Overtaking technical and anatomical challenges of preservation in the treatment

of iliac aneurysmal disease

G Pratesi, MD

Vascular SurgeryIRCCS Policlinico San Martino, University of Genoa

Policlinico Tor Vergata, University of Rome “Tor Vergata”

Disclosure

Speaker name:

Giovanni Pratesi

I have the following potential conflicts of interest to report:

Consulting: Abbott, Cook, Cordis, Medtronic, WL Gore & Associates

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

✓

Chaikof EL et al., J Vasc Surg 2018

• Tortuous iliac anatomy

• Aneurysmal involvement of hypogastric artery

• “Challenging” iliac bifurcation (diameter, take off angulation)

• Small access vessels

Endovascular preservation of hypogastric artery:technical and anatomical challenges

650 iliac branch in 575 Pts between 2005 and 2015; mean follow-up 32.6±9.9

• 621 Cook ZBIS, 29 Gore IBE• Overall postop reintervention rate 8.9%

- 4.6% EIA or CIA occlusion- 4.3% type I EL

Eur J Vasc Endovasc Surg 2013

85 EVAR procedures with IBD in 81 pts between 2007 and 2012

IBD-related reintervention OR p

Ectatic IAA > 10 mm 3.4 .001

BE vs SE stent 2.5 .2

39 vs 59 mm stent .9 .78

ZBIS-45 vs ZBIS-61 1.2 .18

ZBIS-10 vs ZBIS-12 1 .16

Distal sealing zone in iliac branch:need for a healthy hypogastric artery

Donas KP et al., J Vasc Surg 2018

HA group(n=310)

Non HA group(n=595)

p

IBD-related type I EL 3% .7% .019

Buttock claudication 2.2% 5.3% .019

IBD-related migration 0.2% 1.9% <.001

5-year freedom from IBD-related type I EL 93% 98% .006

Overtaking technical and anatomical challenges with IBD: advanced imaging techniques

GORE® EXCLUDER® Iliac Branch Endoprosthesis

Overtaking technical and anatomical challengeswith IBD: more conformable devices

Della Schiava N et al., Ann Vasc Surg 2016

• Monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS

• Three indices of tortuosity measured with EndoSize: common iliac artery (CIA), pelvic artery index (PAI), and the double iliac sign (DIS)

• The centerline lengths of the iliac axis and the IIA were measured by 2 different operators as a blind fashion

IBE, more conformable with the anatomy of the patient, could decrease the incidence of graft related complication due to

anatomical constraints

Technical and anatomical challenges in IBD: external iliac tortuosity

Hypogastric preservation:IBE in external iliac tortuosity

IBE in external iliac tortuosity:expanding iliac branch applicability

Technical and anatomical challenges in IBD: hypogastric aneurysm

• MV, male, 65 yrs• Bilateral CIAA (60 mm

Rt side; 45 mm Lt side)

• Bilateral IIAA (37 mm Rt side; 25 mm Lt side)

IBE in Hypogastric aneurysm:anterior branch embolization +

posterior branch stenting

IBE in hypogastric aneurysm:expanding iliac branch applicability

Technical and anatomical challenges in IBD: Cook’s ZBIS vs Gore’s IBE

• Cook IBD:– Longitudinal indipendent stainless

steel stent

– Different proximal lengths, with longer overlapping zones

– Need for an IIA mating stent

• Gore IBE:– Sinusoidal nitinol stent design

– Increased conformability

– Dedicated IIA component

Study Group

180 iliac branched devicesimplanted betweenJanuary 2007 and December 2017

• 123 Cook ZBIS (Group 1)

• 57 Gore IBE (Group 2)

Comparison of the two groups was performed on the

basis of a propensity score matching (1:1) analysis

Demographics and baseline characteristicsMatched Groups: 35 ZBIS vs 35 IBE

Clinical Features Group 1 (ZBIS; n=35) Group 2 (IBE; n=35) p

Mean age 72.9 ± 8.3 70.1 ± 8.7 .21

Male sex 35 (100%) 35 (100%) 1

Arterial hypertension 26 (74.3%) 30 (85.7%) .20

Hyperlipidemia 14 (40%) 16 (45.7%) .41

Diabetes mellitus 3 (8.6%) 2 (5.7%) .50

CAD 9 (25.7%) 9 (25.7%) 1

COPD 21 (60%) 21 (60%) 1

CKD 2 (5.7%) 2 (5.7%) 1

PAOD 1 (1.7%) 0 (-) .50

Anatomical Features Group 1 (ZBIS; n=35) Group 2 (IBE; n=35) p

Proximal neck diameter 23.3 ± 2.4 mm 23.1 ± 2.5 mm .78

Proximal neck lenght 25.1 ± 17.5 mm 26.1 ± 13.5 mm .81

Aortic diameter 43.3 ± 15.6 mm 48.9 ± 17 mm .18

Right CIA diameter 30.6 ± 11.5 mm 35.1 ± 15.1 mm .19

Left CIA diameter 27.8 ± 10.4 mm 30.1 ± 14.8 mm .49

CIA diameter on branched side 34.5 ± 9.1 mm 39.8 ± 14.7 mm .11

IIA diameter on branched side 12.7± 6.1 mm 10.5 ± 5.6 mm .27

Perioperative Outcomes

Perioperative OutcomesGroup 1

(ZBIS; n=35)

Group 2

(IBE; n=35)p

Technical success 35 (100%) 35 (100%) 1

IBD - occlusion 1 (2.8%) (-) .49

IBD - Type I/III endoleak (-) (-) 1

Adjunctive procedures 35 (28.2%) 240 (21.7%) .10

Conversion (-) (-) 1

Mortality (-) (-) 1

Outcomes at Follow-up

Outcomes at Follow-upGroup 1

(ZBIS; n=35)

Group 2

(IBE; n=35)p

Mortality 3 (8.6%) 4 (11.4%) .69

Aneurysm-related mortality 2 (5.7%) 1 (2.8%) .67

IBD occlusion 0 (-) 0 (-) 1

IBD-type I endoleak 1 (2.8%) 1 (2.8%) 1

IBD-type III endoleak 1 (2.8%) 1 (2.8%) 1

IBD-related reinterventions 2 (5.7%) 1 (2.8%) .57

Migration 1 (2.8%) 0 (-) .49

Bridging stent occlusion 0 (-) 0 (-) 1

Conversion to open surgery 2 (5.7%) 0 (-) .49

Mean follow-up was 46.7 months in group 1 (SD ± 36.3), 20.8 months in group 2 (SD ± 15.9); p <.001

Outcomes at Follow-up

86.8

%

97.1

%

p=.34, log-rank 0.9

93.3

%

97.1

%

p=.81, log-rank 0.5

Conclusions

• Hypogastric preservation with Iliac branch is effective and mandatory whenever anatomically feasible

• GORE® EXCLUDER® Iliac Branch Endograft offers high conformability in challenging anatomies (stenosis, tortuousity, hypogastric aneurysm)

• Tailored iliac branch selection is crucial in overtaking technical and anatomical challenges of hypogastric preservation in the treatment of iliac aneurysmal disease

Overtaking technical and anatomicalchallenges with IBD: tailored device selection

Overtaking technical and anatomical challenges of preservation in the treatment

of iliac aneurysmal disease

G Pratesi, MD

Vascular SurgeryIRCCS Policlinico San Martino, University of Genoa

Policlinico Tor Vergata, University of Rome “Tor Vergata”