the leipzig interventional course 2015 · higher incidence of distal type i endoleak, an increased...
TRANSCRIPT
The Leipzig Interventional Course 2015
January 27–30, 2015
Disclosure
Speaker name:
Mr PAUL BACHOO
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
X I do not have any potential conflict of interest
Clinical considerations in preserving the hypogastric arteries with bilateral treatment. Is there need for an iliac branch system
Innovative solutions for the challenging landing zone in the iliac and thoraco-abdominal segment
Mr. Paul Bachoo
Consultant Vascular
Surgeon
Aberdeen
Scotland
Pathogenesis similar to AAA
M:F 5-16:1
20% of AAA pts will have iliac aneurysm disease 50% bilateral Median expansion rate CIA is 0.29 cm/y
Risk of rupture: 3-4cm: 5-10% over 5yrs >4cm: 10 – 70% over 5 yrs
Background - CIA
Huang Y et al. J Vasc Surg 2008;47:1203-11
Proximal challenges
Distal challenges
Higher incidence of distal type I endoleak, an increased need for secondary interventions, and a higher incidence of aneurysm rupture but similar mortality following EVAR in AAA patients with concomitant CIA aneurysm disease compared with EVAR of simple AAA.
Hobo et al. J Endovas Therapy 2008;15:12–22
The next challenge
Preserving flow into IIA
First clinical consideration
LAND IN A LARGE CIA ?
Is a dilated iliac artery an appropriate landing zone?
Preserving flow into IIA by maintaining the CIA
bifurcation
No
Due to the risk of future dilatation and risk of rupture
Emergency intervention
The internal iliac artery may be preserved by landing an endograft in a dilated or aneurysmal common Iliac
artery and whilst the immediate result may be satisfactory and the vessel(s) subjected to reduced expansible forces the risk of rupture persists as the
aneurysmal biology persists.
Second clinical consideration
If landing in the EIA is Best what do we do with the IIA ?
Exclude flow into IIA
Third clinical consideration
If IIA is sacrificed what clinical outcome can we expect ?
What we have learned from the option of hypogastric artery
embolization during endovascular treatment of aorto-iliac
aneurysm repair is
ISCHAEMIA
Gluteal
Genital
Bowel
Sciatic Nerve
Spinal cord
Bladder dysfunction
Decubitus ulcer
Literature review of patients developing gluteal
claudication / erectile dysfunction after IIA
EMBO
Catheter-directed coil embolization of the
hypogastric artery
• Formation of minute fragments of thrombus because of the presence of foreign bodies
• Propagation of these small thrombi into the capillary beds may prevent adequate collateral vessel formation at the precapillary level
• Irreversible tissue damage can occur when the terminal capillary blood flow is compromised
• Particularly in patients with underlying atherosclerotic disease
The results were pooled to give
n=634 patients
Buttock claudication = 28% overall (178 of 634 patients)
Unilateral embolization in 31% of (99 of 322)
Bilateral embolization and 35% of (34 of 98)
New erectile dysfunction occurred 17% overall (27 of 159 patients):
Unilateral embolization 17% (16 of 97)
Bilateral embolization 24% (9 of 38)
Meta analysis of Literature review of patients developing gluteal claudication / erectile dysfunction
after IIA EMBO
Rayt HS et al.Cardiovasc Intervent Radiol. 2008;31(4):728-34
• Age
• Low cardiac function
• CAD
• 70% stenosis of the origin of the contra lateral hypogastric artery
• Absence of filling of three or more named hypogastric branches
• Disease or absence of ascending branches from the Femoral and External Iliac Artery
• Disease or absence of Profunda Femoris Artery
Likely prognostic factors in developing
ischaemic symptoms after EMBO
Few successful remedial interventions
Fourth clinical consideration
In bilateral cases can we improve patient outcome
by sacrificing one IIA and salvaging the other
Pelvic Hemodynamic Alterations: preoperative
and postoperative penile-brachial index(PBI)
and pulse-volume recording assessment
• Prospective study
• Incidence rate
Erectile dysfunction 45%
Claudication 50%
• Specifically, mean reductions in PBI after unilateral and bilateral
hypogastric artery embolization were 13% and 39% (P <0.05).
Lin PH et al: J Vasc Surg 36:500-506, 2002
The principle can be achieved with several
endovascular techniques
Courtesy of Oderich GS Mayo Clinic
IIA bypass
Sandwich
BYPASS - EVAR with hypogastric flow
EVAR repairs n=444
CIA component n=137 (31%)
Bell bottom repair n=80 (58%) Treatment group n=57 (42%)
Bilateral n=12 EMBO & EMBO+BYPASS
EMBO n=31(69%) : EMBO + BYPASS n=14 (31%)
Single n=45
SURGICAL
Lee WA etal. J Vasc Surg: 44(6); 1162-8
Results
Lee WA etal. J Vasc Surg: 44(6); 1162-8
Sandwich - Male 79yr - Aberdeen
Preoperative
Right iliac sandwich /Left IIA occlusion @12
months Left Gluteal claudication
Right iliac sandwich occlusion @18 months c/o
Bilateral Gluteal claudication
Occlusion of IIA graft
Not always the chimney that lets you down
Female 66yr - Aberdeen
18 moths Preoperative
Alternative solution
Summary
Identify a suitable distal iliac landing zone of an
appropriate length and diameter in a non diseased vessel
to accommodate the endoluminal device minimizing the
risk of migration or endoleak.
Summary
Whether unilateral or bilateral IIA occlusion during
endovascular aortoiliac aneurysm repair (EVAR) is
performed, this procedure is not an innocuous step
and will very much adversely affect QoL post surgery.
Summary
Experimental data and a variety of clinical reported
outcomes testify to the concept of disturbed pelvic
hemodynamic blood flow which has no proven
corrective intervention. In the elderly with other
prognostic factors this may be significant.
In patients with bilateral CIA disease the symptoms are not completely prevented by preserving one IIA
Summary
Male 79yr
Conclusion
When treating a large asymptomatic aneurysm to
prevent death from rupture also remember QoL
Flow to IIA can be maintained by purpose built iliac
branch systems
• Date of Surgery: 18.12.13
• Date of Discharge: 21.12.13
• Procedure: Endovascular aneurysm repair using C3 Gore excluder and iliac branch endovascular device for left common iliac artery aneurysm
• FU @ 1yr – No Gluteal claudication
Conclusion
There is a need for an effective iliac branch system and
when required anatomically both IIA should be
preserved
Thank you
Mr Paul Bachoo
Consultant Vascular Surgeon
Aberdeen
Scotland