Long-Term Outcomes of Staged Iliofemoral Endoconduits Prior to Complex Endovascular Aortic Aneurysm Repair.

OBJECTIVES: Adverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (EC) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral EC prior to complex EVAR.

METHODS: Between 2012 and 2023, 59 patients (44% male, median age 75±6 years) underwent EC before complex EVAR using self-expanding covered (Viabahn). For CFA disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery (IIA) patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency.

RESULTS: Unilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac (CIA), external iliac (EIA), and CFA were 7 mm (IQR, 6-8), 6 mm (IQR, 5-7), and 6 mm (IQR, 6-7), respectively. IIA was inadvertently excluded in 10 (17%) patients. Six (10%) patients had an intraoperative vascular injury during the EC procedure, and six (10%) patients had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. 22 Fr OD devices were used in 23 (39%) patients, 20 Fr in 22 (37%), and 18 Fr in 14 (24%). Technical success for accessing EC was 89%. There was no difference in MAEs at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82% respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six (10%) secondary interventions were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up.

CONCLUSION: Endoconduits improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the endoconduit directly under ultrasound guidance and using sequential dilation to avoid endoconduit disruption.