The Risk of Hypogastric Artery Loss During Treatment of Iliac Artery Occlusive Disease
Charlotte Horne, MD, Kristen Boucher, James Bena, Christopher Smolock, MD.
Cleveland Clinic, Cleveland, OH, USA.
Objective: Iliac arterial occlusive disease poses a unique challenge regarding endovascular management of the common iliac artery bifurcation extending to the external iliac artery. Disease here may necessitate coverage of the hypogastric artery or leaving distal common and/or proximal external iliac artery stenoses untreated. From treatment of aneurysmal disease, it is known that planned procedural embolization of the hypogastric artery prior to coverage can results in symptomatic hypoperfusion in approximately up to 50% of patients. We sought to delineate hypogastric patency after coverage with a bare-metal stent, which is unknown in the treatment of occlusive disease.
Methods: A retrospective analysis of patients undergoing interventions involving the ileofemoral arteries from 2008-2015 at a single institution was conducted. Inclusion criteria were patients with a patent hypogastric artery prior to intervention, who had a bare-metal stent placed over the patent hypogastric artery from common to external iliac artery, along with follow up imaging. Patient factors, pre-treatment hypogastric origin degree of stenosis, and post-treatment hypogastric artery patency were analyzed. Categorical factors were summarized using frequencies and percentages; continuous measures are described using means and standard deviations. Kaplan-Meier estimates and Cox proportional hazard models were used to describe the risk of hypogastric patency loss across factors.
Results: A total of 82 events in 58 patients were analyzed. The majority (63%) of patients had hypogastric origin stenosis </=of 50% or less. A total of 23 hypogastric vessels (28%) lost patency during 3-year follow up (Table) with patency rate at 6 months, 1 year and 3 years of 91.8%, 88.2% and 66.9% respectively. The degree of hypogastric stenosis prior to intervention was not associated with loss of patency.
The presence of an AAA aneurysmal disease was associated with hypogastric patency loss; however, the degree of stenosis prior to intervention was not. Patients on statins were less likely to lose patency.
Conclusion: Coverage of the hypogastric artery results in significant loss of hypogastric patency despite majority of these vessels being without significant stenoses pre-treatment. Symptoms after coverage and comparison to matched controls still require evaluation.
Table. Patency Estimates for Hypogastric Arteries with Bare-metal Stent Coverage
| Factor | Group | Frequency | Patency 6 Months | Patency Year 1 | Patency Year 3 | Hazard Ratio (95% CI) | Overall | |||||||||||||||||
| All Hypogastric | 82 | 91.8 (85.6, 98.1) | 88.2 (80.3, 96.0) | 66.9 (52.0, 81.8) | ||||||||||||||||||||
| Sex | Male | 37 | 91.3 (82.4, 100.0) | 84.0 (72.0, 98.1) | 64.8 (44.8, 93.8) | 1.00 | 0.90 | |||||||||||||||||
| Female | 41 | 92.5 (84.6, 100.0) | 92.5 (84.6, 100.0) | 68.9 (52.1, 91.2) | 1.06 (0.40, 2.82) | . | ||||||||||||||||||
| Diabetes | No | 41 | 94.5 (87.3, 100.0) | 94.5 (87.3, 100.0) | 60.5 (41.0, 89.2) | 1.00 | 0.90 | |||||||||||||||||
| Yes | 35 | 88.3 (78.1, 99.8) | 80.9 (68.1, 96.1) | 72.4 (57.5, 91.2) | 0.94 (0.34, 2.59) | . | ||||||||||||||||||
| CHF | No | 63 | 89.8 (82.3, 97.9) | 85.0 (75.8, 95.4) | 63.7 (48.8, 83.3) | 1.00 | 0.54 | |||||||||||||||||
| Yes | 15 | 100.0 (100.0, 100.0) | 100.0 (100.0, 100.0) | 83.3 (64.7, 100.0) | 0.64 (0.16, 2.64) | . | ||||||||||||||||||
| Statin | No | 18 | 93.8 (82.6, 100.0) | 85.9 (69.5, 100.0) | 40.1 (16.0, 100.0) | 1.00 | 0.010 | |||||||||||||||||
| Yes | 60 | 91.2 (84.2, 98.9) | 88.8 (80.7, 97.8) | 74.1 (60.1, 91.4) | 0.31 (0.13, 0.75) | . | ||||||||||||||||||
| Ambulatory | No | 16 | 87.5 (72.7, 100.0) | 87.5 (72.7, 100.0) | 65.6 (42.2, 100.0) | 1.00 | 0.45 | |||||||||||||||||
| Yes | 62 | 93.1 (86.7, 99.9) | 88.6 (80.4, 97.8) | 69.0 (54.8, 86.9) | 0.64 (0.21, 2.02) | . | ||||||||||||||||||
| Actively smoking | No | 57 | 90.9 (83.6, 98.9) | 86.1 (76.9, 96.4) | 63.3 (47.1, 85.0) | 1.00 | 0.24 | |||||||||||||||||
| Yes | 20 | 94.4 (84.4, 100.0) | 94.4 (84.4, 100.0) | 75.1 (53.4, 100.0) | 0.44 (0.11, 1.75) | . | ||||||||||||||||||
| AAA | No | 47 | 95.0 (88.4, 100.0) | 91.8 (83.3, 100.0) | 80.3 (65.2, 99.0) | 1.00 | 0.016 | |||||||||||||||||
| Yes | 31 | 86.8 (75.6, 99.8) | 82.5 (69.5, 97.9) | 43.7 (22.4, 85.0) | 3.67 (1.27, 10.58) | . | ||||||||||||||||||
| Antiplatelet | No | 19 | 68.4 (50.4, 92.9) | 68.4 (50.4, 92.9) | 51.3 (31.0, 84.9) | 1.00 | 0.22 | |||||||||||||||||
| Aspirin | 32 | 100.0 (100.0, 100.0) | 100.0 (100.0, 100.0) | 73.5 (53.1, 100.0) | 0.35 (0.11, 1.16) | . | ||||||||||||||||||
| Aspirin+Plavix | 14 | 100.0 (100.0, 100.0) | 100.0 (100.0, 100.0) | 85.7 (63.3, 100.0) | 0.16 (0.02, 1.45) | . | ||||||||||||||||||
| Plavix | 13 | 100.0 (100.0, 100.0) | 77.8 (54.9, 100.0) | 62.2 (35.5, 100.0) | 0.36 (0.08, 1.76) | . | ||||||||||||||||||
| Coumadin | No | 60 | 93.2 (86.9, 99.9) | 88.5 (80.1, 97.8) | 59.2 (42.8, 81.8) | 1.00 | 0.53 | |||||||||||||||||
| Yes | 18 | 87.7 (73.0, 100.0) | 87.7 (73.0, 100.0) | 87.7 (73.0, 100.0) | 0.70 (0.23, 2.12) | . | ||||||||||||||||||
| Ipsilateral Symptoms | No | 8 | 100.0 (100.0, 100.0) | 80.0 (51.6, 100.0) | 53.3 (21.4, 100.0) | 1.00 | 0.83 | |||||||||||||||||
| Yes | 62 | 91.4 (84.5, 98.9) | 89.1 (81.2, 97.9) | 71.4 (56.8, 89.7) | 0.86 (0.21, 3.52) | . | ||||||||||||||||||
| Pre-Hypo Stenosis | 50% or less | 52 | 92.2 (85.2, 99.8) | 89.7 (81.4, 98.8) | 76.5 (63.4, 92.3) | 1.00 | 0.32 | |||||||||||||||||
| 75% or more | 26 | 91.6 (81.0, 100.0) | 85.0 (70.3, 100.0) | 35.4 (12.7, 99.2) | 1.65 (0.62, 4.42) | . | ||||||||||||||||||
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