title: Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair.
abstract: OBJECTIVE
  To evaluate the dynamics of the iliac attachment zone after EVAR, and the association with clinical events.
  
  
  METHODS
  A tertiary institution's prospective EVAR database was searched to identify common iliac arteries at risk. Internally validated measurements were made, using centre lumen line reconstructions. Iliac dilatation and endograft limb retraction were the main endpoints. Associations between dilatation, retraction, oversizing, and distal seal length were investigated. Association with clinical events (sealing or occlusion) was also explored.
  
  
  RESULTS
  Of 452 primary EVAR patients treated from 2004 to 2012, 341 were included (mean age 72 years, 12% female, 597 common iliac arteries). Median follow-up was 4.7 years. At 30 days, the mean iliac diameter increased from 14 mm to 15 mm (p < .001). Over follow-up, it increased to 18 mm (p < .001). Iliac dilatation ≥20% occurred in 295 cases (49.4%) and exceeded the implanted endograft diameter in 170 (28.7%). Limb retraction ≥5 mm was identified in 54 patients (9.1%) and was associated with iliac seal complications (p < 0.001). Iliac endograft extension diameter ≥24 mm (OR 3.3, 95% CI 1.7-6.4) and iliac artery dilatation beyond the endograft (OR 2.1, 95% CI 1.2-3.8) were independent risk factors. Overall, there were 34 (5.7%) iliac seal complications. Retraction of the iliac endograft (OR 1.17 per mm, 95% CI 1.10-1.24) and baseline AAA diameter (1.04 per mm, 95% CI 1.01-1.07) were independent risk factors for seal related complications. Greater initial post-operative iliac seal length was protective (OR 0.94 per mm, 95% CI 0.90-0.97).
  
  
  CONCLUSIONS
  Iliac dilatation and endograft retraction are common findings during follow-up, potentially leading to adverse clinical events. Optimisation of the iliac seal zone providing a long distal seal length and added attention to patients with large aneurysms or receiving ≥24 mm diameter iliac extensions are recommended. Also, long-term surveillance including CTA is advised to reveal and correct loss of seal at the iliac attachments before adverse clinical events occur.
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal. Electronic address: f.bastosgoncalves@erasmusmc.nl.
authors.forename: F
authors.initials: F
authors.lastname: Bastos Gonçalves
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital do Divino Espirito Santo, Ponta Delgada - Azores, Portugal.
authors.forename: N F
authors.initials: NF
authors.lastname: Oliveira
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Josee van Rijn
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: K H J
authors.initials: KH
authors.lastname: Ultee
authors.affiliation: Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: S E
authors.initials: SE
authors.lastname: Hoeks
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: S
authors.initials: S
authors.lastname: Ten Raa
authors.affiliation: Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: R J
authors.initials: RJ
authors.lastname: Stolker
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: H J M
authors.initials: HJ
authors.lastname: Verhagen
mesh_terms: D000368:Aged; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D000072226:Computed Tomography Angiography; D016208:Databases, Factual; D004108:Dilatation, Pathologic; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome
keywords: Abdominal (MeSH); Aneurysm; Blood vessel prosthesis implantation (MeSH); Endoleak; Iliac artery; Iliac occlusion; Risk factors