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Comparison Of Aneurysmal Sac Shrinkage In Patients Undergoing Bell-bottom Technique, Iliac Extension Or Iliac Branch Endoprosthesis
Donna Bahroloomi, MD, MPH, Khalil Qato, MD, Nhan Nguyen, BA, MPH, Allan Conway, MD, Deanna Schreiber-Gregory, MS, Gary Giangola, MD, Alfio Carroccio, MD.
Lenox Hill Hospital, New York, NY, USA.

OBJECTIVE: Aneurysmal extension of abdominal aortic aneurysms (AAA) to the common iliac artery (CIA) presents a technical challenge to successful endovascular repair of abdominal aortic aneurysm (EVAR). This study compares sac shrinkage and peri-operative outcomes following Bell-bottom technique (BBT), internal iliac embolization and external iliac artery extension (EIE) and Iliac Branch Endoprosthesis (IBE).
METHODS: Utilizing the Vascular Quality Initiative (VQI) database, a retrospective analysis was conducted for patients who underwent EVAR between 2013-2019. Demographic, anatomic, and peri-operative data were analyzed. All patients with proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. Patients were subdivided into four groups based on distal limb strategy: Group 1-control group with bilateral iliac limb <20mm, Group 2- Bell-bottom technique with either unilateral or bilateral limb >20mm, Group 3-external iliac artery extension, and Group 4-iliac branch endoprosthesis. The primary endpoint was maximal change in aortic diameter on follow-up. Secondary endpoints included post-operative complications and rates of endoleak.
RESULTS: 14,455 patients who underwent EVAR were queried and 5,788 met anatomic criteria. The average age was 73 and 86.3% were male. Compared to the control group, Iliac extension had similar rates of shrinkage, while BBT was 18.4% (OR 0.82 CI .68-.978) less likely to have aneurysmal shrinkage, and IBE was 48.4% less likely (OR .52 CI .33-.82) at a mean follow-up of 420 and 393 days, respectively. BBT and IBE had a significantly higher rate of type 2 endoleak (17.63% and 16.95%, p=0.03), while EIE had a higher rate of type 1B endoleaks. There was no difference between the groups in terms of post-operative MI (p=.47), respiratory (p=0.61) or intestinal complications (p=.71), but there were higher rates of limb complications and re-operation in the external iliac extension group (Table 1).
CONCLUSIONS: Patients with aneurysmal CIA, BBT and IBE have significantly less sac shrinkage compared to conventional EVAR, while iliac extension has similar rates of shrinkage with higher rates of limb-related complications.

VariablesBell-Bottom Iliac Branch Iliac-ExtensionNormal-controlP-value
n (%)n (%)n (%)n (%)
Population with criteria applied
Total1018 (17.6)165 (2.9)657 (11.4)3948 (68.2)
Type 1A Endoleak4 (0.9)0 (0)3 (0.95)13 (0.7).9
Type 1B Endoleak5 (1.1)1(1.7)6 (1.9)6 (0.3).01
Type 2 Endoleak82 (17.6)10 (17)43 (13.6)222 (12.4).03
Type 3 Endoleak0 (0)0 (0)0 (0)2 (0.1).8
Iliac Artery Injury11 (1.1)1 (0.6)26 (3.9)40 (1.0)<.0001
Leg Embolization3 (0.3)1 (0.6)14 (2.1)50 (0.9).01
Re-operation16 (1.57)1 (.6)25 (3.8)102(2.6.0002
Intestinal Ischemia5 (0.5)0 (0)8 (1.2)26 (0.7).2
Follow-up highest change, days (mean, SD)420.0 (170.9)393.3 (154.3)419.2 (208.9)407.1 (163.7).3
Follow-up highest sac change, diameters (mm) (means, SD)6.1 (10.9)4.6 (9.3)6.8 (11.1)7.2 (10.2).06

Table 1

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