Larger Iliac Graft Diameters During Standard Endovascular Aortic Repair Are Associated With Increasing Rates Of Type Ib Endoleak
Xuan-Binh (Ben) Pham, MD, Celine Deslarzes-Dubuis, MD, Kimberly A. Thompson, MD, Graeme McFarland, MD, Kenneth Tran, MD, Jason T. Lee, MD.
Stanford University, Stanford, CA, USA.
OBJECTIVES: Patients with abdominal aortic aneurysm (AAA) and concomitant iliac artery dilation are frequently treated with endovascular aortic repair (EVAR) with flared limbs. The development of FDA-approved iliac branch devices has required we re-evaluate options in these patients. The aim of this study is to evaluate the long-term outcomes of ectatic common iliac arteries treated with EVAR.
METHODS: We retrospectively reviewed a prospectively maintained database of consecutive adult patients undergoing elective standard EVAR for infrarenal AAA at a single institution. We excluded patients undergoing coil embolization and extension into the external iliac, sandwich techniques, and use of branched devices. We classified common iliac artery ectasia/dilation as those vessels which required an iliac limb graft diameter >18-mm. Primary outcome was the presence of a type Ib endoleak >30-days following an initial successful repair.
RESULTS: Between 2000 and 2016, 754 patients (median age 76.6-years, 85% male) underwent standard EVAR, with 1508 limbs treated and 1401 (93%) with available imaging included in the analysis. Mean follow up was 35 months. Of the 1401 limbs, 996 (71%) were normal diameter (<18-mm) and 405 (29%) were large diameter (>18-mm). Large diameter limbs had significantly higher rates of type Ib endoleak compared to normal diameter limbs (3.5% vs 0.4%, OR 8.9; 95%CI 2.9-27), P<0.0001). Mean time to endoleak was 45 months. One patient re-presented as a mortality due to rupture, all other patients found to have an endoleak underwent re-intervention and subsequently did well.
CONCLUSIONS: Larger iliac graft diameter is associated with a nine-fold increase in the rate of type Ib endoleak with a mean time-to-leak of four years. When planning standard EVAR with flared limbs, careful consideration of iliac landing zone strategies, particularly in younger patients, is important for durable long-term freedom from re-intervention.
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