Wyers Mark C, Schermerhorn Marc L, Fillinger Mark F, Powell Richard J, Rzucidlo Eva M, Walsh Daniel B, Zwolak Robert M, Cronenwett Jack L
Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
J Vasc Surg. 2002 Dec;36(6):1138-45. doi: 10.1067/mva.2002.129639.
When abdominal aortic aneurysms and common iliac artery (CIA) aneurysms undergo concomitant endovascular repair, endograft limb extension into the external iliac artery is often necessary. Usually, the internal iliac artery (IIA) is coil embolized in such a case to prevent endoleak. It has been our practice to coil embolize the IIA only in cases where there is not adequate stent graft seal in the CIA immediately proximal to the IIA origin (effectively sealing the entire IIA origin). In this study, we evaluated the outcomes of this approach.
We retrospectively reviewed 204 consecutive endovascular abdominal aortic aneurysm repairs at Dartmouth-Hitchcock Medical Center from 1996 to 2001. Computed tomographic angiography with three-dimensional reconstruction was the primary preoperative imaging modality, and the decision to cover the IIA without concomitant coil embolization was based before surgery on the presence of adequate graft oversizing (> or =10% to 15%) in the most distal 5 mm of CIA and 15 mm of proximal external iliac artery, respectively.
The IIA was occluded 33 times in 31 patients. In 22 cases (67%), the IIA was covered without coil embolization (COVER group). The remaining 11 patients (33%) with inadequate graft oversizing in the CIA underwent IIA coil embolization (COIL group). The follow-up periods for the COVER and COIL groups were 19 +/- 2 months and 10 +/- 3 months, respectively. All operations in both groups were technically successful without evidence of endoleak at completion angiography. No endoleaks, graft migrations, or aneurysm enlargements were associated with the covered or coiled IIAs during the follow-up period. No clinical sequelae were seen in the COVER group, with the exception of buttock claudication in six patients (27%) that resolved completely in five patients. In the COIL group, five patients (45%) had buttock claudication. In addition, one case of buttock necrosis and one case of ischemic neuropathy occurred in the COIL group.
Covering the IIA without coiling effectively excluded the CIA aneurysm in every case and was associated with a low incidence rate of complications compared with coil embolization. With detailed preoperative imaging and patient selection, IIA coil embolization may not be necessary in as many as two thirds of patients who need IIA occlusion.
当腹主动脉瘤和髂总动脉瘤同时进行血管腔内修复时，常常需要将血管内移植物的分支延伸至髂外动脉。通常情况下，在此种情况下需对髂内动脉进行弹簧圈栓塞以预防内漏。我们的做法是仅在紧邻髂内动脉起始部的髂总动脉内支架移植物密封不充分（有效密封整个髂内动脉起始部）的病例中对髂内动脉进行弹簧圈栓塞。在本研究中，我们评估了这种方法的效果。
我们回顾性分析了1996年至2001年在达特茅斯 - 希区柯克医疗中心连续进行的204例血管腔内腹主动脉瘤修复术。术前主要的影像学检查方式为计算机断层血管造影三维重建，在手术前，决定不对髂内动脉进行弹簧圈栓塞而直接覆盖髂内动脉是基于在髂总动脉最远端5毫米和髂外动脉近端15毫米处存在足够的移植物尺寸过大（≥10%至15%）。
31例患者中，髂内动脉被闭塞33次。22例（67%）患者的髂内动脉未进行弹簧圈栓塞而被覆盖（覆盖组）。其余11例（33%）髂总动脉移植物尺寸过大不足的患者接受了髂内动脉弹簧圈栓塞（弹簧圈组）。覆盖组和弹簧圈组的随访时间分别为19±2个月和10±3个月。两组所有手术在技术上均成功，血管造影完成时均无内漏迹象。随访期间，覆盖或栓塞的髂内动脉均未出现内漏、移植物移位或动脉瘤增大。覆盖组除6例患者（27%）出现臀部间歇性跛行，其中5例完全缓解外，未见其他临床后遗症。弹簧圈组有5例患者（45%）出现臀部间歇性跛行。此外，弹簧圈组发生1例臀部坏死和1例缺血性神经病变。
不进行弹簧圈栓塞而直接覆盖髂内动脉在每种情况下均能有效排除髂总动脉瘤，与弹簧圈栓塞相比，并发症发生率较低。通过详细的术前影像学检查和患者选择，在多达三分之二需要闭塞髂内动脉的患者中，可能无需进行髂内动脉弹簧圈栓塞。
