Management of difficult access during EVAR.
Management of difficult access during EVAR.
- 2017
Available online from MWHC library: 1995 - present, Available in print through MWHC library:1999-2007
CONCLUSIONS: EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients, and should definitely be considered in patients with iliac arteries less than 5mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients. Copyright � 2017. Published by Elsevier Inc. METHODS: Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 was collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access, and outcomes. The median follow-up was 38 months. Difficult access (DA) was defined as iliac arteries with a diameter of less than 7mm bilaterally. Fenestrated and snorkel repairs were excluded. OBJECTIVES: To describe a large single institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). RESULTS: Out of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts prior to introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 Aortouniiliac (AUI) devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6mm in the group of patients requiring adjuncts and 5.4mm in the remainder of the patients with small iliac arteries (p=.008). The median size of the main body device was 28mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3(1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) of patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (p=0.12).
English
0890-5096
*Aortic Aneurysm, Abdominal/su [Surgery]
*Blood Vessel Prosthesis Implantation/ae [Adverse Effects]
*Endovascular Procedures/ae [Adverse Effects]
*Iliac Artery/su [Surgery]
*Postoperative Complications/et [Etiology]
Aged
Aged, 80 and over
Aortic Aneurysm, Abdominal/dg [Diagnostic Imaging]
Aortic Aneurysm, Abdominal/mo [Mortality]
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation/is [Instrumentation]
Blood Vessel Prosthesis Implantation/mo [Mortality]
Endovascular Procedures/is [Instrumentation]
Endovascular Procedures/mo [Mortality]
Female
Hospitals, University
Humans
Iliac Artery/dg [Diagnostic Imaging]
Male
Middle Aged
Philadelphia
Postoperative Complications/dg [Diagnostic Imaging]
Postoperative Complications/mo [Mortality]
Postoperative Complications/su [Surgery]
Prosthesis Design
Reoperation
Retrospective Studies
Risk Factors
Stents
Tertiary Care Centers
Time Factors
Treatment Outcome
MedStar Washington Hospital Center
Surgery/Vascular Surgery
Journal Article
Available online from MWHC library: 1995 - present, Available in print through MWHC library:1999-2007
CONCLUSIONS: EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients, and should definitely be considered in patients with iliac arteries less than 5mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients. Copyright � 2017. Published by Elsevier Inc. METHODS: Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 was collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access, and outcomes. The median follow-up was 38 months. Difficult access (DA) was defined as iliac arteries with a diameter of less than 7mm bilaterally. Fenestrated and snorkel repairs were excluded. OBJECTIVES: To describe a large single institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). RESULTS: Out of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts prior to introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 Aortouniiliac (AUI) devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6mm in the group of patients requiring adjuncts and 5.4mm in the remainder of the patients with small iliac arteries (p=.008). The median size of the main body device was 28mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3(1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) of patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (p=0.12).
English
0890-5096
*Aortic Aneurysm, Abdominal/su [Surgery]
*Blood Vessel Prosthesis Implantation/ae [Adverse Effects]
*Endovascular Procedures/ae [Adverse Effects]
*Iliac Artery/su [Surgery]
*Postoperative Complications/et [Etiology]
Aged
Aged, 80 and over
Aortic Aneurysm, Abdominal/dg [Diagnostic Imaging]
Aortic Aneurysm, Abdominal/mo [Mortality]
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation/is [Instrumentation]
Blood Vessel Prosthesis Implantation/mo [Mortality]
Endovascular Procedures/is [Instrumentation]
Endovascular Procedures/mo [Mortality]
Female
Hospitals, University
Humans
Iliac Artery/dg [Diagnostic Imaging]
Male
Middle Aged
Philadelphia
Postoperative Complications/dg [Diagnostic Imaging]
Postoperative Complications/mo [Mortality]
Postoperative Complications/su [Surgery]
Prosthesis Design
Reoperation
Retrospective Studies
Risk Factors
Stents
Tertiary Care Centers
Time Factors
Treatment Outcome
MedStar Washington Hospital Center
Surgery/Vascular Surgery
Journal Article