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Mid-term Outcomes of Retrograde Endovascular External to Internal Iliac Artery Endograft Bypass for Hypogastric Preservation with Complex Aorto-Iliac Aneurysms
Megan I Carroll, Paul A Armstrong, Brad L Johnson, Martin R Back
University of South Florida, Tampa, FL

Complex aorto-iliac aneurysmal disease involving one or both common iliac arteries (CIA) presents a challenge in maintenance of pelvic perfusion. We evaluated outcomes of retrograde external to internal iliac (EIA- IIAs) artery endograft bypass (ie EHB) as adjunctive therapy for patients with complex aorto-iliac aneurysms.
Eight consecutive male patients (mean age 70 yrs, range 58-80) undergoing EHB between 2006 and 2012 were retrospectively reviewed. Patients possessed unilateral or bilateral CIA or hypogastric artery aneurysms with or without AAA (>5.5cm) that precluded antegrade revascularization into at least one hypogastric artery. EHB procedures were planned to simultaneously exclude ipsilateral CIA aneurysms (mean diameter 3.6 + 1.1 cm) and maintain IIA perfusion. Anatomically, target hypogastric arteries were not severely calcified, had patent anterior and posterior (gluteal) branches, were not aneurysmal (≤2cm), ipsilateral EIAs had minimal occlusive disease, and the iliac bifurcation angle between the EIA and IIAs was ≥ 45 degrees. Contralateral IIAs were chronically occluded (3) or required embolization (5) for CIA and/or IIAs aneurysms. Retrograde inflow to the EHB from the ipsilateral femoral artery was done from an existing aortofemoral bypass limbs (3 secondary EHBs remote from ABF, 1 simultaneous EHB + ABF) and from a cross femoral bypass done concomitantly with contralateral aorto-uni-iliac endografting (4 primary EHB). EHBs were done with flexible endograft limbs of 8-16 mm diameter and lengths 7-12 cm and adjunctive balloon angioplasty. Clinical outcomes and EHB patency adjudicated by CT angiographic and/or arterial duplex imaging were recorded.

A single 30-day death occurred after the simultaneous open ABF + EHB. Mean length of hospital stay was 6 days (range 2-12) for surviving patients. Follow-up ranged from 2 to 56 months (mean 21 + 19 mo) with all EHBs remaining patent and non-stenotic. No ipsilateral buttock claudication symptoms developed however contralateral buttock claudication occurred post-operatively in one patient and resolved by 4 months. Ipsilateral CIA aneurysms were excluded by EHB without detectable endoleaks and overall size regression or stability (mean diameter 3.3 + 1.3 cm at last follow-up). There were no events of bowel or bladder dysfunction, colonic or distal spinal cord/cauda equina ischemia.
Retrograde EIA-IIA endograft bypass (EHB) for preservation of at least one patent hypogastric artery is low-risk, technically feasible when specific anatomic criteria are met, and are a durable adjunctive option in treating complex aorto-iliac aneurysms.

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