title: Systematic Review and Meta-analysis of the Effect of Internal Iliac Artery Exclusion for Patients Undergoing EVAR.
abstract: OBJECTIVE
  Endovascular abdominal aortic aneurysm repair (EVAR) sometimes requires internal iliac artery (IIA) coverage to achieve a landing zone in the external iliac artery. The aim of this study was to determine complication rates following IIA exclusion.
  
  
  METHODS
  A systematic review of key journals was undertaken from January 1980 to April 2016. Studies detailing occlusion (using coils or plugs) or coverage of the IIA with outcome data were included. Weighted means were calculated for continuous variables. Meta-analysis was performed when comparative data were available. Quality was assessed using the GRADE system.
  
  
  RESULTS
  Sixty-one non-randomised studies (2671 patients; 2748 IIAs) were analysed. Fifteen per cent of EVARs require IIA sacrifice. Buttock claudication (BC) occurred in 27.9% of patients, although 48.0% resolved after 21.8 months. BC rates were 32.6% with coils, 23.8% with plugs, and 12.9% with coverage alone, and less with unilateral (vs. bilateral) IIA treatment (OR 0.57, 95% CI 0.36-0.91). More proximal coil placement resulted in lower rates of BC (OR 0.12, 95% CI 0.03-0.48). Erectile dysfunction occurred in 10.2% of males, with higher rates after coiling. Type II endoleaks were more frequent after covering alone; however re-interventions were rare. Significant ischaemic events (bowel/gluteal/spinal ischaemia) were very rare. Plugs were quicker to place and required less radiation (p < .001) than coils. GRADE scoring was very low for all outcomes.
  
  
  CONCLUSIONS
  Overall the quality of reported data on IIA sacrifice is poor. Buttock claudication and erectile dysfunction occurred frequently after IIA sacrifice. Where both options are technically possible, plugs could be considered preferential to coils, and placed as proximally in the IIA as possible.
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK. Electronic address: davebosanquet@hotmail.com.
authors.forename: D C
authors.initials: DC
authors.lastname: Bosanquet
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: C
authors.initials: C
authors.lastname: Wilcox
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: L
authors.initials: L
authors.lastname: Whitehurst
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: A
authors.initials: A
authors.lastname: Cox
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: I M
authors.initials: IM
authors.lastname: Williams
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK; Division of Population Medicine, Cardiff University, Cardiff, UK.
authors.forename: C P
authors.initials: CP
authors.lastname: Twine
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D006801:Humans; D007083:Iliac Artery / Q000601:surgery*; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology; D011474:Prosthesis Design; D012307:Risk Factors; D016896:Treatment Outcome
keywords: EVAR; Endovascular aneurysm repair; Hypogastric artery; Internal iliac artery