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Bifurcated aortic stent grafts are safe and effective for endovascular repair of aortic aneurysms in patients with narrow distal aortic bifurcations - Aorto-iliac converters are rarely needed in the current era
Veljko Strajina, MD, Gustavo S. Oderich, MD, Javariah Fatima, MD, Peter Gloviczki, MD, Audra A. Duncan, MD, Manju Kalra, MBBS, Mark Flemming, MD, Thanila A. Macedo, MD, Thomas C. Bower, MD.
Mayo Clinic, Rochester, MN, USA.

Objectives: Endovascular aortic aneurysm repair (EVAR) in patients with narrow distal aortic bifurcations can be complicated by inability to access the contra-lateral gate, iliac limb compression or aortic disruption. This study analyzes outcomes of EVAR using bifurcated stent grafts or aorto-uni-iliac converters in patients with narrow distal aortic bifurcation.
Methods: We reviewed the clinical data of 1070 patients who underwent EVAR between 2000-2011. Digital computed tomographic angiography (CTA) was analyzed using centerline of flow measurements to determine aortic diameters. Patients with diameter ≤18mm at the distal aortic bifurcation (AoB) were included in the study. End-points were technical success, aortic disruption with retroperitoneal hemorrhage, stent-graft complications (endoleaks, migration, sac enlargement, stenosis), re-intervention and iliac limb patency.
Results: There were 112 patients (84 males and 28 females; mean age, 75 years) with AoB ≤18mm treated by EVAR, including 34 (30%) who had diameter ≤14mm. Mean outer and inner AoB diameter was 16±3 and 14±2mm, respectively. Bifurcated stent grafts were used in 106 patients (95%). Six patients (5%) treated prior to 2005 had planned aorto-uni-iliac converter with femoral crossover graft. The aortic bifurcation was dilated after placement of bifurcated stent grafts using ‘kissing’ balloon angioplasty in 80 patients (75%). All bifurcated stent grafts were successfully implanted with no conversions to open repair or aorto-uni-iliac converters. There was one early death (0.8%) and 12 patients (11%) developed early complications. There were no aortic disruptions or retroperitoneal hematomas. After a median follow up of 34 months, 11 patients (11%) treated by bifurcated stent grafts required re-intervention to treat endoleak in 6 or iliac limb stenosis/occlusion in 5; one patient (17%) treated by aorto-uni-iliac converter required femoral crossover graft revision for restenosis. At 3-years, freedom from stent-graft complication or re-intervention was 91±6% and 91±6% for bifurcated stent grafts, and 83±10% and 83±10% for aorto-uni-iliac converters (P=NS). Primary and secondary iliac limb patency was 98±3% and 100% for bifurcated stent grafts and 83±10% and 100% for aorto-uni-iliac converters, respectively (P=NS).
Conclusion: Endovascular aortic aneurysm repair in patients with narrow distal aortic diameter is safe and effective using bifurcated stent grafts, even when the aortic bifurcation measures ≤14mm. Using adjunctive balloon dilatation, there were no bleeding complications from aortic disruption and limb patency was excellent. Aorto-uni-iliac converters are rarely needed for this indication.


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