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BACKGROUND:Concurrent iliac occlusion and abdominal aortic aneurysm is rare. Traditionally, the endovascular approach to these patients has consisted of aorto-uni-iliac devices combined with femoral-femoral bypass. This approach may hinder future endovascular interventions and potentially increase the risk of groin infections. With improved facility of subintimal angioplasty techniques, standard bifurcated endografts represent an alternative option in these patients. The purpose of this study was to examine outcomes of patients undergoing iliac recanalization and traditional bifurcated EVAR in the face of access vessel occlusion.
METHODS:A retrospective review of patients at three academic tertiary-referral centers who underwent attempted iliac recanalization of chronic iliac occlusions and concurrent endovascular repair of an infrarenal aortic aneurysm was performed. Patients with acute iliac thrombosis, as well as those with severely stenotic (but patent) iliac vessels were excluded.
RESULTS:Over a 6-year period, 15 occluded iliac arteries were treated in fourteen patients. Mean age was 67.8 years (range 52-80) and male:female ratio was 13:1. Primary indication for intervention was disabling claudication in 4 patients and size of AAA in 10 patients.
Seven patients presented with a unilateral common iliac artery (CIA) occlusion, 4 with a unilateral external iliac artery (EIA) occlusion, 3 with a unilateral combined CIA and EIA occlusion, and one with bilateral CIA occlusions. Two of the occluded CIAs and one of the occluded EIAs had prior stents. Average length of the occluded segment was 7.5 cm (Range 2-17). The mean diameter of the occluded CIAs and EIAs were 8.6 and 5.7 mm, respectively.
Successful recanalization was achieved in 14 of the 15 vessels (93.3%). One EIA ruptured during recanalization, but was easily controlled with a Viabahn stent. A re-entry device was used in two cases. Overall, 13 bifurcated devices were implanted: 8 Gore Excluder, 4 Cook Zenith, and 1 Medtronic Talent. The lone technical failure was in the patient with an occluded EIA stent, who was treated with a Cook Renu graft and adjuvant femoral-femoral bypass.
The mean length of stay was 2.3 days (range 1-6). There were no major peri-operative complications or mortality. During a mean follow-up of 28.2 months (range 1-86 months) there was 100% primary patency of successfully recanalized iliacs. Aneurysm sac size decreased from a mean of 5.1 cm (range 3.1-7.6) pre-op to 4.4 cm (range 2.8-7.1) at follow-up. No aneurysms grew or ruptured. There were 3 endoleaks (all Type II), one of which required coiling at 15 months. There were two late deaths: one at 36 months secondary to complications from a CABG/MVR and one at 34 months from a myocardial infarction.
CONCLUSIONS:The use of bifurcated endovascular devices following recanalization of an occluded iliac system is both technically feasible and durable at midterm follow-up. This technique reestablishes aortoiliac inflow to both extremities, obviates the need for extra-anatomic bypass, and may preserve hypogastric perfusion in some patients. Prior stent placement in the occluded access vessel may increase the risk of technical failure.