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Life-threatening arterioureteral fistula treatment by endovascular complete anatomic iliac artery bifurcation reconstruction.

ABSTRACT: We present an endovascular approach for anatomic reconstruction of the iliac bifurcation in life-threatening arterioureteral fistula without sacrificing the pelvic arterial vascular supply. Five consecutive patients suffering from acute onset of significant gross hematuria caused by iliac-ureteral fistula resulting from previous oncologic surgery and radiation therapy were treated by transfemoral stent graft implantation in a double-barrel technique. Iliac-ureteral pseudoaneurysm coverage succeeded in an iliac neobifurcation with preservation of pelvic perfusion. Follow-up ranging from 9 to 37 months confirmed cessation of hematuria. One patient experienced stent graft thrombosis of the external iliac artery as a result of large cervical cancer invasion treated by crossover bypass. In all other patients, stent grafts were patent.

SUBMITTER: Massmann A

PROVIDER: S-EPMC7160530 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Project description:To the best of our knowledge, the present report is the first on the safety and efficacy of complete endovascular aortic reconstruction from zone 0 to 10 using a standardized approach and parallel stent graft configurations in high-risk patients considered unfit for surgery. During a 7-year period, five patients with complex thoracoabdominal aortic aneurysms and dissections involving zone 0-10 presented with rupture (n = 1; 20%), were symptomatic (n = 2; 40%), or had an aortic pseudoaneurysm (n = 2; 40%) and underwent complete endovascular zone 0-10 reconstruction using off-the-shelf stent grafts in parallel configurations that included chimneys, periscopes, and endovascular docking stations. The zone 0-5 complete arch chimney thoracic endovascular repair included chimneys that extended from the ascending thoracic aorta to the innominate, left common carotid, and left subclavian arteries and a thoracic stent graft extending from zone 0 to 5. The zone 5-10 aortic reconstructions were staged. Stage 1 included either thoracic stent graft and antegrade four visceral chimney placement or abdominal aortic stent graft and retrograde four visceral chimney placement. Stage II included completion of the remainder of the aortic reconstruction with cerebrospinal fluid drainage. A total of 15 aortic procedures included 34 chimneys (14 aortic arch and 20 visceral). Two patients (40%) underwent zone 0-5 aortic reconstruction first, and three patients (60%) underwent zone 5-10 aortic reconstruction first. The incidence of 30-day mortality, spinal cord ischemia, myocardial infarction, stroke, and visceral ischemia was 0%. At a mean follow-up of 4.5 ± 3.1 years, the aortic reconstruction-related mortality was 0%. All-cause mortality was 20%; one patient had died of pneumonia at 3 years postoperatively. Two endoleaks each occurred in zone 0-5 and zone 5-10 (40% for both groups). All endoleaks were treated with coil embolization. Complete endovascular zone 0-10 aortic reconstruction using parallel stent grafts with a docking station is a feasible and relatively safe technique that offers the ability to customize off-the-shelf devices for the treatment of high-risk patients with limited morbidity and mortality.

Project description:PurposeTo determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR).MethodsThis single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality.ResultsThe mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak.ConclusionAneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

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Life-threatening arterioureteral fistula treatment by endovascular complete anatomic iliac artery bifurcation reconstruction.

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