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.
| Variables | Bell-Bottom | Iliac Branch | Iliac-Extension | Normal-control | P-value | ||||
| n (%) | n (%) | n (%) | n (%) | ||||||
| Population with criteria applied | |||||||||
| Total | 1018 (17.6) | 165 (2.9) | 657 (11.4) | 3948 (68.2) | |||||
| Type 1A Endoleak | 4 (0.9) | 0 (0) | 3 (0.95) | 13 (0.7) | .9 | ||||
| Type 1B Endoleak | 5 (1.1) | 1(1.7) | 6 (1.9) | 6 (0.3) | .01 | ||||
| Type 2 Endoleak | 82 (17.6) | 10 (17) | 43 (13.6) | 222 (12.4) | .03 | ||||
| Type 3 Endoleak | 0 (0) | 0 (0) | 0 (0) | 2 (0.1) | .8 | ||||
| Iliac Artery Injury | 11 (1.1) | 1 (0.6) | 26 (3.9) | 40 (1.0) | <.0001 | ||||
| Leg Embolization | 3 (0.3) | 1 (0.6) | 14 (2.1) | 50 (0.9) | .01 | ||||
| Re-operation | 16 (1.57) | 1 (.6) | 25 (3.8) | 102(2.6 | .0002 | ||||
| Intestinal Ischemia | 5 (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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