Endovascular Management of Iliac Rupture During Endovascular Aneurysm Repair: A Single Center’s Experience

BACKGROUND: Diminished iliac diameter, calcification and severe tortuosity have been associated with an increased incidence of iliac injury during abdominal endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR). Despite careful preoperative assessment and the use of iliac conduits, inadvertent iliac rupture may be a source of morbidity and mortality. Our single center 9 year experience with patients who suffered inadvertent iliac rupture during endovascular aneurysm repair is reviewed. These patients were treated with emergent endovascular stent graft repair of the ruptured iliac artery. The outcomes and durability of endovascular repair of a ruptured access vessel is reported.
METHODS: All patients undergoing endovascular aneurysm repair between November 1998 and June 2008 were reviewed. During this time period computed tomography (CT) measurements of access vessels were obtained on all patients. The smallest diameter of the external or common iliac artery was used to determine suitability for vascular access based on instructions for use for each individual device. Patients who suffered procedure related iliac artery rupture were included in this review. Outcomes between patients who did not suffer an access vessel rupture (non-ruptured group) and those that did (ruptured group) were then compared. The patency of the endovascular iliac repair is also reported.
RESULTS: During the study period 369 EVAR and 67 TEVAR were performed. A total of 11 iliac conduits (16%) were used during this time period, all during TEVAR. There were 18 ruptured iliac arteries in 17 patients. Of these, 11/369(2.98%) EVAR patients suffered iliac rupture compared to 6/67(8.9%) TEVAR. One EVAR patient during this time period was converted to open repair given the additional need to address a large type I endoleak. All others were treated with endovascular stent graft placement.
Iliac rupture was more likely to occur during TEVAR 8.9% versus EVAR 2.98% (p=0.0239 Fisher’s Exact Test). There were significantly more females in the ruptured group 82% versus 18% (p =0.0001 by Chi-square analysis). Patients in the ruptured group had longer lengths of stays 7.6 versus 5.1 days (p=0.0895 Student T-Test). In the iliac rupture group there was a procedure related mortality of 1/6 (16.7%) for TEVAR and 1/11(9.1%) for EVAR. In the non-rupture group the procedure related mortality was 6/61(9.8%) and 11/358(3.07%), respectively. Following endovascular repair of an inadvertent iliac rupture, the primary and secondary patency was 87.5% and 93.8%, respectively, with a median follow up of 39.5 months (range 10-102).
CONCLUSIONS: Iliac rupture during EVAR or TEVAR may be successfully managed with good long term durability with endovascular stent grafting, minimizing the effect on morbidity and mortality. The higher mortality and length of stay associated with inadvertent iliac artery rupture testifies to the fact that there is no substitute for prevention. The access vessels of all patients undergoing endovascular aneurysm repair should be examined for suitability including diameter, tortuosity and calcification. There should be a low threshold for creation of an iliac conduit especially in women undergoing TEVAR.