Mansukhani Neel A, Havelka George E, Helenowski Irene B, Rodriguez Heron E, Hoel Andrew W, Eskandari Mark K
Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL.
Department of Surgery, Northwestern University, Chicago, IL.
Ann Vasc Surg. 2017 Jul;42:162-168. doi: 10.1016/j.avsg.2016.10.052. Epub 2017 Mar 8.
Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass.
Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded.
The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent.
Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.
在单纯性血管腔内髂总动脉瘤（CIAA）修复术或腹主动脉瘤血管腔内修复术（EVAR）期间，因故意覆盖/栓塞髂内动脉（IIA）导致盆腔动脉血流减少，可能会引发有症状的盆腔缺血。尽管通常耐受性良好，但在严重情况下，盆腔缺血可能表现为顽固性臀部间歇性跛行、血管性阳痿或会阴、膀胱、直肠和/或脊髓缺血。分支移植物技术最近已可用；然而，许多患者并不适合使用这些装置进行血管腔内修复。因此，需要保留盆腔动脉血流的技术。我们回顾了我们在单纯性血管腔内CIAA修复术或EVAR联合单侧髂外-髂内动脉旁路移植术的治疗结果。
对2006年至2015年间连续10例接受杂交血管腔内腹主动脉瘤（AAA）或CIAA修复术并同时进行髂外-髂内动脉旁路移植术的患者进行单中心回顾性研究。记录患者的人口统计学资料、手术细节、术后症状、住院时间（LOS）、随访影像学检查结果以及旁路移植血管的通畅情况。
10例患者均为男性，平均年龄71岁（范围：56 - 84岁）。杂交修复术包括对侧IIA线圈栓塞，随后进行EVAR并同时进行髂外动脉-髂内动脉（EIA-IIA）旁路移植术。所有EIA-IIA旁路移植术均通过标准的下腹部腹膜后入路使用人工旁路移植物进行。技术成功率为100%，且无围手术期死亡病例。1例患者出现短暂性截瘫，1例患者在其髂动脉旁路移植术对侧的髂内动脉栓塞侧出现臀部间歇性跛行，1例患者出现术后阳痿。20%的患者出现长期并发症（臀部间歇性跛行和术后阳痿）。平均住院时间为2.8天（范围：1 - 9天）。90%的患者进行了术后影像学检查，平均随访时间为10.8个月（范围：0.5 - 36个月）。所有旁路移植血管均保持通畅。
尽管分支移植物技术不断发展，但维持充足盆腔循环的策略对于避免盆腔缺血的灾难性并发症是必要的。我们已经证明，一种将EVAR或单纯性血管腔内髂总动脉隔绝术与通过腹膜后入路进行的单侧髂外-髂内动脉旁路移植术相结合的杂交方法耐受性良好，住院时间短且通畅率高。
