title: Endovascular management of iliac rupture during endovascular aneurysm repair.
abstract: BACKGROUND
  Inadequate iliac artery diameter, calcification, and tortuosity are associated with increased incidence of iliac injury during abdominal (EVAR) and thoracic endovascular aneurysm repair (TEVAR). Despite careful preoperative assessment and use of iliac conduits, inadvertent iliac rupture is a source of morbidity and mortality. This report details our single-center, 10-year experience with intraoperative iliac artery rupture and describes a successful endovascular salvage technique.
  
  
  METHODS
  All patients undergoing EVAR and TEVAR between August 1997 and June 2008 were reviewed. Computed tomography (CT) measurements of access vessels were obtained for all patients. The smallest diameter of the external or common iliac artery was used to determine suitability for access based on the instructions for use for each device. Patients who underwent repair of a procedure-related iliac artery rupture were identified. Outcomes among patients who did not have an access vessel rupture (nonruptured group) and those who did (ruptured group) were compared. Patency of the endovascular iliac repair is reported.
  
  
  RESULTS
  During the study period, 369 EVARs and 67 TEVARs were performed. Eleven iliac conduits were used, all during TEVAR (16%). There were 18 ruptured iliac arteries in 17 patients; 11 EVAR patients (2.98%) sustained iliac rupture vs six TEVAR patients (8.9%). One EVAR patient was converted to open repair. Seventeen ruptures in 16 patients were successfully treated with endovascular stent graft placement. Iliac rupture was more likely to occur during TEVAR (8.9%) than EVAR (2.98%; P = .0239, Fisher exact test). Significantly more women were in the ruptured group (76% vs 19%; P < .0001, Fisher exact test). Patients in the ruptured group had longer lengths of stay (7.6 vs 5.1 days; P = .0895, t test), no 30-day mortality, but a procedure-related mortality of 11.8%. In the nonrupture group, 30-day mortality was 6.6% (4 of 61) and 2.8% (10 of 358) for TEVAR and EVAR, respectively, and procedure-related mortality was 9.8% (6 of 61) and 3.1% (11 of 358). For endovascular repair of iliac rupture, primary and primary-assisted patency was 88.2% and 94.1%, respectively, with median follow-up of 40 months (range 10-115 months).
  
  
  CONCLUSIONS
  Iliac rupture during EVAR or TEVAR can be successfully managed with endovascular stent grafting. Higher mortality and length of stay associated with iliac artery rupture confirm that there is no substitute for prevention. Access vessels of all patients undergoing EVAR should be examined closely for suitability. The threshold for using an iliac conduit, especially in women undergoing TEVAR, should be low.
authors.affiliation: Division of Vascular Surgery, Department of Preventive Medicine, University of Tennessee-Memphis, Memphis, TN, USA. drosos.kotelis@med.uni-heidelberg.de
authors.forename: Joss D
authors.initials: JD
authors.lastname: Fernandez
authors.forename: John M
authors.initials: JM
authors.lastname: Craig
authors.forename: H Edward
authors.initials: HE
authors.lastname: Garrett
authors.forename: Suzanne R
authors.initials: SR
authors.lastname: Burgar
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Bush
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011474:Prosthesis Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012421:Rupture; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome