Banding of the common iliac artery: An expedient in endoluminal correction of aortoiliac aneurysms☆☆☆
Article Outline
Abstract
Dilatation of the common iliac arteries is one of the most frequent causes for exclusion of patients in a series of endovascular correction of abdominal aortic aneurysms (AAAs). In this article we describe the banding technique we use to constrict the large iliac arteries. Four patients underwent endovascular treatment for AAAs with bifurcated grafts. Five of the eight common iliac arteries were 16 to 20 mm in diameter and were constricted around the endoprosthesis by banding with two cotton tapes through a retroperitoneal access. An angioplasty balloon was used as a counterresistance inside the graft. Completion angiogram and postoperative computed tomographic scans showed no endoleak in all cases. No complications occurred in the follow-up (3-10 months). Banding of the common iliac artery is an efficient procedure for endoluminal correction of AAAs when the diameter of the common iliac arteries is greater than 16 mm and less than 20 mm. (J Vasc Surg 2000;32:1232-4.)
Despite the increasing worldwide acceptance of the endovascular technique for correction of infrarenal aortic aneurysms, anatomic aspects still influence case selection. One of the most frequent causes for exclusion of patients is dilatation of the common iliac arteries,1, 2, 3 because most commercially available bifurcated devices are manufactured with 12- to 16-mm wide iliac limbs and these arteries are frequently more than 16 mm in diameter. When only one of the common iliac arteries is involved, the graft can be extended to the external iliac artery, and the internal iliac artery can be ligated or occluded with coils, providing that the contralateral internal iliac artery is patent. However, when bilateral iliac aneurysm is present, the occlusion of both internal iliac arteries may potentially lead to several types of complications.4
Several alternatives have been proposed to overcome this situation. A custom-made graft can be ordered from some manufacturers, although this is not practical or possible in all countries and in all instances. Some researchers use a tapered aortoiliac or aortofemoral graft combined with a transverse femorofemoral bypass graft and endovascular occlusion of the aneurysmal common iliac artery,5, 6 as first described by Parodi.7 This option may preserve at least one of the internal iliac arteries, but it certainly adds the risk of late complications associated with the presence of prosthetic grafts in the inguinal region. Others have created bell-bottom grafts by implanting larger extensions within a smaller cuff. Recently, Parodi and Ferreira8 proposed the relocation of the iliac artery bifurcation as an expedient to preserve the flow to the internal iliac arteries.
In 1996, Chuter et al9 reported the treatment in one case of a persistent perigraft leakage at the level of the common iliac artery; the artery was squeezed onto the device in a second operation using a cloth tape. In June 1999, we decided to electively include constriction of the iliac artery in the operative procedure in cases where the preoperative evaluation showed that the arterial diameter would be larger than that of the graft. Only four patients have been treated with this expedient since then because it was our decision to wait for a 3-month follow-up evaluation of the first patient before extending the technique to others. The purpose of this report is to describe the banding technique we used to constrict the large iliac arteries and to report the early results in four cases.
Patients and method
The expedient herein described was used bilaterally in one patient and unilaterally in the other three. All patients were good candidates for surgery but had chosen endoluminal correction and had signed an informed consent, which was approved by the Hospital Ethics and Research Committee. Preoperative diameters of the common iliac arteries selected for banding were 20 mm (2 cases), 18 mm (2 cases), and 16 mm (1 case), and computed tomographic (CT) scan revealed that there were no mural thrombi.
An extraperitoneal access to the common iliac artery was performed as the first step of the operation. The artery was dissected circumferentially in an extension of 2 to 3 cm cranial to its bifurcation, and two 0.30 × 80-cm cotton tapes (cardiac tape; Ethicon, Somerville, NJ) were passed around it, which left approximately 1 cm between them (Fig 1).
Fig. 1.
Schematic representation of the cotton tapes passed around the left common iliac artery. Approximately 1 cm is left between them.
The bifurcated endograft (Vanguard; Boston Scientific, Inc, Watertown, Mass) was inserted by means of the standard technique.2, 10 The size of the device varied in the aortic portion, but the limbs were always 12 mm wide, the largest produced by that manufacturer. A grasping forceps was placed in the adventitia of the iliac artery through the retroperitoneal access, and the level of the most distal tape was marked for fluoroscopic reference. Whenever the iliac limb of the device was not long enough to reach a few millimeters beyond that point, an extension (Passenger; Boston Scientific, Inc) was inserted. Of five sides treated, one extension was necessary in two sides, two extensions in one side, and no extension in two sides.
With the device in place, an angioplasty balloon of the same diameter as the limb of the endograft (12 × 40 mm, Medi-Tech; Boston Scientific, Inc) was introduced under fluoroscopy and was inflated at the level of the distal end of the graft with the radiopaque marks in the device as reference. The two cotton tapes were then tied; the artery was squeezed until the resistance of the balloon was felt (Fig 2).
Fig. 2.
Schematic representation of constriction of left common iliac artery. An angioplasty balloon is inflated inside distal segment of the graft and acts as counterresistance.
Results
Completion angiography in all patients showed no signs of endoleak and showed patency of the internal iliac arteries. No contrast medium outside the graft was seen in any of the postoperative CT scan examinations. No patients required blood transfusion. All four patients could walk and eat on the first postoperative day and were ready for discharge on the second. No major complications occurred in this small group. The follow-up time ranged from 3 to 10 months.
Discussion
In this small series, banding of the common iliac artery proved to be an efficient procedure for endoluminal correction of infrarenal aortic aneurysms when the diameter of the common iliac arteries was greater than 16 mm and less than 20 mm. On the basis of our experience, we would not recommend this procedure for aneurysmal arteries with diameters larger than 20 mm, when the arterial wall may be very thin, nor would we recommend it for heavily calcified arteries or when mural thrombi are present. Despite the presence of the balloon in the lumen, distal embolization may occur at the moment of the constriction.
The reaction of the arterial wall at the level of the cotton tape at long-term follow-up may certainly be a concern. Arterial rupture distal to or at the tapes is a theoretic possibility. However, the previous experience of others with sutureless-ringed prosthesis for surgical correction of aortic aneurysms has shown no complications of constricting the aortic wall around the ring.11 In the situation herein described, the tape is tied around a rigid balloon, but once the balloon is withdrawn, the only counterresistance remaining is the nitinol stent, which is probably not rigid enough to cause ischemia with rupture of the arterial wall. We have chosen to extend the graft to the distal segment of the common iliac artery to leave the minimun extension of the vessel to dilate in the future.
In our experience, extraperitoneal access to the distal segment of the common iliac artery results in only a small increase in surgical stress and recovery time and still carries much less risk and discomfort than classical abdominal access to aortic bypass grafts. However, dissection of the artery at this level is sometimes laborious, and one must be careful to avoid damage of the adjacent iliac vein. An experienced surgeon can perform the procedure successfully in almost all cases; however, in a few instances, it may be necessary to convert to another technical option, either surgical or endovascular.
In all of the cases herein described, the common iliac artery, in all of its extension, was more than 2 mm larger than the graft limb as measured in the preoperative CT scan. Therefore, an endoleak was assumed to be predictable, and the bands were placed before the insertion of the device. When there is a slight and segmental disproportion, the endograft may be inserted first, and the surgeon may proceed with the banding if an endoleak is detected in the completion angiogram. This sequence, however, is only possible if systemic heparin is not administered.
References
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☆ Competition of interest: nil.
☆☆ Reprint requests: Prof Dr Pedro Puech-Leão, Rua Barata Riberio 237 cj 131, 01308-000, São Paulo, Brazil (e-mail: drpuech@usp.br ).
PII: S0741-5214(00)84846-6
doi:10.1067/mva.2000.109771
© 2000 Society for Vascular Surgery and The American Association for Vascular Surgery, a Chapter of the International Society for Cardiovascular Surgery. Published by Elsevier Inc. All rights reserved.
