The Leipzig Interventional Course 2015

January 27–30, 2015

Disclosure

Speaker name:

Mr PAUL BACHOO

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

X I do not have any potential conflict of interest

Clinical considerations in preserving the hypogastric arteries with bilateral treatment. Is there need for an iliac branch system

Innovative solutions for the challenging landing zone in the iliac and thoraco-abdominal segment

Mr. Paul Bachoo

Consultant Vascular

Surgeon

Aberdeen

Scotland

Pathogenesis similar to AAA

M:F 5-16:1

20% of AAA pts will have iliac aneurysm disease 50% bilateral Median expansion rate CIA is 0.29 cm/y

Risk of rupture: 3-4cm: 5-10% over 5yrs >4cm: 10 – 70% over 5 yrs

Background - CIA

Huang Y et al. J Vasc Surg 2008;47:1203-11

Proximal challenges

Distal challenges

Higher incidence of distal type I endoleak, an increased need for secondary interventions, and a higher incidence of aneurysm rupture but similar mortality following EVAR in AAA patients with concomitant CIA aneurysm disease compared with EVAR of simple AAA.

Hobo et al. J Endovas Therapy 2008;15:12–22

The next challenge

Preserving flow into IIA

First clinical consideration

LAND IN A LARGE CIA ?

Is a dilated iliac artery an appropriate landing zone?

Preserving flow into IIA by maintaining the CIA

bifurcation

No

Due to the risk of future dilatation and risk of rupture

Emergency intervention

The internal iliac artery may be preserved by landing an endograft in a dilated or aneurysmal common Iliac

artery and whilst the immediate result may be satisfactory and the vessel(s) subjected to reduced expansible forces the risk of rupture persists as the

aneurysmal biology persists.

Second clinical consideration

If landing in the EIA is Best what do we do with the IIA ?

Exclude flow into IIA

Third clinical consideration

If IIA is sacrificed what clinical outcome can we expect ?

What we have learned from the option of hypogastric artery

embolization during endovascular treatment of aorto-iliac

aneurysm repair is

ISCHAEMIA

Gluteal

Genital

Bowel

Sciatic Nerve

Spinal cord

Bladder dysfunction

Decubitus ulcer

Literature review of patients developing gluteal

claudication / erectile dysfunction after IIA

EMBO

Catheter-directed coil embolization of the

hypogastric artery

• Formation of minute fragments of thrombus because of the presence of foreign bodies

• Propagation of these small thrombi into the capillary beds may prevent adequate collateral vessel formation at the precapillary level

• Irreversible tissue damage can occur when the terminal capillary blood flow is compromised

• Particularly in patients with underlying atherosclerotic disease

The results were pooled to give

n=634 patients

Buttock claudication = 28% overall (178 of 634 patients)

Unilateral embolization in 31% of (99 of 322)

Bilateral embolization and 35% of (34 of 98)

New erectile dysfunction occurred 17% overall (27 of 159 patients):

Unilateral embolization 17% (16 of 97)

Bilateral embolization 24% (9 of 38)

Meta analysis of Literature review of patients developing gluteal claudication / erectile dysfunction

after IIA EMBO

Rayt HS et al.Cardiovasc Intervent Radiol. 2008;31(4):728-34

• Age

• Low cardiac function

• CAD

• 70% stenosis of the origin of the contra lateral hypogastric artery

• Absence of filling of three or more named hypogastric branches

• Disease or absence of ascending branches from the Femoral and External Iliac Artery

• Disease or absence of Profunda Femoris Artery

Likely prognostic factors in developing

ischaemic symptoms after EMBO

Few successful remedial interventions

Fourth clinical consideration

In bilateral cases can we improve patient outcome

by sacrificing one IIA and salvaging the other

Pelvic Hemodynamic Alterations: preoperative

and postoperative penile-brachial index(PBI)

and pulse-volume recording assessment

• Prospective study

• Incidence rate

Erectile dysfunction 45%

Claudication 50%

• Specifically, mean reductions in PBI after unilateral and bilateral

hypogastric artery embolization were 13% and 39% (P <0.05).

Lin PH et al: J Vasc Surg 36:500-506, 2002

The principle can be achieved with several

endovascular techniques

Courtesy of Oderich GS Mayo Clinic

IIA bypass

Sandwich

BYPASS - EVAR with hypogastric flow

EVAR repairs n=444

CIA component n=137 (31%)

Bell bottom repair n=80 (58%) Treatment group n=57 (42%)

Bilateral n=12 EMBO & EMBO+BYPASS

EMBO n=31(69%) : EMBO + BYPASS n=14 (31%)

Single n=45

SURGICAL

Lee WA etal. J Vasc Surg: 44(6); 1162-8

Results

Lee WA etal. J Vasc Surg: 44(6); 1162-8

Sandwich - Male 79yr - Aberdeen

Preoperative

Right iliac sandwich /Left IIA occlusion @12

months Left Gluteal claudication

Right iliac sandwich occlusion @18 months c/o

Bilateral Gluteal claudication

Occlusion of IIA graft

Not always the chimney that lets you down

Female 66yr - Aberdeen

18 moths Preoperative

Alternative solution

Summary

Identify a suitable distal iliac landing zone of an

appropriate length and diameter in a non diseased vessel

to accommodate the endoluminal device minimizing the

risk of migration or endoleak.

Summary

Whether unilateral or bilateral IIA occlusion during

endovascular aortoiliac aneurysm repair (EVAR) is

performed, this procedure is not an innocuous step

and will very much adversely affect QoL post surgery.

Summary

Experimental data and a variety of clinical reported

outcomes testify to the concept of disturbed pelvic

hemodynamic blood flow which has no proven

corrective intervention. In the elderly with other

prognostic factors this may be significant.

In patients with bilateral CIA disease the symptoms are not completely prevented by preserving one IIA

Summary

Male 79yr

Conclusion

When treating a large asymptomatic aneurysm to

prevent death from rupture also remember QoL

Flow to IIA can be maintained by purpose built iliac

branch systems

• Date of Surgery: 18.12.13

• Date of Discharge: 21.12.13

• Procedure: Endovascular aneurysm repair using C3 Gore excluder and iliac branch endovascular device for left common iliac artery aneurysm

• FU @ 1yr – No Gluteal claudication

Conclusion

There is a need for an effective iliac branch system and

when required anatomically both IIA should be

preserved

Thank you

Mr Paul Bachoo

Consultant Vascular Surgeon

Aberdeen

Scotland