Ann Surg Treat Res.  2016 Sep;91(3):139-144. 10.4174/astr.2016.91.3.139.

Self expandable stent application to prevent limb occlusion in external iliac artery during endovascular aneurysm repair

Affiliations
  • 1Division of Vascular and Endovascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea. khpark@cu.ac.kr

Abstract

PURPOSE
Iliac extension of stent-graft during endovascular aneurysm repair (EVAR) increases the incidence of limb occlusion (LO). Hypothetically, adjunctive iliac stent (AIS) could offer some additional protection to overcome this anatomic hostility. But still there is no consensus in terms of effective stent characteristics or configuration. We retrospectively reviewed our center's experience to offer a possible answer to this question.
METHODS
Our study included 30 patients (38 limbs) with AIS placed in the external iliac artery (EIA) from January 2010 to December 2013. We classified iliac tortuosity based on anatomic characteristics. AIS's were deployed in EIA with a minimum 5-mm stick-out configuration from the distal edge of the stent-graft.
RESULTS
According to the iliac artery tortuosity index, grade 0, grade 1, and grade 2 were 5 (13.2%), 30 (78.9%), and 3 (7.9%), respectively. The diameter of all AIS was 12 mm, which was as large as or larger than the diameter of the stent-graft distal limb. SMART stents were preferred in 34 limbs (89.5%) and stents with 60-mm length were usually used (89.5%). During a mean follow-up of 9.13 ± 10.78 months, ischemic limb pain, which could be the sign of LO, was not noticed in any patients. There was no fracture, kinking, migration, in-stent restenosis, or occlusion of AIS.
CONCLUSION
The installation of AIS after extension of stent-graft to EIA reduced the risk of LO without any complications. AIS should be considered as a preventive procedure of LO if stent-graft needs to be extended to EIA during EVAR.

Keyword

Abdominal aortic aneurysm; Endovascular procedures; Stents; Iliac artery

MeSH Terms

Aneurysm*
Aortic Aneurysm, Abdominal
Consensus
Endovascular Procedures
Extremities*
Follow-Up Studies
Hostility
Humans
Iliac Artery*
Incidence
Retrospective Studies
Stents*

Figure

  • Fig. 1 (A) Both iliac stent-graft limbs were deployed on external iliac arteries. The right internal iliac artery was embolized with coils, and adjunctive iliac stents were deployed on both external iliac arteries. (B) Both iliac stent-graft limbs were deployed on external iliac arteries. The right internal iliac artery was embolized with coils, and adjunctive iliac stents were deployed on both external iliac arteries.

  • Fig. 2 (A) Measuring the iliac tortuosity index. The iliac tortuosity index was defined by dividing L1 by L2, where L1 (A and B) was the distance along the central lumen line between the common femoral artery and the aortic bifurcation, and L2 (B) was the straight-line distance from the common femoral artery and the aortic bifurcation. In this case, the iliac tortuosity index was 1.36 (197 of 145). (B) Measuring the iliac tortuosity index. The iliac tortuosity index was defined by dividing L1 by L2, where L1 (A and B) was the distance along the central lumen line between the common femoral artery and the aortic bifurcation, and L2 (B) was the straight-line distance from the common femoral artery and the aortic bifurcation. In this case, the iliac tortuosity index was 1.36 (197 of 145).


Reference

1. Hobo R, Sybrandy JE, Harris PL, Buth J. EUROSTAR Collaborators. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther. 2008; 15:12–22.
2. Armon MP, Wenham PW, Whitaker SC, Gregson RH, Hopkinson BR. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 1998; 15:255–257.
3. Conway AM, Modarai B, Taylor PR, Carrell TW, Waltham M, Salter R, et al. Stent-graft limb deployment in the external iliac artery increases the risk of limb occlusion following endovascular AAA repair. J Endovasc Ther. 2012; 19:79–85.
4. Oshin OA, Fisher RK, Williams LA, Brennan JA, Gilling-Smith GL, Vallabhaneni SR, et al. Adjunctive iliac stents reduce the risk of stent-graft limb occlusion following endovascular aneurysm repair with the Zenith stent-graft. J Endovasc Ther. 2010; 17:108–114.
5. Hobo R, Buth J. EUROSTAR collaborators. Secondary interventions following endovascular abdominal aortic aneurysm repair using current endografts. A EUROSTAR report. J Vasc Surg. 2006; 43:896–902.
6. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005; 365:2179–2186.
7. EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet. 2005; 365:2187–2192.
8. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351:1607–1618.
9. Ouriel K, Green RM, Donayre C, Shortell CK, Elliott J, DeWeese JA. An evaluation of new methods of expressing aortic aneurysm size: relationship to rupture. J Vasc Surg. 1992; 15:12–18.
10. Sivamurthy N, Schneider DB, Reilly LM, Rapp JH, Skovobogatyy H, Chuter TA. Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: implications for limb patency. J Vasc Surg. 2006; 43:662–670.
11. Shin ES, Garcia-Garcia HM, Okamura T, Wykrzykowska JJ, Gonzalo N, Shen ZJ, et al. Comparison of acute vessel wall injury after self-expanding stent and conventional balloon-expandable stent implantation: a study with optical coherence tomography. J Invasive Cardiol. 2010; 22:435–439.
12. Dyet JF, Watts WG, Ettles DF, Nicholson AA. Mechanical properties of metallic stents: how do these properties influence the choice of stent for specific lesions? Cardiovasc Intervent Radiol. 2000; 23:47–54.
13. A comparison of balloon- and self-expanding stents. Minim Invasive Ther Allied Technol. 2002; 11:173–178.
14. Joh JH, Ahn HJ, Park HC. Reference diameters of the abdominal aorta and iliac arteries in the Korean population. Yonsei Med J. 2013; 54:48–54.
15. Carroccio A, Faries PL, Morrissey NJ, Teodorescu V, Burks JA, Gravereaux EC, et al. Predicting iliac limb occlusions after bifurcated aortic stent grafting: anatomic and device-related causes. J Vasc Surg. 2002; 36:679–684.
16. Woody JD, Makaroun MS. Endovascular graft limb occlusion. Semin Vasc Surg. 2004; 17:262–267.
17. Carpenter JP, Neschis DG, Fairman RM, Barker CF, Golden MA, Velazquez OC, et al. Failure of endovascular abdominal aortic aneurysm graft limbs. J Vasc Surg. 2001; 33:296–302.
18. Amesur NB, Zajko AB, Orons PD, Makaroun MS. Endovascular treatment of iliac limb stenoses or occlusions in 31 patients treated with the ancure endograft. J Vasc Interv Radiol. 2000; 11:421–428.
19. Nordon IM, Hinchliffe RJ, Malkawi AH, Taylor J, Holt PJ, Morgan R, et al. Validation of DynaCT in the morphological assessment of abdominal aortic aneurysm for endovascular repair. J Endovasc Ther. 2010; 17:183–189.
Full Text Links
  • ASTR
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr