lifelong surveillance is standard after endovascular repair of abdominal aortic aneurysm (EVAR), but remains costly, heterogeneous and poorly calibrated. This study aimed to develop and validate a scoring system for aortic complications after EVAR, informing rationalized surveillance. METHODS: Patients undergoing EVAR at two centres were studied from 2004 to 2010. Preoperative morphology was quantified using three-dimensional computed tomography according to a validated protocol, by investigators blinded to outcomes. Proportional hazards modelling was used to identify factors predicting aortic complications at the first centre, and thereby derive a risk score. Sidak tests between risk quartiles dichotomized patients to low- or high-risk groups. Aortic complications were reported by Kaplan-Meier analysis and risk groups were compared by log rank test. External validation was by comparison of aortic complications between risk groups at the second centre. RESULTS: Some 761 patients, with a median age of 75 (interquartile range 70-80) years, underwent EVAR. Median follow-up was 36 (range 11-94) months. Physiological variables were not associated with aortic complications. A morphological risk score incorporating maximum aneurysm diameter (P < 0·001) and largest common iliac diameter (measured 10 mm from the internal iliac origin; P = 0·004) allocated 75 per cent of patients to a low-risk group, with excellent discrimination between 5-year rates of aortic complication in low- and high-risk groups at both centres (centre 1: 12 versus 31 per cent, P < 0·001; centre 2: 12 versus 45 per cent, P = 0·002). CONCLUSION: The risk score uses commonly available morphological data to stratify the rate of complications after EVAR. The proposals for rationalized surveillance could provide clinical and economic benefits.

Right iliac aortic aneurysmal hemorrhage as a complication of lumbar discectomy.

BACKGROUND: Vascular injury is rarely reported but can be a life-threatening complication after lumbar disc surgery. CASE DESCRIPTION: We report a case of the rupture of a pseudoaneurysm of the right common iliac artery after spinal surgery for herniation of an intervertebral disc. It was successfully treated by prompt surgical repair. CONCLUSION: This case reminds us of this rare but possible complication, and emphasizes the importance of early diagnosis and urgent intervention.

Endovascular aneurysmal models at the external iliac artery of dogs.

INTRODUCTION: Establishing an aneurysm model using simple and easy operative techniques is desirable to develop new endovascular treatment devices such as stent grafts. We developed an aneurysm model using the external iliac arteries (EIAs) of adult Beagles, a relatively large animal that we thought would be easy to handle, using simple and less complicated endovascular procedures. In addition, we evaluated the generated aneurysm model histologically and determined the factors that were necessary for creating more dilated aneurysms. METHODS: Experimental animals consisted of 16 beagles (average weight, 14.0 kg). The animals were divided into four groups (S, E, B+S, and B+E). Eight Beagles were in the S and E groups, without balloon dilation. S group Beagles were injected with normal saline into the right EIA and served as a control group. Elastase was injected into the left EIA of the same Beagles (E group). Eight Beagles were in the B+S and B+E groups with balloon dilation. After balloon dilation, normal saline was injected into right EIA of the B+S group. Elastase was injected into the left EIA of the same Beagles (B+E). After 4 weeks, we measured the EIA diameter using abdominal ultrasound imaging from a body surface. Both sides of the EIA were harvested. We evaluated the dilation rate of the EIA diameter, and histologically, evaluated the disappearance of the internal elastic lamina, degeneration and disappearance of medial smooth muscle and the external elastic lamina, and neointimal thickening. RESULTS: Inner diameters were dilated more in the B+E group vs the other groups. The B+E group internal elastic lamina had almost disappeared, with significantly more severe degeneration and disappearance of external elastic lamina. CONCLUSIONS: We developed a muscular artery aneurysm model using the EIA arteries of adult Beagles and a simple endovascular procedure. Histologically, internal and external elastic lamina degeneration was an important factor to create significantly dilated aneurysms in this muscular artery model.

Mycotic aneurysm of the right iliac artery: imaging diagnosis and correlation with pathological findings.

We report the case of a 55-year-old woman who presented at the emergency department with hypogastric pain, fever, clinical signs of sepsis and a critical inflammation syndrome in her blood test values. CT-scan of the abdomen demonstrated an infected aneurysm of the right iliac artery. The patient underwent surgery with a favorable outcome. Histological examination of resected artery was performed and compared to the CT features. The authors review the literature and stress the importance of early diagnosis and treatement.

Spontaneous dissection of the iliac artery in a patient with fibromuscular dysplasia.

A 49-year-old man was referred to our hospital at 10 days after the onset of sudden intermittent claudication of the right lower limb and with right lower abdominal pain. Diagnosis by computed tomography scan and pelvic angiography was dissection from the common iliac artery to peripheral external iliac artery with thrombosed false lumen. Replacement of the common and external iliac artery was performed using a 10-mm Dacron prosthesis. A pathological examination of the right common iliac artery revealed an arterial disorder caused by fibromuscular dysplasia.

Aneurysmal extension to the iliac bifurcation increases the risk of complications and secondary procedures after endovascular repair of abdominal aortic aneurysms.

BACKGROUND: To compare the outcome of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) in patients with and without associated common iliac artery aneurysm (CIAA) extending to the iliac bifurcation. METHODS: Review of 157 patients who underwent endovascular aneurysm repair between 1999 and 2007. Group 1 included 133 patients with and without CIAA and suitable distal common iliac neck (type A, B, C, or D). Group 2 included 24 patients with associated CIAA extending to the iliac bifurcation (type E). Stent-grafts were Powerlink (Endologix, Irvine, CA) in 42, Zenith (Cook, Bjaeverskov, Danemark) in 55, and Talent (Medtronic, Sunnyvale, CA) in 60 patients. Forty patients had aorto-uni-iliac stent-grafts. RESULTS: No difference in overall mortality and AAA rupture was observed. AAA-related complication-free survival at 5 year was 72 +/- 5% and 41 +/- 14% in group 1 and 2, respectively (p = 0.006). Secondary intervention-free survival was 84 +/- 5% and 55 +/- 12% in group 1 and 2, respectively (p = 0.0008). Incidence of distal type 1 endoleak and stent-graft thrombosis was 17 and 8 % in group 2, 3.8 and 0.8 % in group 1, respectively (p = 0.07 and p = 0.01, respectively). CONCLUSION: AAA-related complications and secondary interventions occur more frequently in patients with type E AAA. Distal type 1 endoleak and stent-graft thrombosis are more frequent in these patients. These results warrant further development of technologies that are better adapted for treatment of CIAAs, such as branched and flexible stent-grafts.

Histopathology of an iliac aneurysm in a case of Menkes disease.

In Menkes disease, arterial tortuosity is frequent, whereas true aneurysms are rare. Here, we report aneurysmal pathology occurring in an infant with Menkes disease. An iliac aneurysm was diagnosed in a 2-month-old boy and attributed to Menkes syndrome on the basis of plasma copper deficiency. Samples of the aneurysmal wall were taken during surgery for histopathological analysis. As in other forms of aneurysm, the arterial wall was characterized by smooth muscle cell (SMC) disappearance, linked to SMC apoptosis and oxidative stress, areas of mucoid degeneration, and extracellular matrix breakdown, including disappearance of elastic fibers and presence of abnormal collagen.

Laparoscopic surgery in the management of complex aortic disease: techniques and lessons learned.

Laparoscopic vascular surgery must be assessed in the context of both open and endovascular interventions. The development of improved laparoscopic equipment and endoscopic techniques makes performance of laparoscopy easier, but endovascular interventions still hold wide appeal because they are minimally invasive and are easier to master by vascular surgeons. Despite decreased morbidity and recovery time, endovascular interventions have inferior durability and higher reintervention rates when compared with open aortoiliac interventions. In particular, after endovascular aneurysm repair, patients need lifelong surveillance because there is potential for delayed endoleaks, aortic neck dilatation, graft migration, and ongoing risk of aneurysmal rupture. These limitations of endovascular therapy are the impetus behind the pursuit of other minimally invasive techniques, such as laparoscopy, in vascular surgery. Currently, two evolving laparoscopic approaches are available for abdominal vascular surgery: total laparoscopic aortic surgery and hybrid techniques that combine laparoscopy with endovascular techniques to treat failing endografts.

Fate of iliac arteries following open abdominal aortic aneurysm repair.

Iliac artery aneurysms are a frequent finding in patients with abdominal aortic aneurysms. The decision of whether to perform a tubular or bifurcated repair rests on a balance between the natural history of the iliac arteries during the lifetime of the patient versus the risk of symptomatic pelvic ischemia and the increased complexity of a bifurcated repair. The relatively recent increase in the use of cross-sectional imaging, especially in the setting of long-term endograft surveillance, has provided useful data on which to base these clinical decisions. A tube graft repair appears to be safe and durable in patients undergoing open aneurysm repair, when suitable distal aortic anatomy and normal iliac arteries are present. A bifurcated graft should be considered in younger patients with moderate sized iliac aneurysms (<30 mm in diameter), as well as in almost all patients with larger iliac aneurysms.

Endovascular treatment of iliac aneurysm: Concurrent comparison of side branch endograft versus hypogastric exclusion.

OBJECTIVE: To analyze early and mid-term outcome of endovascular treatment in patients with iliac aneurysms, comparing the results of hypogastric revascularization by branch endografting with those of hypogastric occlusion. METHODS: Consecutive patients with iliac aneurysms receiving side branch endograft (Group I) were compared with those receiving endograft with hypogastric exclusion (Group II) during the interval from January 2000 to May 2008. Procedural details and outcomes were prospectively collected and were analyzed at one year to avoid mismatch in follow-up length. RESULTS: A total of 74 patients (mean age, 75.8 years, 95% males) were treated: 32 in Group I and 42 in Group II. No differences in baseline risk factors and aneurysm diameter (40.2 +/- 7.9 mm in Group I vs. 38.4 +/- 10.8 in Group II) were found. Concurrent treatment of aortic aneurysm was performed in 25/32 (78%) of Group I and 36/42 (86%) of Group II. Fluoro time was 48 minutes (interquartile range [IQR] 31-57) in Group I vs. 31 minutes (IQR 23-38) in Group II (P = .04). The amount of contrast was similar in both Groups: 184 ml (IQR 155-210) in Group I vs. 183 ml (IQR 155-200) in Group II. No intestinal ischemia or deaths occurred. There were no significant differences in failures of hypogastric side branch deployment (2/32) compared with hypogastric coiling (3/42). Limb occlusions all occurring in the external iliac artery side were 2/32 in Group I vs. 3/42 in Group II. Reintervention rates were similar (5/32 vs. 4/42) at one year. Shrinkage of 5 mm or more was detected in 7/23 (30%) of Group I and in 13/37 (34%) of Group II. Iliac endoleak was present in eight patients (19%) in Group II and in one patient in Group I (4%) (P = .1). Similarly, buttock claudication or impotence were more frequent after hypogastric exclusion, recorded in eight patients in Group II and in one patient in Group I (P = .1). CONCLUSIONS: Endovascular treatment of iliac aneurysm with hypogastric revascularization through side branched endografts is feasible and safe in the mid-term. When compared with hypogastric embolization, this option leads to similar technical success and reintervention rates. Endoleak and buttock claudication occur frequently in patients with iliac aneurysm treated with hypogastric exclusion, while are uncommon in those with hypogastric revascularization. Side branch endografting for iliac aneurysm may be considered a primary choice in younger, active patients with suitable anatomy, but larger studies and longer postoperative observation periods are needed.

Endovascular correction of a distal re-entry in an abdominal aorta dissection.

The re-entries are still a problem for the endovascular treatment of aortic dissections. A 60-year-old man was treated for an abdominal aortic dissection using aortic monoiliac endograft until the left iliac external artery and a femoro-femoral bypass with occlusion of the right common iliac artery and the left hypogastric artery. In his third year of follow-up, a re-entry tear in the right hypogastric ostium was diagnosed with pressurization of the aortic and common iliac aneurysmatic sac, that required correction. A self-expandable covered stent in a 'U' configuration was implanted, connecting the right external and internal iliac arteries, with preservation of the pelvic circulation, and exclusion of the aneurysmatic sac. In conclusion, the use of a flexible stent graft is a safe alternative, and simplifies some procedures in complex circumstances.

Natural history of common iliac arteries after aorto-aortic graft insertion during elective open abdominal aortic aneurysm repair: a prospective study.

BACKGROUND: This study aimed to determine the natural history of common iliac arteries (CIAs) after elective open infrarenal abdominal aortic aneurysm (AAA) repair with an aorto-aortic prosthetic graft. METHODS: All patients who had a straight tube graft inserted during elective AAA repair at our institution between 1995 and 2005 were prospectively followed up with preoperative and postoperative computed tomography (CT) scans to monitor changes in CIA diameter; their latest CT scan was performed in 2007. Based on preoperative CIA diameter, patients were divided into groups A (both CIAs normal, up to 12 mm in diameter), B (at least 1 ectatic CIA, 13-18 mm), and C (at least 1 aneurysmal CIA, 19-25 mm). The mean follow-up was 7.1 years (range, 2.1-12.3 years). RESULTS: Among 201 patients eligible for the study, 92 patients (45.8%) were in group A, 63 patients (31.3%) were in group B, and 46 patients (22.9%) were in group C. Overall, the diameter increased in 119 CIAs (29.6%) by a mean of 1.1, 1.8, and 2.4 mm in groups A, B, and C, respectively. In all, 14 CIAs (5.4%) progressed from "normal" to "ectatic," and 9 CIAs (10.2%) progressed from "ectatic" to "aneurysmal." Three aneurysmal CIAs slightly exceeded the 25-mm threshold, but none of these were repaired. No patients showed a progression or development of occlusive iliac artery disease or required repeat operation because of excessive CIA enlargement. CONCLUSIONS: This analysis showed that most CIAs do not expand after tube graft insertion during AAA repair, and when they do, the degree of dilation is minimal. Tube graft insertion during AAA repair is justified even for ectatic or moderately aneurysmal CIAs, and the procedure is safe and durable. The skepticism surrounding its selective use instead of a systematic bifurcated graft placement seems to be unwarranted.