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Management of Difficult Access During EVAR
Yana Etkin, MD1, Ksenia Orlova, MD, PhD1, Paul J. Foley, III, MD1, Grace J. Wang, MD1, Edward Y. Woo, MD2, Jeffrey P. Carpenter, MD3, Ronald M. Fairman, MD1, Benjamin M. Jackson, MD1.
1Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 2MedStar Health, Washington DC, DC, USA, 3Cooper University Hospital, Camden, NJ, USA.
OBJECTIVES:
To describe a large single institutional experience in managing challenging access situations during EVAR.
METHODS:
Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access, and outcomes. The median follow-up was 38 months. Difficult access (DA) was defined as having diameter of iliac arteries smaller than 7cm bilaterally. Fenestrated and snorkel repairs were excluded.
RESULTS:
Out of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of these, 42 patients (22%) underwent adjuncts prior to introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 AUI devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown and 3 iliac stents. In another 35 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 48mm in the group of patients requiring adjuncts and 54mm in the rest of the patients with small iliac arteries (p=.008). The average size of the main body device was 28mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3(1.6%) limb ischemia, 5 (2.6%) need for early reoperation. Two patients (1%) had type I endoleaks at the conclusion their EVAR. During follow-up, 12 (6.3%) of patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (p=0.12).
CONCLUSIONS:
EVAR can be successfully performed even in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients, and should definitely be considered in patients with iliac arteries less than 50mm in diameter. Next generation and “low-profile” devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.
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