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A Multi-institution Series of Hypogastric Preservation During Endovascular Repair of Aneurysms Involving the Common Iliac Artery
Grant T Fankhauser1, Gustavo Oderich2, David J Minion3, Mark O'Donnell1, William M Stone1, Manju Kalra2, Samuel R Money1
1Mayo Clinic Arizona, Phoenix, AZ;2Mayo Clinic, Rochester, MN;3University of Kentucky, Lexington, KY

INTRODUCTION: Iliac artery involvement can complicate endovascular aneurysm repair (EVAR). Hypogastric artery interruption is a common strategy used to overcome this anatomical challenge, but is associated with ischemic complications in up to 50% of cases. Studies have suggested that hypogastric artery preservation can minimize these iatrogenic complications with no increase in morbidity. However, specific iliac branched grafts are currently unavailable in the United States. The purpose of this study was to review outcomes of hypogastric preservation during EVAR utilizing currently available techniques.
METHODS: A retrospective review of consecutive cases from three institutions was performed. Hypogastric preservation was achieved using 4 different techniques, depending on institutional and physician preference. Physician-modified devices (PMD) were created by attaching a 7 mm Dacron side branch to a standard iliac limb, then reloading the device into a larger sheath for delivery. Trifurcated devices (TRI) utilized a second bifurcated aortic endoprosthesis to create the iliac branched configuration. Parallel endografts involved deployment of both a hypogastric and external iliac extension alongside each other in a common iliac limb. These were classified as the Sandwich Technique (ST) when two self-expanding stent grafts were used to create a “Double-D” configuration. They were classified as Eye of the Tiger (EOT) when a balloon-expandable stent-graft was used for the hypogastric extension and molded into an “eye” shape for the parallel portion to facilitate apposition.
RESULTS: Preservation was attempted for 35 hypogastric arteries in 32 patients, including 17 PMDs (48%), 5 TRIs (14%), 10 EOTs (29%), and 3 STs (9%). Primary success was achieved in 100% of cases. However, one ST had to be converted to an EOT due to a persistent intra-operative endoleak. There was no peri-operative mortality. Early morbidity included one CHF exacerbation and 4 wound complications. In addition, there was one early external iliac limb occlusion and 1 external iliac limb stenosis in the ST group due to compression by the 2nd parallel graft. At mean follow-up of 10 months (range 0-30 months), no ruptures, significant sac growth, or aneurysm-related deaths occurred. Overall, four endoleaks occurred (all type II), two of which were treated successfully by endovascular means and two were observed. One hypogastric branch occluded at 13 months in the PMD group.
CONCLUSIONS: Hypogastric preservation during EVAR for cases with iliac involvement is both safe and feasible with a broad variety of techniques that utilize currently available devices. At early to mid follow-up, gross patency rates exceed 90%. Sample sizes are too small to demonstrate superiority of any specific technique. When parallel grafts are employed, the Eye of the Tiger technique may offer some benefit over the Sandwich Technique. Hypogastric preservation can be effectively performed when clinically indicated.


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