Safety of Iliac Conduits for Endovascular Aortic Repair: A Ten Year Single Center Review
Jarrad W. Rowse, MD, Katherine Morrow, James F. Bena, MS, Matthew J. Eagleton, MD, Federico E. Parodi, MD, Christopher J. Smolock, MD.
Cleveland Clinic, Cleveland, OH, USA.
Iliac conduits (IC) are used for challenging iliac access during endovascular aortic aneurysm repair with contradictory reports of safety and increased surgical complications, morbidity and mortality in national database reviews. The objective of this study is to examine outcomes related to IC placement prior to or concomitant with endovascular aortic aneurysm repair at a high volume single center.
A retrospective analysis of patients who underwent IC placement for endovascular aortic repair from 2006-2016 was conducted. Planned and unplanned as well as staged and concomitant IC for EVAR, TEVAR, and F/B-EVAR were included. Categorical factors were described using frequencies and percentages. Continuous measures were summarized in comparative tables. Comparisons between planned and unplanned groups and between those with and without a post-operative event were performed using Pearson chi-square tests, two-sample t-tests, and Wilcoxon rank sum tests.
A total of 126 patients underwent IC with 18 bilateral procedures for total of 144 IC in EVAR 14 (9.7%), TEVAR 38 (26.4%) or F/B-EVAR 92 (63.9%). Related 30-day mortality was 3 (2.1%); and major morbidity was return to OR 8 (5.6%), 4 for bleeding (2.8%), 3 reinterventions (2.1%), and 1 graft thrombosis (0.7%), 1 graft infection (0.7%), MI 4 (2.8%), respiratory failure 5 (3.5%), wound complications 12 (8.3%), renal injury 7 (4.9%) and progression to dialysis 3 (2.1%). 112 (77.8%) were planned IC and 65 (45.1%) were staged alone. ICs were done to accommodate 20-24F sheath sizes in 131 (91.0%) instances. Factors associated with unplanned IC were iliac rupture and inability to advance the endograft in arteries deemed size-appropriate preoperatively (p<0.001). Unplanned IC were associated with higher EBL (p<0.001), OR transfusion volume (p<0.001), and overall complication rates (p<0.05). Women (p<0.05), preoperative CKD (p<0.05), and concomitant IC (p<0.001) were associated with higher overall complication rates. Operative time, EBL, and OR transfusion volume were associated with increased rate of complications (p<0.05).
IC are a safe and viable option for high-risk patients with challenging iliac artery access for endovascular aortic aneurysm repair. IC are best performed in planned fashion as well as in a staged manner when feasible.
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