title: Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.
abstract: BACKGROUND
  Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass.
  
  
  METHODS
  Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded.
  
  
  RESULTS
  The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent.
  
  
  CONCLUSIONS
  Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL.
authors.forename: Neel A
authors.initials: NA
authors.lastname: Mansukhani
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL.
authors.forename: George E
authors.initials: GE
authors.lastname: Havelka
authors.affiliation: Department of Surgery, Northwestern University, Chicago, IL.
authors.forename: Irene B
authors.initials: IB
authors.lastname: Helenowski
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL.
authors.forename: Heron E
authors.initials: HE
authors.lastname: Rodriguez
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Hoel
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL. Electronic address: meskanda@nm.org.
authors.forename: Mark K
authors.initials: MK
authors.lastname: Eskandari
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D002641:Chicago; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000098:blood supply*; D011183:Postoperative Complications / Q000209:etiology; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency