Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair

Enrico Gallitto, Mauro Gargiulo, Gianluca Faggioli, Rodolfo Pini, Chiara Mascoli, Antonio Freyrie, Stefano Ancetti, Andrea Stella
Journal of Vascular Surgery 2017, 66 (6): 1659-1667

OBJECTIVE: Fenestrated and branched endovascular aneurysm repair (FB-EVAR) is a valid option to treat juxtarenal and pararenal abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Because successful deployment depends on complex maneuvers, hostile iliac artery anatomy (HIA) can prejudice the FB-EVAR outcome. The aim of the study was to evaluate the impact of HIA on FB-EVAR outcome.

METHODS: Between 2010 and 2015, all patients undergoing FB-EVAR were prospectively categorized according to iliac anatomy (friendly iliac artery anatomy [FIA] or HIA). HIA was defined as the presence of one of the following: severe (>90-degree) iliac angle, extensive (>50%) iliac circumferential calcification, hemodynamic iliac stenosis or obstruction, external iliac artery diameter <7 mm, or previous aortoiliac/femoral graft. Early end points were technical success (absence of type I or type III endoleak, target visceral vessel [TVV] loss, conversion to open repair), intraoperative adjunctive maneuvers (IAMs; iliac percutaneous transluminal angioplasty/stenting, surgical iliac conduit, intra-aortic graft rotations, several attempts of TVV cannulation), intraoperative technical problems (iliac rupture, significant endograft twisting, difficult TVV cannulations, TVV injuries, TVV loss), and 30-day mortality. Follow-up end points were survival, TVV patency, and freedom from reintervention.

RESULTS: Ninety-four patients (male, 87%; age, 73 ± 6 years) with 59 (63%) juxtarenal and pararenal abdominal aortic aneurysms and 35 (37%) thoracoabdominal aortic aneurysms underwent FB-EVAR, for a total of 324 TVVs; 60 (64%) patients had HIA and 34 (36%) had FIA. Patients with HIA and FIA had similar preoperative clinical characteristics, except for coronary artery disease, peripheral artery occlusive disease, and American Society of Anesthesiologists class 4 (47% vs 24% [P = .03], 12% vs 0% [P = .04], and 28% vs 9% [P = .03], respectively). Technical success was 96% (HIA, 97%; FIA, 95%; P = .6). In HIA, adjunctive iliac procedures were performed in 32 cases (surgical conduit, 14 [15%]; percutaneous transluminal angioplasty/stenting, 27 [29%]). Endograft twisting and difficult TVV cannulation occurred in 13 (14%) and 33 (35%) cases, respectively (HIA 18% vs FIA 15% [P = .09]; HIA 28% vs FIA 21% [P = .03]). TVV cannulation failed in nine cases and injury occurred in five (TVV patency rate, 97.8%; HIA 94.7% vs FIA 98.3%; P = .3). One (1%) iliac rupture occurred in HIA, needing surgical repair. Overall, 44 (47%; HIA 55% vs FIA 25%; P = .03) IAMs were necessary. Perioperative mortality was 4% (HIA 3% vs FIA 5%; P = .9). At multivariate analysis, predictors of IAMs were external iliac diameter <7 mm (odds ratio [OR], 12.5; 95% confidence interval [CI], 2.2-71.4; P = .004) and extensive iliac calcifications (OR, 8.3; 95% CI, 1.4-50.0; P = .02). The mean follow-up was 24 ± 17 months, with an overall survival of 87% and 71% at 1 year and 3 years, respectively, significantly lower in HIA compared with FIA (at 3 years, HIA 60% vs FIA 92%; P = .02). On multivariate analysis, HIA was a significant predictor of late mortality (OR, 3.6; 95% CI, 1.1-13.2; P = .04). Freedom from reintervention (87%) and 3-year TVV patency (92%) were similar in the two groups.

CONCLUSIONS: HIA does not significantly affect the early outcome of FB-EVAR. However, in patients with HIA, procedures are technically more demanding and late mortality is increased. Iliac characteristics should be taken into account to correctly stratify the surgical risk in FB-EVAR.

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