title: Adjunctive stenting of endograft limbs during endovascular treatment of infrarenal aortic and iliac aneurysms according to 3-projection completion angiography.
abstract: OBJECTIVE
  To evaluate the role of 3-projection completion angiography in defining endograft limb stenosis after endovascular aneurysm repair (EVAR) and to determine the role of adjunctive stenting in reducing the risk of endograft limb occlusion.
  
  
  METHODS
  In our center, stent-graft limb dilation was routinely done after endograft deployment in patients with preoperatively identified severe iliac axis angulation to reduce the incidence of limb stenosis. Completion angiography was then routinely performed in anteroposterior (AP) and 45° right and left oblique projections to identify perioperative endograft limb stenosis after the stiff guidewires were removed. Adjunctive stenting was used in iliac limbs with postangioplasty residual stenosis >50%. From January 2005 to November 2010, 302 EVAR patients (296 men; mean age 74.25 ± 7.04 years, range 53-90) with 589 stent-graft limbs (aortomonoiliac stent-graft in 15 patients) who had a minimum 6 months of follow-up and a nonstenotic aortic bifurcation were selected for this study. Patient demographics, clinical risk factors, iliac anatomical features, procedure data, and limb patency were analyzed. Primary endpoints were the incidence of limb stenosis >50% and any associated risk factors; the secondary endpoint was the primary patency of stent-graft limbs with adjunctive stenting.
  
  
  RESULTS
  On 3-projection completion angiography, 40 (6.8%) limbs presented limb stenosis and were treated with adjunctive stenting; in only 28 (70%) of these cases was the >50% limb stenosis evident on the AP view. According to the degree of preoperative iliac angulation, limb stenosis occurred in mild (<60°), moderate (60°-89°), and severe (≥ 90°) angulations in 14 (4.6%), 9 (5.6%), and 17 (13.4%) cases, respectively; positive predictors for limb stenosis were severe iliac artery angulation [vs. moderate (p = 0.02) and mild (p = 0.001)] and stent-graft limb diameter <16 mm (p = 0.02). In the adjunctive stenting group, the mean follow-up was 16.1 months; no graft occlusion, graft erosion, or restenosis was seen during follow-up (100% primary patency at 12 and 24 months).
  
  
  CONCLUSIONS
  Three-projection completion angiography is crucial to identifying limb stenosis, for which adjunctive stenting appears to ensure primary patency in midterm follow-up. Preoperative iliac artery angulation and small endograft limb diameter are positive prognostic factors for limb stenosis >50%.
authors.affiliation: Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy. claudiobianchinim@gmail.com
authors.forename: Claudio
authors.initials: C
authors.lastname: Bianchini Massoni
authors.forename: Mauro
authors.initials: M
authors.lastname: Gargiulo
authors.forename: Federica
authors.initials: F
authors.lastname: Giovanetti
authors.forename: Antonio
authors.initials: A
authors.lastname: Freyrie
authors.forename: Gianluca
authors.initials: G
authors.lastname: Faggioli
authors.forename: Enrico
authors.initials: E
authors.lastname: Gallitto
authors.forename: Andrea
authors.initials: A
authors.lastname: Stella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging* / Q000601:surgery*; D001027:Aortography / Q000379:methods*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D016009:Chi-Square Distribution; D003251:Constriction, Pathologic; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D017543:Iliac Aneurysm / Q000000981:diagnostic imaging* / Q000601:surgery*; D021621:Imaging, Three-Dimensional; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011857:Radiographic Image Interpretation, Computer-Assisted; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency