Iliac artery recanalization of chronic occlusions to facilitate endovascular aneurysm repair

Abstract

Introduction: Concurrent iliac occlusion and abdominal aortic aneurysm is rare. Traditionally, the endovascular approach to these patients has consisted of aortouniiliac devices combined with femoral-femoral bypass. With improved facility of endovascular techniques, standard bifurcated endografts represent an alternative option in these patients. This study examined outcomes of patients undergoing iliac recanalization and traditional bifurcated endovascular aneurysm repair in the face of access vessel occlusion.

Methods: Outcomes of patients at three academic tertiary referral centers who underwent attempted iliac recanalization of chronic iliac occlusions and concurrent endovascular aneurysm repair of an infrarenal aortic aneurysm were retrospectively reviewed. Patients with acute iliac thrombosis and those with severely stenotic (but patent) iliac vessels were excluded.

Results: During a 6-year period, 15 occluded iliac arteries were treated in 14 patients (13 men). Mean age was 67.8 years (range, 52-80 years). Primary indication for intervention was disabling claudication in four patients, size of abdominal aortic aneurysm in nine, and symptomatic aneurysm in one. Seven patients presented with a unilateral common iliac artery (CIA) occlusion, four with a unilateral external iliac artery (EIA) occlusion, three with a unilateral combined CIA and EIA occlusion, and one with bilateral CIA occlusions. Stents had been placed previously in two of the occluded CIAs and in one of the occluded EIAs. Average length of the occluded segment was 7.5 cm (range, 2-17 cm). The occluded CIAs and EIAs had mean diameters of 8.6 and 5.7 mm, respectively. Successful recanalization was achieved in 14 of the 15 vessels (93.3%). One EIA ruptured during recanalization but was easily controlled with a covered stent. A re-entry device was used in two cases. Overall, 13 bifurcated devices were successfully implanted. Bilateral iliac occlusions in one patient were recanalized. One Talent (Medtronic, Santa Rosa, Calif), eight Excluder (W. L. Gore and Associates, Flagstaff, Ariz), and four Zenith (Cook Medical, Bloomington, Ind) devices were used. Mean length of stay was 2.3 days (range, 1-6 days). No major perioperative complications or deaths occurred. During a mean follow-up of 28.2 months (range, 1-86 months), there was 100% primary patency of successfully recanalized iliac arteries. Aneurysm sac size decreased from a mean of 5.1 cm (range, 3.1-7.6 cm) preoperatively to 4.4 cm (range, 2.8-7.1 cm) at follow-up. No aneurysms grew or ruptured. Three type II endoleaks occurred, one of which required coiling at 15 months. Two late deaths occurred: one at 36 months secondary to complications from a coronary artery bypass graft/mitral valve replacement and one at 34 months from a myocardial infarction.

Conclusions: The use of bifurcated endovascular devices after recanalization of an occluded iliac system is technically feasible and durable at midterm follow-up. This technique re-establishes aortoiliac inflow to both lower extremities, obviates the need for extra-anatomic bypass, and may preserve hypogastric perfusion in some patients.