Radiol med DOI 10.1007/s11547-014-0468-y
VASCULAR AND INTERVENTIONAL RADIOLOGY
Isolated iliac artery aneurysms: a single‑centre experience Rita Fossaceca · Giuseppe Guzzardi · Paolo Cerini · Ignazio Divenuto · Carmelo Stanca · Giuseppe Parziale · Piero Brustia · Alessandro Carriero
Received: 31 May 2013 / Accepted: 19 May 2014 © Italian Society of Medical Radiology 2014
Abstract Purpose This paper reviews our experience in endovascular treatment of isolated iliac artery aneurysms (IIAAs) with a large number of patients. Materials and methods From May 2005 to September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs underwent endovascular treatment at our institute. We evaluated technical success, long-term patency, early and late complications and overall mortality. Patients were divided into two
R. Fossaceca · G. Guzzardi · P. Cerini (*) · I. Divenuto · C. Stanca · G. Parziale · A. Carriero Department of Diagnostic and Interventional Radiology, ‘‘Maggiore della Carita`’’Hospital, University of Eastern Piedmont ‘‘Amedeo Avogadro’’, C.so Mazzini 18, 28100 Novara, NO, Italy e-mail: [email protected] R. Fossaceca e-mail: [email protected] G. Guzzardi e-mail: [email protected] I. Divenuto e-mail: [email protected] C. Stanca e-mail: [email protected] G. Parziale e-mail: [email protected] A. Carriero e-mail: [email protected] P. Brustia Department of Vascular Surgery, ‘‘Maggiore della Carita`’’ Hospital, University of Eastern Piedmont ‘‘Amedeo Avogadro’’, C.so Mazzini 18, 28100 Novara, NO, Italy e-mail: [email protected]
groups: emergency-treatment group and elective-treatment group. Results At a median follow-up of 34.3 months, we achieved a technical success of 97.8 %, a primary patency of 95.5 % and a secondary patency of 100 %, with complete exclusion of the aneurysm in 84.5 % of cases. The incidence of endoleaks was of 15.5 %: eight were type II and one was type III; perioperative mortality was 4.7 %. Conclusions Our study documents the effectiveness, in both emergency and elective settings, of the endovascular treatment of iliac aneurysms (EVIAR), which has become the first-choice treatment at our institute. In particular cases, it is also possible to avoid embolisation of the internal iliac artery. Keywords EVAR · Isolated iliac artery aneurysms · Endoprosthesis · Endovascular treatment
Introduction Isolated iliac artery aneurysms (IIAAs) are the less frequent intra-abdominal aneurysms, but they are associated with a high risk of rupture and death [1]. Published papers deal exclusively with IIAA although the series also includes AAA [2, 3]. IIAAs are located in the common iliac artery (CIA) in 70 % of cases, in the internal iliac artery (IIA) in 20 % of cases and in the external iliac artery (EIA) in only 10 % of cases [4]. Clinical manifestations are frequently related to the compression of adjacent structures; in the case of rupture, the patient generally complains of rapid onset abdominal pain associated with bradycardia, hypotension and sweating [4, 5]. IIAA treatment is indicated if the aneurysm is >3 cm, if it has a growth rate >5 mm in 6 months or >1 cm in a year or if the patient is symptomatic [1, 6].
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Open surgery has been the standard treatment for years [7, 8]; although it generally achieved high levels of technical success, it is accompanied by several complications such as bleeding, surgical infections, ureteral injury and distal embolisation with lower-limb ischaemia. The mortality rate of elective aneurysm surgery is relatively low (0–6.2 %), whereas that of emergency surgery is significant and ranges from 0 to 55.5 % [9–14]. Over the last decade, endovascular treatment has become a good alternative to open surgery for IIAAs because it combines shorter operative times, a lower incidence of complications and perioperative mortality and excellent long-term results [15–17]. As a result, in many centres the endovascular approach has become the first-choice treatment in both elective and emergency settings. We have previously reported our experience in the endovascular treatment of IIAAs with a smaller number of patients [18]. The purpose of this study was to review our experience to date, which has a number of patients amongst the largest reported in the literature, and to assess the proper management of aneurysms involving IIA treated in emergency and elective circumstances.
Materials and methods Between May 2005 and September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs (mean diameter 4.4 cm) underwent endovascular treatment: an Excel database was prospectively recorded and retrospectively analysed. All patients with concomitant AAA were excluded from our analysis. Twelve IIAAs were restricted to the CIA and 20 involved the CIA near the aortic carrefour and/or iliac bifurcations. Ten patients had concomitant CIA and IIA; seven patients had IIA. Table 1 shows the characteristics of the patients and aneurysms. In all cases, preliminary computed tomography angiography (CTA) was performed to adequately assess aneurysm characteristics and to select the most suitable stent-graft. Prior to the procedure, all patients were informed about the benefits and risks and provided their informed consent. As the study was retrospective, approval of the local ethics committee was not sought. In 18 cases, the procedure was performed in the angiography room with an Integris V5000 angiography unit (Philips Medical System, Best, The Netherlands). The remaining 27 cases were treated in an operating room with a portable BV300 angiography unit (Philips Medical System, Best, The Netherlands). In 18 cases, the procedure was performed under local anaesthesia and with anaesthesiological assistance (lidocaine 2 %), in 15 cases under intraspinal anaesthesia and in 12 cases under general anaesthesia. In 23 cases, treatment was performed
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Radiol med Table 1 Characteristics of patients and of treated aneurysms Characteristics
N (%)
Sex (male) Average age Coronary disease Peripheral artery disease Chronic obstructive pneumonia disease Tumours Chronic kidney disease Hypertension Diabetes Dyslipidaemia Smoking Aneurysms
43/45 (95.5) 74 ± 10 15 (33.3) 13 (28.8) 9 (20) 8 (17.7) 8 (17.7) 26 (57.7) 16 (35.5) 9 (20) 17 (37.7)
N CIA CIA + IIA IIA Elective treatment Mean diameter, cm Emergency treatment Mean diameter, cm Clinical manifestations Asymptomatic Abdominal pain Hypovolaemic shock Urinary symptoms
59
Positive physical examination
32 (54.2) 10 (16.9) 7 (11.8) 33/45 (73.3) 4 cm 12/45 (26.6) 5.9 cm 27 (60) 7 (15.5) 9 (20) 2 (4.4) 7 (15.5)
CIA common iliac artery, IIA internal iliac artery
exclusively by percutaneous access; in nine cases, surgical exposure of both femoral arteries was made; in the remaining 13 cases, a combined approach was used with surgical exposure of the femoral artery ipsilateral to the aneurysm to be treated and a contralateral percutaneous puncture. As a general rule, in agreement with published data [19], patients with CIA aneurysms were treated by stent-graft placement. Those with aneurysms of the CIA near the aortic bifurcation (
VASCULAR AND INTERVENTIONAL RADIOLOGY
Isolated iliac artery aneurysms: a single‑centre experience Rita Fossaceca · Giuseppe Guzzardi · Paolo Cerini · Ignazio Divenuto · Carmelo Stanca · Giuseppe Parziale · Piero Brustia · Alessandro Carriero
Received: 31 May 2013 / Accepted: 19 May 2014 © Italian Society of Medical Radiology 2014
Abstract Purpose This paper reviews our experience in endovascular treatment of isolated iliac artery aneurysms (IIAAs) with a large number of patients. Materials and methods From May 2005 to September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs underwent endovascular treatment at our institute. We evaluated technical success, long-term patency, early and late complications and overall mortality. Patients were divided into two
R. Fossaceca · G. Guzzardi · P. Cerini (*) · I. Divenuto · C. Stanca · G. Parziale · A. Carriero Department of Diagnostic and Interventional Radiology, ‘‘Maggiore della Carita`’’Hospital, University of Eastern Piedmont ‘‘Amedeo Avogadro’’, C.so Mazzini 18, 28100 Novara, NO, Italy e-mail: [email protected] R. Fossaceca e-mail: [email protected] G. Guzzardi e-mail: [email protected] I. Divenuto e-mail: [email protected] C. Stanca e-mail: [email protected] G. Parziale e-mail: [email protected] A. Carriero e-mail: [email protected] P. Brustia Department of Vascular Surgery, ‘‘Maggiore della Carita`’’ Hospital, University of Eastern Piedmont ‘‘Amedeo Avogadro’’, C.so Mazzini 18, 28100 Novara, NO, Italy e-mail: [email protected]
groups: emergency-treatment group and elective-treatment group. Results At a median follow-up of 34.3 months, we achieved a technical success of 97.8 %, a primary patency of 95.5 % and a secondary patency of 100 %, with complete exclusion of the aneurysm in 84.5 % of cases. The incidence of endoleaks was of 15.5 %: eight were type II and one was type III; perioperative mortality was 4.7 %. Conclusions Our study documents the effectiveness, in both emergency and elective settings, of the endovascular treatment of iliac aneurysms (EVIAR), which has become the first-choice treatment at our institute. In particular cases, it is also possible to avoid embolisation of the internal iliac artery. Keywords EVAR · Isolated iliac artery aneurysms · Endoprosthesis · Endovascular treatment
Introduction Isolated iliac artery aneurysms (IIAAs) are the less frequent intra-abdominal aneurysms, but they are associated with a high risk of rupture and death [1]. Published papers deal exclusively with IIAA although the series also includes AAA [2, 3]. IIAAs are located in the common iliac artery (CIA) in 70 % of cases, in the internal iliac artery (IIA) in 20 % of cases and in the external iliac artery (EIA) in only 10 % of cases [4]. Clinical manifestations are frequently related to the compression of adjacent structures; in the case of rupture, the patient generally complains of rapid onset abdominal pain associated with bradycardia, hypotension and sweating [4, 5]. IIAA treatment is indicated if the aneurysm is >3 cm, if it has a growth rate >5 mm in 6 months or >1 cm in a year or if the patient is symptomatic [1, 6].
13
Open surgery has been the standard treatment for years [7, 8]; although it generally achieved high levels of technical success, it is accompanied by several complications such as bleeding, surgical infections, ureteral injury and distal embolisation with lower-limb ischaemia. The mortality rate of elective aneurysm surgery is relatively low (0–6.2 %), whereas that of emergency surgery is significant and ranges from 0 to 55.5 % [9–14]. Over the last decade, endovascular treatment has become a good alternative to open surgery for IIAAs because it combines shorter operative times, a lower incidence of complications and perioperative mortality and excellent long-term results [15–17]. As a result, in many centres the endovascular approach has become the first-choice treatment in both elective and emergency settings. We have previously reported our experience in the endovascular treatment of IIAAs with a smaller number of patients [18]. The purpose of this study was to review our experience to date, which has a number of patients amongst the largest reported in the literature, and to assess the proper management of aneurysms involving IIA treated in emergency and elective circumstances.
Materials and methods Between May 2005 and September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs (mean diameter 4.4 cm) underwent endovascular treatment: an Excel database was prospectively recorded and retrospectively analysed. All patients with concomitant AAA were excluded from our analysis. Twelve IIAAs were restricted to the CIA and 20 involved the CIA near the aortic carrefour and/or iliac bifurcations. Ten patients had concomitant CIA and IIA; seven patients had IIA. Table 1 shows the characteristics of the patients and aneurysms. In all cases, preliminary computed tomography angiography (CTA) was performed to adequately assess aneurysm characteristics and to select the most suitable stent-graft. Prior to the procedure, all patients were informed about the benefits and risks and provided their informed consent. As the study was retrospective, approval of the local ethics committee was not sought. In 18 cases, the procedure was performed in the angiography room with an Integris V5000 angiography unit (Philips Medical System, Best, The Netherlands). The remaining 27 cases were treated in an operating room with a portable BV300 angiography unit (Philips Medical System, Best, The Netherlands). In 18 cases, the procedure was performed under local anaesthesia and with anaesthesiological assistance (lidocaine 2 %), in 15 cases under intraspinal anaesthesia and in 12 cases under general anaesthesia. In 23 cases, treatment was performed
13
Radiol med Table 1 Characteristics of patients and of treated aneurysms Characteristics
N (%)
Sex (male) Average age Coronary disease Peripheral artery disease Chronic obstructive pneumonia disease Tumours Chronic kidney disease Hypertension Diabetes Dyslipidaemia Smoking Aneurysms
43/45 (95.5) 74 ± 10 15 (33.3) 13 (28.8) 9 (20) 8 (17.7) 8 (17.7) 26 (57.7) 16 (35.5) 9 (20) 17 (37.7)
N CIA CIA + IIA IIA Elective treatment Mean diameter, cm Emergency treatment Mean diameter, cm Clinical manifestations Asymptomatic Abdominal pain Hypovolaemic shock Urinary symptoms
59
Positive physical examination
32 (54.2) 10 (16.9) 7 (11.8) 33/45 (73.3) 4 cm 12/45 (26.6) 5.9 cm 27 (60) 7 (15.5) 9 (20) 2 (4.4) 7 (15.5)
CIA common iliac artery, IIA internal iliac artery
exclusively by percutaneous access; in nine cases, surgical exposure of both femoral arteries was made; in the remaining 13 cases, a combined approach was used with surgical exposure of the femoral artery ipsilateral to the aneurysm to be treated and a contralateral percutaneous puncture. As a general rule, in agreement with published data [19], patients with CIA aneurysms were treated by stent-graft placement. Those with aneurysms of the CIA near the aortic bifurcation (
