Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair
Presented at The Society for Vascular Surgery, Vascular Annual Meeting, Philadelphia, Pa, June 1 to 4, 2006.
Received 4 June 2006; accepted 17 August 2006.
Background
Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass.
Methods
A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (≥20 mm) and patent hypogastric arteries not amenable to a cuff or “bell bottom” technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass.
Results
Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 ± 72 minutes; EMBO, 153 ± 39 minutes; BYPASS, 283 ± 75 minutes) and estimated blood loss (CTRL, 251 ± 313 mL; EMBO, 233 ± 158 mL; BYPASS, 400 ± 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 ± 11% (SE) at 36 months by life-table analysis.
Conclusions
Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.
aDivision of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
bDivision of Vascular Surgery, Malcom Randall Veterans Affairs Medical Center, Gainesville, Fla
Correspondence: Thomas S. Huber, MD, PhD, Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, PO Box 100286, Gainesville, Fl 32610-0286
Competition of interest: Dr Lee is a consultant and received grant support from W. L. Gore & Associates, Medtronic Vascular, and Cook, Inc.
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