Management Of Small Distal Aortic Diameters During Endovascular Aortic Aneurysm Repair
Nicholas Russo, MD, R. Clement Darling, III, MD, Jeffrey C. Hnath, MD.
Albany Medical Center Hospital, Albany, NY, USA.
Introduction: Small distal aortic diameters offer a challenge for bifurcated endovascular aortic aneurysm repairs (EVAR). Small aortic diameters can be a contraindication for bifurcated configurations secondary to limb compression and potential occlusion. Generally, these aneurysms are treated with aorto-unilateral iliac devices or open surgical reconstruction. The purpose of this study is to evaluate outcomes of placing kissing balloon mounted stents inside of bifurcated EVARs in small diameter distal aortas.
Methods: Retrospective review of prospectively maintained data was queried at a single tertiary care vascular center. A query for EVAR with kissing balloon mounted stents placed during the index procedure was reviewed from 2015-2020. Demographics, indications, operative details, long-term results were recorded and analyzed. Standard endovascular technique was utilized with balloon mounted stents deployed inside of the endograft limbs at the distal aorta and proximal common iliac arteries in kissing fashion to provide radial force to the EVAR limbs.
Results: 48 EVARs met criteria for inclusion between 2015 and 2020 that had kissing balloon mounted stents placed in small distal aortas. Demographics: 23 male (47.9%) mean age 73 years (range 55-91). Comorbidities: hypertension 77% (37/48), hyperlipidemia 64.6% (31/48), coronary artery disease 39.6% (19/48), diabetes 22.9% (11/48), COPD 39.6% (19/48), current smokers 39.6% (19/48), former smokers 25% (12/48), renal insufficiency 8.3% (4/48). Median follow up was 15 months (range 1 -50). Mean intra-operative estimated blood loss was 184mL (range 50- 1000). No perioperative deaths occurred. Maximum aortic aneurysm diameter was 9.0 cm with mean of 5.1 cm (range 3- 9). Median distal aortic diameter measured 15.9 cm (range 10 - 24.7). Endograft devices used: Medtronic 66.7% (32/48), Gore 29.2% (14/48), and Endologix 4.1% (2/48). Balloon mounted stents used: Boston Scientific Express 87.5% (42/48) and Gore VBX 12.5% (6/48). Median diameter of stents used was 10mm (range 8- 11). 3 limbs occluded during follow up 2/3 Medtronic and 1/3 Gore. Limb occlusions were treated with an ilio-femoral or femoral-femoral bypass. There were no major amputations. Conclusion: Small distal aortic diameter can be a contraindication to bifurcated EVAR configuration secondary to limb compression. Placement of large balloon mounted stents in kissing fashion in the distal aorta and proximal common iliac arteries as a radial force adjunct in endografts may serve to prevent limb compression and improve patency long term.
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