Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT.
Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
Ann Vasc Surg. 2021 Nov;77:38-46. doi: 10.1016/j.avsg.2021.05.065. Epub 2021 Aug 26.
Endovascular treatment of complex common iliac artery (CIA) and internal iliac artery (IIA) aneurysms using iliac branch endoprostheses (IBE) has proven safe and effective. Instructions for use (IFU) require deployment of current IBE technology with the corresponding manufacturer's modular bifurcated aortic endograft. Concomitant aortoiliac occlusive disease, inadequate renal artery-iliac bifurcation length, and unfavorable aortic anatomy preclude on-label IBE deployment. This study aimed to evaluate the technical feasibility and safety of Alternative Endograft Aortoiliac Reconstruction (AEGAR) for branched endovascular treatment of complex iliac artery aneurysms.
In 7 consecutive patients with CIA or IIA aneurysms, computed tomography angiography (CTA) and center-line reconstruction revealed aortoiliac anatomy incompatible with the current IBE IFU due to inadequate proximal CIA landing zone (n = 7), inadequate renal artery to iliac bifurcation length (n = 2), compromised aortic anatomy (n = 3), or short infrarenal neck <15 mm (n = 1), either alone or in combination. To overcome these restrictions and facilitate IBE deployment, aortoiliac reconstruction was performed using the Endologix AFX, Endologix Ovation limbs or the Medtronic Endurant II platforms (AEGAR technique). All internal iliac artery reconstructions and external iliac artery extensions were performed using the Gore VBX or Viabahn stent grafts. Technical success was defined as successful delivery of all endograft components without migration or endoleak.
The mean patient age was 69 years (range 52-82 years; 6 male). Four patients had bilateral CIA aneurysms and 3 patients had unilateral CIA aneurysms (mean diameter 4.3cm; range 2.2-7 cm). There were 13 IIA VBX stent grafts used for a total of 9 IIAs treated with IBE (bilateral IBE = 2 patients). The mean fluoroscopy time was 38.8 min (range 21.3-64.3 min) and the mean contrast volume was 168.5 mL (range 122-226 mL). Technical success was achieved in all patients and there were no perioperative complications. Mean hospital-stay was 2.2 days (range 1-3 days). Follow-up ranged from 82-957 days (mean = 487 days). At last follow-up, all patients were alive without cardiovascular morbidity; and CTA revealed stable or decreased aneurysm size, patent endografts, and no evidence of endoleak or migration.
The AEGAR technique can be used to safely and effectively overcome certain aortoiliac anatomic constraints that preclude use of current IBE technology. We encourage broader use of these alternative endografts in pertinent anatomic configurations.
使用髂分支覆膜支架（IBE）对复杂的髂总动脉（CIA）和髂内动脉（IIA）动脉瘤进行血管内治疗已被证明是安全有效的。使用说明（IFU）要求使用相应制造商的模块化分叉主动脉覆膜支架来部署当前的 IBE 技术。同时存在腹主动脉髂动脉闭塞性疾病、肾动脉-髂动脉分叉长度不足和不利的主动脉解剖结构会妨碍标签内 IBE 的部署。本研究旨在评估替代血管内重建髂动脉分叉重建术（AEGAR）用于分支血管内治疗复杂髂动脉动脉瘤的技术可行性和安全性。
在 7 例 CIA 或 IIA 动脉瘤患者中，计算机断层血管造影（CTA）和中心线重建显示，由于近端 CIA 着陆区不足（n=7）、肾动脉至髂动脉分叉长度不足（n=2）、主动脉解剖结构受损（n=3）或短肾下颈<15mm（n=1），主动脉髂动脉解剖结构与当前 IBE IFU 不兼容，这些限制单独或联合存在，妨碍了 IBE 的部署。为了克服这些限制并促进 IBE 的部署，使用 Endologix AFX、Endologix Ovation 分支或 Medtronic Endurant II 平台（AEGAR 技术）进行了腹主动脉髂动脉重建。所有髂内动脉重建和髂外动脉延伸均使用 Gore VBX 或 Viabahn 支架移植物进行。技术成功定义为所有移植物组件均成功输送，无迁移或内漏。
患者平均年龄为 69 岁（52-82 岁；6 名男性）。4 例患者为双侧 CIA 动脉瘤，3 例患者为单侧 CIA 动脉瘤（平均直径 4.3cm；范围 2.2-7cm）。共使用 13 个 IIA VBX 支架移植物治疗 9 个 IIA（双侧 IBE=2 例）。平均透视时间为 38.8 分钟（范围 21.3-64.3 分钟），平均造影剂用量为 168.5ml（范围 122-226ml）。所有患者均成功实现技术成功，且无围手术期并发症。平均住院时间为 2.2 天（范围 1-3 天）。随访时间为 82-957 天（平均 487 天）。最后一次随访时，所有患者均存活且无心血管疾病；CTA 显示动脉瘤大小稳定或减小，移植物通畅，无内漏或迁移证据。
AEGAR 技术可安全有效地克服某些妨碍当前 IBE 技术使用的主动脉髂动脉解剖结构限制。我们鼓励在相关解剖结构中更广泛地使用这些替代移植物。
