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Utility Of Balloon-expandable Covered Stents As Iliac Limbs In Endovascular Aortic Aneurysm Repair
Kiera Zehner, BS, Ziad Al Adas, MD, Grace Wang, MD, MSCE, FACS, DFSVS, Shang Loh, MD, Alexa Mazur, BS, Darren Schneider, MD.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: Tortuous, calcified, and stenotic/occluded iliac arteries can pose a challenge for iliac limb delivery and deployment during endovascular repair of aortic aneurysms (EVAR). The purpose of this study is to present our experience using balloon-expandable covered stents (BECS) as an alternative to commercially-available iliac limbs during EVAR procedures.
METHODS: From 2017 to 2025, BECS (VBX; W.L. Gore & Associates, Flagstaff, AZ) were used as an iliac limb for eighty-nine iliac arteries in sixty-four patients undergoing complex EVAR in a prospective, nonrandomized, investigator-sponsored Investigational Device Exemption (IDE). A BECS was used as an iliac limb when distal landing-zone diameter <16 mm in patients with occlusive disease or tortuosity that was deemed unfavorable for treatment using a commercially-available iliac limb. Cases in which a BECS was used with an iliac-branch-device or to reinforce or extend commercially available iliac limbs were excluded.
RESULTS: The mean age of patients treated with a BECS as an iliac limb was 74.0 years (range:61-89), and 45.3% were women. The mean distal landing zone diameter was 10.6 mm (range:5.6-15.6). BECS were delivered via axillary artery access for 15 iliac arteries (16.9%) and were delivered via femoral artery access for the remaining 74 (83.1%). A single BECS covered stent was used in 57 iliac arteries (64%) and 2 BECS were used in 32 iliac arteries (36%). The most used BECS size was 11 mm in diameter (62 iliac arteries;65.3%). BECS were implanted into 71 native iliac arteries and into 18 iliac limbs from prior EVARs or prosthetic surgical grafts. Median follow-up was 19.7 months. Freedom from iliac limb stenosis/occlusion was 98.9% and freedom from reintervention was 96.6%. Three patients (3.4%) had a type 1b endoleak, and two patients (2.2%) had a type 3 endoleak on follow-up imaging.
CONCLUSIONS: The use of BECS as iliac limbs during complex EVAR appears safe and can be useful for small, diseased, or tortuous iliac arteries. Potential benefits of using BECS compared to commercially available iliac limbs include lower profile, improved trackability, increased radial force for occlusive disease treatment, and suitability for delivery from either upper extremity or contralateral femoral access.
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