1

A NEW MANAGEMENT FOR HYPOGASTRIC FLOW EXCLUSION IN

EVAR USING AN EXTENSION OF THE SAC THROMBIZATION

PROCEDURE

Ronsivalle S, Faresin F, Franz F , Pedon L *Vascular and Endovascular

Surgery and Angiology Department of cardiology *

Cittadella, Padova (Italy)

Introduction

EL type II the most common complication of EVAR procedure is due to

partial or incomplete thrombosis of the aneurysm sac after successful

aneurysm exclusion in conjunction with retrograde perfusion from aortic

collateral branches (lumbar, inferior mesenteric, sacral and renal accessory

arteries). It could also be caused by the hypogastric artery when the common

iliac artery aneurysmatic is involved. 1

Our previously published results about EL type II reduction through the use

of inconel coils and fibrin glue injection in aneurysm sac have been

reconfirmed after a further year of follow up.

We had already demonstrated that biomaterials stimulate and accelerate the

intrasac thrombization process causing efferent vessels flow exclusion and

ensuring long lasting sturdy stabilization of the entire complex en bloc and

reduced EL type II incidence. 4 It has also been further proven that in

abdominal aortic aneurysms with an ectatic common iliac artery, the Bell

Bottom technique is recommended. 5

But there are many situations in which an external iliac artery landing is

necessary: aorto-iliac aneurysm or isolated common iliac artery aneurysm or

2

distal aneurysmatic disease progression after EVAR or pseudoaneurysm of

aorto bisiliac by pass distal anastomosis.

Both Sandwich and Branching techniques could be alternatives in preserving

hypogastric artery flow. 6-7-8And, in episodes of multiple vessel involvement

(aorta and common, internal and external iliac arteries) open surgery is

recommended. But when an external iliac landing is necessary and it is not

possible to preserve the hypogastric artery flow, it is mandatory a selective

internal iliac artery origin embolization before or during EVAR with ipsi or

contralateral (crossing) access.

After a hypogastric artery exclusion failure or incomplete exclusion through

an endovascular procedure, it is possible to close it via surgical open

extraperitoenal access in iliac fossa.

Considering the difficulties in hypogastric selective exclusion, and taking into

account our vast experience in aortic aneurysmatic sac thrombization, we

have decided to try using iliac aneurysmatic sac thrombization with

biomaterials for hypogastric artery origin exclusion.

Materials and Methods

From June 2006 to April 2013, 492 patients underwent EVAR plus

aneurymatic sac thrombization with biomaterials.

We performed 66 Bell Bottom procedures in 54 patients that had aortic

abdominal aneurysms with an ectatic common iliac artery.

In 60 of 492 patients an external iliac landing was necessary: 38 had a

concomitant common iliac aneurysm (Fig.1) and 11 had an isolated common

iliac artery aneurysm (Fig.2) with bifurcation involvement, 9 had a distal

3

aneurysmatic disease progression (Fig.3) 4 had an associated EL IB and 1

had a pseudoaneurysm of aorto bisiliac by pass distal anastomosis (Fig 4).

Twenty-nine patients of 60 underwent successful selective internal iliac

artery embolization (22 ipsi-lateral, and 7 contro-lateral through a crossing

access) .

During our past experience in aortic aneurysmatic sac thrombization, we have

had to deal numerous times with the difficulties encountered in hypogastric

embolization, and we have cone to the conclusion that using iliac

aneurysmatic sac thrombization with biomaterials for hypogastric artery

origin exclusion may be the best solution.

This approach, designed as an alternative in episodes of difficult selective

hypogastric embolization, has become now a routine technique in our

Operative Unit.

31 patients have been treated with this method without complications.

In 29 patients, who underwent successfully selective internal iliac artery

embolization, there were 8 buttock claudications.

During follow up, 6 patients experienced a symptomatic improvement or

resolution and only 2 had persistent buttock claudications.

There were 6 buttock claudications in 31 patients who underwent successfully

aneurysm sac common iliac artery thrombization with biomaterials.

During follow up, 4 patients experienced symptomatic improvement or

resolution and only 2 had persistent buttock claudication. 10

No major complications were observed.

Thrombization Technique

4

After deployment of the endograft, leaving a 180-cm-long 0.035-inch

standard J guidewire between the endograft and the native arterial wall,

through a 23- to 35-cm-long 5-F Brite Tip introducer (Cordis, a Johnson &

Johnson company, Miami Lakes, FL, USA) some MReye embolization coils

(IMWCE 35-20-20; Cook Medical, Bloomington , IN, USA) and fibrin glue

(Tisseel/Tissucol, Baxter-Hyland Immuno AG, Vienna, Austria) are inserted

into the sac.

An aneurysmogram is performed to verify sac thrombization with root

occlusion of the collateral arteries.

The Brite Tip introducer is then removed, and the completion angiogram is

performed. 4

In case of aorto bis-iliac stent graft positioning at first guidewire and brite tip

are positioned inside the aneurysm sac, than pulled out in the iliac

aneurysmatic sac.

Discussion

Even though at low –flow, type II endoleak may prevent thrombosis of the

aneurysmatic sac and create a potential risk of continued aneurysm expansion

and potential rupture, it may be due not only to retrograde flow from lumbar,

inferior mesenteric, sacral and renal accessory arteries, but also from the

hypogastric artery in cases of common iliac artery aneurysmatic involvement.

There is a high probability of endoleak type II without a hypogastric artery

exclusion.

5

We can have an EL type II in the iliac aneurysmatic sac in episodes of

isolated iliac aneurysm or an EL type II which involves both aortic and iliac

sac when there is an aorto iliac aneurysm.

An EL type II due to hypogastric artery has a high load, most of all in cases in

which there is a contralateral hypogastric patency refuelling the collateral

pelvic pathways.

To avoid an EL type II , hypogastric artery exclusion is mandatory.

At first, in all patients in whom an external iliac artery landing was necessary,

a selective hypogastric artery embolization was tried and when we couldn’t

embolize it, sac thrombization with internal iliac artery exclusion was

performed successfully.

After many years of practice, our prolonged experience in aortic aneurysmatic

sac thrombization, has become quite extensive and we have come to the

conclusion that iliac aneurysmatic sac thrombization with biomaterials for

hypogastric artery exclusion can be an effective alternative procedure not

only in cases of difficult selective internal iliac artery embolization, but also

as a routine technique.

Conclusions

Preventive intrasac (aortic and iliac ) thrombization proves to be a quick,

money saving and safe technique, regardless of stent graft used.

It has been successfully demonstrated to be a useful alternative to hypogastric

artery embolization, a procedure ,which many times can be problematic.

References

6

1. Muthu C, Maani J, Plank LD, et al. Strategies to reduce the rate of type II

endoleaks: routine intraoperative embolization of the inferior mesenteric

artery and thrombin injection into the aneurysm sac. J Endovasc Ther.

2007;14: 661–668.

2. Jonker FH, Aruny J, Muhs BE. Management of type II endoleaks:

preoperative versus postoperative versus expectant management. Semin

Vasc Surg. 2009;22:165–171.

3. Marchiori A, von Ristow A, Guimaraes M, et al. Predictive factors for the

development of type II endoleaks. J Endovasc Ther. 2011;18:299–305.

4. Ronsivalle S, Faresin F, Franz F, et al. Aneurysm sac ‘‘thrombization’’ and

stabilization in EVAR: a technique to reduce the risk of type II

endoleak. J Endovasc Ther. 2010;17:517–524.

5. Naughton PA, Park MS, Kheirelseid EA, O'Neill SM, Rodriguez HE,

Morasch MD, Madhavan P, Eskandari MK.A comparative study of the bell-

bottom technique vs hypogastric exclusion for the treatment of

aneurysmal extension to the iliac bifurcation J Vasc Surg. 2012

Apr;55(4):956-62. Epub 2012 Jan 5

6 Use of Chimneys, Snorkels, and Periscopes to Preserve

Aortic Branches During Endograft Repair Criado FJ J End Ther

2010;17:221

7. Lee WA Branched endograft for aortoiliac artery aneurysms. Vascular.

2009 Nov-Dec;17 Suppl 3:S111-8

8. Lobato AC Sandwich technique for aortoiliac aneurysms extending to the

internal iliac artery or isolated common/internal iliac artery aneurysms: a new

endovascular approach to preserve pelvic circulation. J Endovasc Ther. 2011

Feb;18(1):106-11

9. Hosaka A, Kato M, Kato I, Isshiki S, Okubo N Outcome after concomitant

unilateral embolization of the internal iliac artery and contralateral external-

7

to-internal iliac artery bypass grafting during endovascular aneurysm repair J

Vasc Surg. 2011 Oct;54(4):960-4. Epub 2011 May 31

10. Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London

NJ, Sayers RD Buttock claudication and erectile dysfunction after internal

iliac artery embolization in patients prior to endovascular aortic aneurysm

repair Cardiovasc Intervent Radiol. 2008 Jul-Aug;31(4):728-34. Epub 2008

Mar 13