Post on 06-Jan-2020
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Endovascular treatmentof aortoiliac aneurysms: is hypogastric artery
preservation the new standard of care?
G Pratesi, MD
Vascular and Endovascular SurgeryIRCCS Policlinico San Martino - University of Genoa
Chief: Prof. D Palombo
Disclosures
Speaker name:
Giovanni Pratesi
I have the following potential conflicts of interest to report:
• Consulting: Abbott, Cook, Cordis, Medtronic, WL Gore & Associates, Terumo Aortic
• Employment in industry
• Stockholder of a healthcare company
• Owner of a healthcare company
• Other(s)
• I do not have any potential conflict of interest
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Hypogastric artery preservation with iliac branch devicehas reached a state of maturity
• Learning curves in the selection of patients and performance of the procedure
• Dedicated endograft
• High technical success
• Low risk of graft-related reintervention rate
• Improved clinical outcomes and quality of life
Eur J Vasc Endovasc Surg 2013
Vascular Surgery – University of Florence, University of Rome “Tor Vergata”
700 EVAR: 85 branch endograft (12.1%)(September 2007 – August 2012)
4-year outcome N %
Non-AAA related mortality 7 8.6
Branch occlusion -
Iliac endoleak -
Reinterventions 3 3.7
CIAA shrinkage 43 53.1
Non IBD limb occlusion -
Buttock claudication 7 8.6
Donas et al. JET 2017
650 iliac branch in 575 Pts between 2005 and 2015; mean follow-up 32.6±9.9
• 621 Cook ZBIS, 29 Gore IBE
• Overall postop reintervention rate 8.9%
• 30 (4.6%) EIA or CIA occlusion
• 28 (4.3%) type I EL
Simple coverage of the IIA may result in significantly fewer major complications compared to embolization; at the same time, the rates
of endoleaks and reinterventions are similar between groups
“…Regardless of the technique used, IIA interruption during EVAR have a significant risk of persistent ischemic
complications.”
“…IIA preservation techniques denote a significant improvement in the treatment of aorto-iliac aneurysms and
should be carefully considered when exclusion of an iliac aneurysm is needed.”
Chaikof EL et al., J Vasc Surg 2018
Eur J Vasc Endovasc Surg 2019
Hypogastric artery preservation with iliac branch device:standard of care for unilateral, bilateral, isolated
Bilateral iliac artery aneurysm:hypogastric preservation with iliac branch device
Isolated iliac artery aneurysm:hypogastric preservation with iliac branch device
Isolated iliac artery aneurysm:hypogastric preservation with iliac branch device
J Vasc Surg 2018
Pelvis Registry• 910 IBDs in 804 patients underwent EVAR for aorto-iliac aneurysm• 9 high-volume European vascular centers• January 2005 and April 2017
231 IBDs were implanted in 207 patientsto treat an isolated common iliac aneurysm
91 isolated IBDs(group 1)
140 IBDs+bifurcated EG(group 2)
Long-term outcomes
Group 1(91 isolated IBDs)
Group 2(140 IBDs+bif EG)
p
Overall mortality 13 (14.3%) 14 (10%) .31
Aneurysm-related mortality 1 (1.1%) 1 (0.7%) .77
Type 1 A-B endoleak 4 (4.4%) 8 (6.1%) .66
Type III endoleak 2 (2.2%) 2 (1.4%) .65
IBD occlusions 5 (5.5%) 8 (5.7%) .96
Isolated target IIA occlusions 2 (2.2%) 2 (1.4%) .65
Isolated EIA occlusions - 4 (2.8%) .11
All-cause reinterventions 14 (15.8%) 26 (18.6%) .53
Conversion to OSR 1 (1.1%) 2 (1.4%) .83
Long-term results
Long-term results
• Tortuous iliac anatomy
• Aneurysmal involvement of hypogastric artery
• “Challenging” iliac bifurcation (diameter, take off angulation)
• Small access vessels
Endovascular preservation of hypogastric artery:technical and anatomical challenges
Eur J Vasc Endovasc Surg 2013
85 EVAR procedures with IBD in 81 pts between 2007 and 2012
IBD-related reintervention
OR p
Ectatic IAA > 10 mm 3.4 .001
BE vs SE stent 2.5 .2
39 vs 59 mm stent .9 .78
ZBIS-45 vs ZBIS-61 1.2 .18
ZBIS-10 vs ZBIS-12 1 .16
650 iliac branch in 575 Pts between 2005 and 2015; mean follow-up 32.6±9.9
• 621 Cook ZBIS, 29 Gore IBE• Overall postop reintervention rate 8.9%
- 4.6% EIA or CIA occlusion- 4.3% type I EL
Distal sealing zone in iliac branch:need for a healthy hypogastric artery
Donas KP et al., J Vasc Surg 2018
HA group(n=310)
Non HA group
(n=595)p
IBD-related type I EL 3% .7% .019
Buttock claudication 2.2% 5.3% .019
IBD-related migration 0.2% 1.9% <.001
5-year freedom from IBD-related typeI EL
93% 98% .006
Overtaking technical and anatomical challenges with IBD: advanced imaging techniques
Overtaking technical and anatomical challenges with IBD: advanced imaging techniques
Overtaking technical and anatomical challenges with IBD: more conformable devices
GORE® EXCLUDER® Iliac Branch Endoprosthesis
Della Schiava N et al., Ann Vasc Surg 2016
• Monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS• Three indices of tortuosity measured with EndoSize: common iliac artery
(CIA), pelvic artery index (PAI), and the double iliac sign (DIS)• The centerline lengths of the iliac axis and the IIA were measured by 2
different operators as a blind fashion
IBE, more conformable with the anatomy of the patient, could decrease the incidence of graft related complication due to anatomical constraints
Technical and anatomical challenges in IBD: external iliac tortuosity
Hypogastric preservation:IBE in external iliac tortuosity
IBE in external iliac tortuosity:expanding iliac branch applicability
Technical and anatomical challenges in IBD:hypogastric aneurysm
• MV, male, 65 yrs• Bilateral CIAA (60 mm
Rt side; 45 mm Lt side)
• Bilateral IIAA (37 mm Rt side; 25 mm Lt side)
IBE in Hypogastric aneurysm:anterior branch embolization +
posterior branch stenting
IBE in hypogastric aneurysm:expanding iliac branch applicability
Technical and anatomical challenges in IBD:Cook’s ZBIS vs Gore’s IBE
◼ Cook IBD:− Longitudinal indipendent stainless
steel stent− Different proximal lengths, with
longer overlapping zones
− Need for an IIA mating stent
◼ Gore IBE:− Sinusoidal nitinol stent design− Increased conformability
− Dedicated IIA component
Aim of the study
To compare early and late outcomes of endovascular treatment of aorto-iliac aneurysms with two different dedicated iliac branch devices:
◼ Cook ZBIS(Cook Medical, Bloomington, In, USA)
◼ Gore IBE(W. L. Gore and Associates, Flagstaff, Ariz)
Study Group
180 iliac brancheddevices implantedbetween January2007 and December 2017
◼ 123 Cook ZBIS (Group 1)
◼ 57 Gore IBE (Group 2)
Comparison of the two groups was performed on the basis of a propensity score matching (1:1) analysis
Demographics and baseline characteristicsMatched Groups: 35 ZBIS vs 35 IBE
Clinical Features Group 1 (ZBIS; n=35) Group 2 (IBE; n=35) p
Mean age 72.9 ± 8.3 70.1 ± 8.7 .21
Male sex 35 (100%) 35 (100%) 1
Arterial hypertension 26 (74.3%) 30 (85.7%) .20
Hyperlipidemia 14 (40%) 16 (45.7%) .41
Diabetes mellitus 3 (8.6%) 2 (5.7%) .50
CAD 9 (25.7%) 9 (25.7%) 1
COPD 21 (60%) 21 (60%) 1
CKD 2 (5.7%) 2 (5.7%) 1
PAOD 1 (1.7%) 0 (-) .50
Anatomical Features Group 1 (ZBIS; n=35) Group 2 (IBE; n=35) p
Proximal neck diameter 23.3 ± 2.4 mm 23.1 ± 2.5 mm .78
Proximal neck lenght 25.1 ± 17.5 mm 26.1 ± 13.5 mm .81
Aortic diameter 43.3 ± 15.6 mm 48.9 ± 17 mm .18
Right CIA diameter 30.6 ± 11.5 mm 35.1 ± 15.1 mm .19
Left CIA diameter 27.8 ± 10.4 mm 30.1 ± 14.8 mm .49
CIA diameter on branched side 34.5 ± 9.1 mm 39.8 ± 14.7 mm .11IIA diameter on branched side 12.7± 6.1 mm 10.5 ± 5.6 mm .27
Perioperative Outcomes
Perioperative OutcomesGroup 1
(ZBIS; n=35)
Group 2
(IBE; n=35)p
Technical success 35 (100%) 35 (100%) 1
IBD - occlusion 1 (2.8%) (-) .49
IBD - Type I/III
endoleak(-) (-) 1
Adjunctive procedures 35 (28.2%) 240 (21.7%) .10
Conversion (-) (-) 1
Mortality (-) (-) 1
Outcomes at Follow-up
Outcomes at Follow-upGroup 1
(ZBIS; n=35)
Group 2
(IBE; n=35)p
Mortality 3 (8.6%) 4 (11.4%) .69
Aneurysm-related mortality 2 (5.7%) 1 (2.8%) .67
IBD occlusion 0 (-) 0 (-) 1
IBD-type I endoleak 1 (2.8%) 1 (2.8%) 1
IBD-type III endoleak 1 (2.8%) 1 (2.8%) 1
IBD-related reinterventions 2 (5.7%) 1 (2.8%) .57
Migration 1 (2.8%) 0 (-) .49
Bridging stent occlusion 0 (-) 0 (-) 1
Conversion to open surgery 2 (5.7%) 0 (-) .49
Mean follow-up was 46.7 months in group 1 (SD ± 36.3), 20.8 months in group 2 (SD ± 15.9); p <.001
Outcomes at Follow-up
86.8%
97.1%
p=.34, log-rank0.9
93.3%
97.1%
p=.81, log-rank0.5
Expanding hypogastric artery preservation:conformable endograft and bridging stent
Aorto-iliac aneurysm: challenging anatomyGore IBE with Viabahn VBX bridging stent
Aorto-iliac aneurysm: challenging anatomyGore Excluder endograft with active control
Aorto-iliac aneurysm: Excluder with active control andIBE with VBX bridging stent
Conclusions
◼ Hypogastric preservation with Iliac branch is the standard of care to preserve antegrade flow to IIAs, whenever anatomically feasible, during endovascular aneurysm repair involving the iliac bifurcation
◼ New generation branch endograft and bridging stents offer high conformability in challenging anatomies (stenosis, tortuousity, hypogastric aneurysm)
◼ Tailored iliac branch selection is crucial in overtaking technical and anatomical challenges of hypogastric preservation in the treatment of iliac aneurysmal disease