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The Impact of Iliac Artery Anatomy on Distal Landing Zone After EVAR During the 12-Month Follow-Up

      Background

      Proximal sealing zone has been the main interest in endovascular abdominal aortic aneurysm repair (EVAR), although the distal landing zone remodeling may also affect EVAR durability. The aim of this study was to assess iliac anatomy and its potential impact on distal landing zone adverse events after EVAR during the 12-month follow-up.

      Methods

      A prospective data collection of patients treated with standard bifurcated EVAR devices for abdominal aortic aneurysm was undertaken between 2017 and 2019. Patients that received extension to the external iliac artery were excluded. Follow-up included computed tomography angiography (CTA) at the 1st and 12th month postoperatively. The common iliac artery (CIA) diameter was assessed in three levels: origin (just below the aortic bifurcation), distally (just above the iliac bifurcation) and the middle of the distance between these two landmarks. Iliac angle, tortuosity indexes, relining and oversizing were also analyzed. Distal landing zone-related adverse events were any limb related re-intervention, endoleak type Ib, graft migration, limb stenosis, or occlusion.

      Results

      In total, 268 iliac limbs (134 patients) were included. In all three levels, the mean iliac artery diameters increased at 12-month follow-up. At the origin of the CIA, the diameter increased from 18.7 ± 10.5 mm to 19.9 ± 9.4 mm (P = 0.04), at the middle portion of the CIA, the diameter changed significantly from 15.5 ± 5.1 mm to 17.4 ± 5.4 mm (P < 0.001) and at the distal CIA, from 14.6 ± 3.3 mm to 15.1 ± 3.9 mm (P = 0.03). The iliac angle remained stable (P = 0.14) while the CIA index decreased significantly from 1.17 ± 0.13 to 1.11 ± 0.09 (P < 0.001). The mean value of oversizing was 21.5 ± 14.5% and affected distal iliac diameter increase (P < 0.001). The composite outcome of distal landing zone adverse events was not associated to diameter changes at any level. In 57 cases, a distal iliac diameter ≥18 mm was recorded. The estimated oversizing was lower (16.3 ± 11.8%) compared to <18 mm arteries (22.5 ± 14.9%, P = 0.01). At 12-month follow-up, iliac diameters remained stable in the ≥18 mm group. Endoleak type Ib was more common in iliac arteries ≥18 mm [3 (5.3%) vs. 1 (0.5%) (P = 0.04)] at 12-months.

      Conclusions

      Post-EVAR iliac artery dilation does not seem to have an impact on distal landing zone adverse events during the 12-month follow-up. Aggressive oversizing may be related to iliac dilation. EVAR patients with iliac arteries ≥18 mm are at higher risk for ET Ib.
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      References

        • Qin K.R.
        • Perera M.
        • Papa N.
        • et al.
        Open versus endovascular abdominal aortic aneurysm repair in the Australian private sector over twenty Years.
        J Endovasc Ther. 2021; 28: 844-851
        • Debono S.
        • Nash J.
        • Tambyraja A.L.
        • et al.
        Endovascular repair for abdominal aortic aneurysms.
        Heart. 2021; 107: 1783-1789
      1. 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
        • de la Motte L.
        • Falkenberg M.
        • Koelemay M.J.
        • et al.
        Is EVAR a durable solution? Indications for reinterventions.
        J Cardiovasc Surg (Torino). 2018; 59: 201-212
        • Nana P.
        • Spanos K.
        • Kouvelos G.
        • et al.
        Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.
        Int Angiol. 2021; 40: 240-247
        • Malina M.
        Reinterventions after open and endovascular AAA repair.
        J Cardiovasc Surg (Torino). 2015; 56: 257-268
        • Bianchini Massoni C.
        • Perini P.
        • Tecchio T.
        • et al.
        A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair.
        Vascular. 2018; 26: 90-98
        • Wang J.
        • Wang T.
        • Zhao J.
        • et al.
        Effect of limb oversizing on the risk of type Ib endoleak in patients after endovascular aortic repair.
        J Vasc Surg. 2021; 74: 1214-1221
        • Taudorf M.
        • Jensen L.P.
        • Vogt K.C.
        • et al.
        Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA.
        Eur J Vasc Endovasc Surg. 2014; 48: 527-533
        • Wang Y.
        • Li C.
        • Xin H.
        • et al.
        Predisposing factors for migration of the iliac limb and reintervention after endovascular abdominal aortic aneurysm repair.
        Ann Vasc Surg. 2019; 59: 91-101
        • Kainth A.S.
        • Sura T.A.
        • Williams M.S.
        • et al.
        Outcomes after endovascular reintervention for aortic interventions.
        J Vasc Surg. 2022; 75: 877-883.e2
        • Moll F.L.
        • Powell J.T.
        • Fraedrich G.
        • et al.
        Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.
        Eur J Vasc Endovasc Surg. 2011; 41: S1-S58
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • et al.
        Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
        • Chaikof E.L.
        • Blankensteijn J.D.
        • Harris P.L.
        • et al.
        Reporting standards for endovascular aortic aneurysm repair.
        J Vasc Surg. 2002; 35: 1048-1060
        • Johnston K.W.
        • Rutherford R.B.
        • Tilson M.D.
        • et al.
        Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc committee on reporting standards, society for vascular surgery and North American chapter, International society for cardiovascular surgery.
        J Vasc Surg. 1991; 13: 452-458
        • Kapetanios D.
        • Banafsche R.
        • Jerkku T.
        • et al.
        Current evidence in aortic remodeling after endovascular repair.
        J Cardiovasc Surg (Torino). 2019; 60: 186-190
        • Torsello G.
        • Pratesi G.
        • van der Meulen S.
        • et al.
        Aortoiliac remodeling and 5-year outcome of an ultra-low profile endograft.
        J Vasc Surg. 2019; 69: 1747-1757
        • Oliveira N.F.G.
        • Oliveira-Pinto J.
        • van Rijn M.J.
        • et al.
        Risk factors, dynamics, and clinical consequences of aortic neck dilatation after standard endovascular aneurysm repair.
        Eur J Vasc Endovasc Surg. 2021; 62: 26-35
        • Roos H.
        • Sandström C.
        • Koutouzi G.
        • et al.
        Predisposing factors for Re-interventions with additional iliac stent grafts after endovascular aortic repair.
        Eur J Vasc Endovasc Surg. 2017; 53: 89-94
        • Bastos Gonçalves F.
        • Oliveira N.F.
        • Josee van Rijn M.
        • et al.
        Iliac seal zone dynamics and clinical consequences after endovascular aneurysm repair.
        Eur J Vasc Endovasc Surg. 2017; 53: 185-192
        • Kirkwood M.L.
        • Saunders A.
        • Jackson B.M.
        • et al.
        Aneurysmal iliac arteries do not portend future iliac aneurysmal enlargement after endovascular aneurysm repair for abdominal aortic aneurysm.
        J Vasc Surg. 2011; 53: 269-273
        • Gray D.
        • Shahverdyan R.
        • Reifferscheid V.
        • et al.
        EVAR with flaired iliac limbs has a high risk of late type Ib endoleak.
        Eur J Vasc Endovasc Surg. 2017; 54: 170-176
        • McFarland G.
        • Tran K.
        • Virgin-Downey W.
        • et al.
        Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure.
        J Vasc Surg. 2019; 69: 385-393
        • Donas K.P.
        • Inchingolo M.
        • Cao P.
        • et al.
        Secondary procedures following iliac branch device treatment of aneurysms Involving the iliac bifurcation: the PELVIS registry.
        J Endovasc Ther. 2017; 24: 405-410
        • Gibello L.
        • Varetto G.
        • Ruffino M.A.
        • et al.
        Long-term outcomes of endovascular aortic repair in patients with abdominal aortic aneurysm and ectatic common iliac arteries.
        Eur J Vasc Endovasc Surg. 2020; 60: 356-364
        • Bahroloomi D.
        • Qato K.
        • Nguyen N.
        • et al.
        External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm.
        J Vasc Surg. 2022; 76: 132-140
        • van der Veen D.
        • Holewijn S.
        • Bellosta R.
        • et al.
        One year outcomes of an International multicentre prospective cohort study on the Gore excluder iliac branch endoprosthesis for aorto-iliac aneurysms.
        Eur J Vasc Endovasc Surg. 2021; 62: 177-185
        • Roos H.
        • Djerf H.
        • Brisby Jeppsson L.
        • et al.
        Re-interventions after endovascular aortic repair for infrarenal abdominal aneurysms: a retrospective cohort study.
        BMC Cardiovasc Disord. 2016; 16: 124