Endovascular Treatment of Common Iliac Artery Aneurysm after open Repair for Ruptured AAA with Commercially Available Devices in Bulgaria - Case Report

1. Abstract Background: True iliac aneurysms development is a major sign of aneurysm disease progression after openrepair for Abdominal Aortic Aneurysm (AAA). We present our experience in en- dovascular repair of true iliac aneurysm after open reconstruction for ruptured AAA with commercially available stentgraft devices.

CaseReport:InMarch2012,a50yearsoldmaleunderwent emergencyoperationduetoruptured,8cmAAA.A24mmDacron tubegraftwasused.InJanuary2013twostentgraftsAdvantawere placedinkissingconfigurationintheleftexternalandinternaliliac arteries(EIA)(IIA)(10/59;8;59)duetodevelopmentofcommon iliac artery aneurysm.ACTscan had been performed yearly after that. In 2020 we observed true aneurysm of the distal part of the aorta and the right common iliac artery and IIA. Elective surgery was performed.The proximal stent graft was anchored in Dacron tube graft right above the aortic bifurcation way below renal ar- teries. On the left, we bridged previously implantedAdvantas by two new Advanta stent grafts (9/58). For the right side we used iliac extension to EIA and two Advanta stent grafts (6/59) to the biggestbranchofIIAandcoilembolizationintheotherbranchfor maximumsealing.Stentgraftsdeploymentwassuccessful.Nooperativemorbidityandcomplicationsoccurred.Allaneurysmswer e excluded with no endoleaks. The IIA was preserved as planned.

Conclusion: Conventional open repair of AAA with tube prosthesis may be followed by development of true iliac aneurysms.Endovascularapproachappearstobebeneficialinpatients withahistoryofhostileabdomenandinthoseatincreasedsurgical risk.The remaining open question is whether the primary success of endoluminal stent-graft deployment of commercially available devices will be confirmed by long-term treatment results

Keywords: Trueiliacaneurysm; Ruptured abdominalaortic aneurysm; Endovascular treatment

2. Introduction Conventional abdominal aortic prosthetic reconstruction for Abdominal Aortic Aneurysm (AAA) repair is a reliable procedure. Trueiliacaneurysmsdevelopmentisrecognizedprogressionofthe aneurysmal disease that occurs years after the initial surgery [1]. Reoperations are technically challenging procedures that require dissection through previously used operative sites. Furthermore, the patients are likely to develop more comorbidities than during primary aortic surgery. We present our experience in endovascularrepairoftrueiliacaneurysmwithcommerciallyavailablestent graftdevices.Theinitialsurgerywasopenreconstructionforruptured AAA with Dacron tube graft performed 8 years ago.

3. Case Report In Мarch 2012, a 50 years old male underwent emergency open surgery due to ruptured, 8cm AAA. A 24mm Dacron tube graft was used. He is an active smoker, heavily obese (BMI 40,1), has arterialhypertensionandnootherknowconcomittantdiseases.In December 2012 a follow up CTscan was performed - patent tube graft, dilatation of the right Common Iliac Artery (CIA) (24mm) and internal iliac artery (IIA) (19mm), aneurysm of the left CIA (44mm). In January 2013 two stent graftsAdvanta were placed in kissingconfigurationintheleftexternaliliacartery(EIA)andIIA (10/59; 8;59) to treat the left CIAaneurysm.ACT scan had been performedyearlyafterthat(Table1).InJuly2020thesizeofthe rightCIA/IIAreached36mmand22mmrespectively.Thepatient didnothaveclinicalorCTsignsofgraftinfection.Throughpreoperative risk assessment the patient was classified as ASA III. The time interval from primary operation to diagnosis of left CIA aneurysmwas1year.Thetimeintervalfromprimaryoperationto diagnosis of true aneurysm of the distal part of the aorta and the right CIA and IIA was 6 years (Table 1). The patient underwent elective surgery. The procedure was performedinanangiographicequippedoperatingtheater.Undergen- eral anesthesia - open right femoral access (for the main body), openleftaxillaryaccess(for7FrDestination90cminordertohave lengthtotheinternaliliacartery)andpercutaneousleftfemoralaccess7Fr(forAdvantaimplantation)wereperformed.Theproximal stentgraftwasanchoredinDacrontubegraftrightabovetheaortic bifurcation and way below renal arteries. We had some concerns aboutstentgraftbehaviorinDacronprosthesisbutstabilityofthe system was excellent. We suggest that it is important to preserve theIIAwheneverpossiblesoweusedparallelgraftstechniquefor the right side. For the left side we bridged previously implanted Advantas with the left leg of the main body by two newAdvanta stentgrafts(9/58).Fortherightsideweusedaniliacextensionto EIAand twoAdvanta stent grafts (6/59) to the biggest branch of IIAandcoilembolization(ConcertoHelix)intheotherbranchfor maximum sealing of IIA aneurysm. Stent grafts deployment was successful. There was no operative morbidity and no complications occurred during operation. On completionangiography,allaneurysmswereexcludedwithnoendoleaks.TheIIAwaspreservedasplanned.Theoperationduration was 150 mins with 200ml blood loss. The patient circulation was stable without a fall in systolic arterial pressure perioperatively. Postoperatively,thepatientwenttomediumcareunit,onanormal dietandmobilizedonthefirstpostoperativeday.Pre-dischargeultrasoundexam,performedonthesecondpostoperativedayshowed patentgraftsandnosignsofendoleaks.DAPTwasprescribedfor 6months.ACTscanonfirstandsixthmonthsshowedpatentstent graftswithnoendoleaks,completeclosureoftheaneurysmalsacs and patent IIA on both sides.

4. Discussion True iliac aneurysm development years after the initial open reconstruction ofAAAis a robust manifestation of aneurysmal disease progression. AAAandiliacaneurysmsareacommondegenerativediseasethat leadstoitsdilatationand,ultimately,torupture.Mortalityfrom a rupturedAAAapproximates 90% [1].AAArupture can be preventedbyelectiveopensurgicalorendovascularaneurysmrepair, which have an overall combined mortality of 5% [2]. Surgical repairisconsideredappropriatewhentheaorticdiameterexceeds55 mm.Ingeneral,atthisthreshold,theriskofruptureexceedsthose of surgery related morbidity and mortality [3]. However, for the individualpatientthisthresholdisapoorpredictorofrisk,assome AAAs rupture at a diameter below 55 mm and others progress to over70mmwithoutruptureoccurring.waitinguntiltheaorticdiameter reaches 55 mm before elective repair could be too late for somepatientsandleadtounnecessarysurgeryinothers.Thereisa needforapatient-specificpredictorofAAAprogression.Circulat- ing biomarkers could provide such prediction and offer a tool for targeted therapy. The results of studies on CIAexpansion rate are difficult to compare because in most series: (1) the diameter at which a CIA is consideredaneurysmalisnotclearlydefined;(2)themethodsused tomeasurearterialdiametervaryconsiderably;and(3)evenwhen there is a definition of CIA aneurysm, it differs from one authorto another. For instance, Provan et al [4] defined a CIAof 15–30 mm indiameterasectaticand30 mmasaneurysmal.Santillietal [5]consideredanyCIAwithapermanentlocalizeddilationlarger than 15 mm in diameter as aneurysmal, and any CIA with a di- ameter greater than 25 mm was aneurysmal according to Krupski et al [6]. One year after the initial open repair for ruptured AAA we diagnosed aneurysm of the left common iliac artery (40mm). Kalman et al6.1 found a high incidence (30.8%; 12 of 39) of late iliac aneurysms after a mean 129 months, and they emphasized theimportanceofthesurgeon’schoicebetweentubeinsertionand moredistalrepairatiliacorfemoralarterylevelwhentheiliacarteriesshowsomeectasiaalreadyatthetimeoftheoriginalrepair. In our case the patient developed left common iliac aneurysm at the first year after the open repair and right common and internal iliac artery aneurysm at the 6th year.

Kasirajan et al [7], on the contrary, reported no enlargements in a series of 9 isolated CIAs with a mean diameter of 2.1 cm (range, 2–2.5cm)followedupforameanof57months.WhenDosluoglu etal[8]comparedtheCIA’sexpansionrateinpatientswith(n=9; mean,2.7±0.8cmindiameter)orwithout(n=4;2.6±0.9cmin diameter)previousAAArepair,theyfoundthatthesizeremained stableforthefirst5yearsafterdiagnosis.Balottaetal.[9]report- ed that most CIAs do not expand after tube graft insertion during AAArepair, and when they do, the degree of dilation is minimal. Anotherimportantaspectofthecommoniliacarteryaneurysmsis the preservation of the internal iliac artery. One of the basic principles of vascular surgery is vessel preservation/reconstruction wheneverpossible.EvenifIIAsacrificehasbeengenerallyreport- ed to be safe, pelvic ischemic complications may actually occur andtheycansignificantlyimpairpatients’qualityoflife.Arecent systematic review showed that buttock/thigh claudication develops in approximately one-third of patients undergoing IIAexclusion, and about 10% of men experience a new-onset erectile dysfunction [10]. The factors that influence the development of buttock/thighclaudicationanderectiledysfunctionarenotcompletely understood,buttheadequacyofpelviccollateralcirculationlikely plays an important role. Even though the exact definition of patientsathighriskofpelvicischemiaisdifficult,thelikelihoodand severityofpostoperativeischemicmanifestationsareconsistently higherafterbilateralthanunilateralocclusion[11,12].Thus,preservationofbloodflowtoatleastoneIIAisstronglyrecommended, ifitdoesnotcompromiseaneurysmexclusion,byclinicalpractice guidelinesfromvascularsurgicalsocietiesinUSAand Europe[13, 14]. The way the IIAis excluded also seems to play a major role in the development of pelvic ischemic complications: Coils are generally associated with poorer outcomes than plugs, and occlusionoftheproximalIIAtrunkisgenerallyassociatedwithreduced ratesofpelvicischemiccomplicationsascomparedwithocclusion of the distal IIA branches [15]. The timing of IIA embolization might be another determinant of pelvic ischemic complications. Bilateralembolizationisusuallyperformedinatwo-stagefashion afewweeksaparttoallowforcollateralcirculationdevelopment; similarly,unilateralembolizationmayalsobestagedorperformed concomitantlywithEVAR.However,despiteclaimsthatbuttock/ thigh claudication is more common after concomitant rather than stagedprocedures,thereisnoobviousbenefitforsequentialversus simultaneous IIA embolization [16]. Iliac branch devices (IBD) IBD represents the first dedicated endovascular option to preserve antegrade flow to the IIA, when anatomically feasible [17]. These devices offer reduced rates of mortality and morbidity as compared to open approaches, while maintainingexcellenttechnicalsuccessandprimarypatency [18]. The bell-bottom technique has been used widely to facilitate achievementofadistalsealinadilatedCIAwhilepreservingpelvicflow[19].However,concernsaboutlongtermstabilitystill remain,andhighincidenceoflatetype1Bendoleaksfromlossof distal fixation and seal has been reported. IIAbypass has excellent results in terms of patency and freedom from ischemic complications but is technically demanding and a more invasive operation that may reduce the benefit from EVAR [20]. The parallel-graft technique for IIA preservation is also feasible with acceptable short-term results, but the gutters created by the parallel grafts may cause endoleaks and the durability is the main concern [21]. Furthermore, the parallel stent grafts may compress eachother,thereforepotentiallyincreasingtheriskofthrombosis. Use of physician-modified devices has also been described to maintainIIAperfusion[22].However,theyrequiretimeformodificationandshouldbeusedcautiouslybyadequatelytrainedphysicians in patients without other reasonable options. Use of aortouniiliac endografting with crossover femoro-femoral bypassisanalternativesolution.ThismayincludeCIAembolization.However,thesesolutionsseemlessdesirable,sincetheymay cause contralateral IIA malperfusion and thrombotic or infective events, which would lead to serious complications following repair. Simple IIAcoverage without prior embolization has been shown by some authors as not increasing the risk of type 2 endoleaks or secondaryinterventions[23].However,thereisalackofrandomizedcontrolledtrialsandtheavailableevidencecomesfromsmall retrospective series which are difficult to compare. InBulgariawedon'thaveallthemodernendovasculardeviceson the shelf. Furthermore, their use is not covered from the National Health Insurance. In order to preserve the IIA we used Advanta coveredstents.Theirpatencyratefor2yearsis100%.Intheliter- ature there is no scientific data about the applicability ofAdvanta stent grafts in the settings of CII aneurysms. Lattermost this was our “bail-out” alternative.

5. Conclusion Although most CIAs do not expand after tube graft insertion duringAAArepair,someofthemareaffectedfromaneurysmprogression. The endovascular option may be advantageous to this group of patients with history of previous abdominal operationsorwithseriouscardiopulmonaryriskfactorsascomparedw iththe more invasive open surgical repair. The remaining open question iswhethertheuseofcommerciallyavailablestentgraftsintreating these cases will be confirmed by long-term treatment results.Althoughlong-termevidenceisnotyetavailable,themethodappears to be beneficial in patients with hostile abdomen and in those at increased surgical risk.

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Margaret Dimova. Endovascular Treatment of Common Iliac Artery Aneurysm after open Repair for Ruptured AAA with Commercially Available Devices in Bulgaria - Case Report. Annals of Clinical and Medical Case Reports 2022