Sharif Ellozy, MD, Vascular Surgeon
The use of endovascular aneurysm repair (EVAR) to treat an abdominal aortic aneurysm (AAA) that involves the common and internal iliac arteries has been steadily increasing, particularly since the introduction of the first FDA approved, off-the-shelf branched stent-graft: the GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE). Endovascular procedures decrease perioperative mortality and morbidity for patients, but adjunctive procedures such as hypogastric embolization can affect quality of life. The use of a branched stent-graft such as the IBE can reduce complications and sustain patient quality of life by maintaining blood flow to both the internal and external iliac arteries.
One such case is that of my patient, a 48-year-old triathlete who, following his annual physical in January of 2015, was diagnosed with an aortic aneurysm and bilateral common iliac artery aneurysms. Prior to diagnosis, he had set a personal goal of completing four triathlons in the following calendar year. In February, he underwent endovascular repair, including bilateral GORE® EXCLUDER® Iliac Branch Devices, with an eye toward preserving pelvic perfusion. In short order, the patient was able to return to his very active lifestyle, training for and achieving his personal goal of completing four triathlons in 2015.
Conventional open repair of AAAs that involve the iliac arteries can lead to short- and long-term complications for patients. Erectile dysfunction after open AAA repair is often multifactorial, with neurogenic and vascular causes. Additionally, open repair of aortoiliac aneurysms is technically more challenging than simple infrarenal AAA repair, with more extensive pelvic dissection and the potential for greater blood loss.
Methods such as "coil and cover" or embolization of the internal iliac artery often result in complications, including buttock claudication and new onset sexual dysfunction. Off-label uses of multiple non-branched stent-grafts to achieve a construct similar to the IBE (i.e., the "sandwich" method) have not yet demonstrated long-term durability and are at risk for developing type III endoleaks.
The IBE has demonstrated efficacy and durability in a series of studies. Multiple reports on the Gore device from Europe have yielded a 100% technical success rate (as measured by the presence of a Type I or III endoleak), with no perioperative mortality, and clinical success rates evident in the absence of adverse long-term symptoms.1 Data from use of the stent-graft in the U.S. IDE clinical trial have yielded similar outcomes, with the additional results including an internal iliac limb patency rate of 95.1% at six-months, no new type I or III endoleaks, and zero patients experiencing new onset buttock claudication through six months.2 In summary, it is an excellent treatment option that allows patients the benefits of endovascular therapy yet preserves pelvic perfusion.