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Aortoiliac Anatomic Characteristics Predisposing To Type Ib Endoleak And Limb Occlusion After EVAR
Georgios Tzavellas, MD, Spyridon Monastiriotis, MD, Patrick Jasinksi, MD, George Koullias, MD, David Landau, MD, Apostolos Tassiopoulos, MD.
Stony Brook University Hospital, Stony Brook, NY, USA.

Objective(s): Aortoiliac anatomy plays a significant role in endovascular repair of AAA, with specific anatomies being related with increased incidence of immediate or remote complications. Iliac complications following EVAR can present as limb occlusion or Type Ib endoleak. This retrospective study aimed to identify specific aortoiliac anatomic characteristics that increase the risk of iliac complications.
Methods: Between 2000 and 2016, 421 patients in our institution underwent EVAR. Their inpatient and outpatient records were reviewed and all patients that developed iliac complications (Type Ib endoleak, limb occlusion/ compression) which required subsequent re-intervention were included in the study group. In addition, a control group of patients for age, sex, and device used for repair was identified and used for comparison. All pre-operative CT scans were uploaded to the Terarecon image processing system and the following parameters were calculated: common iliac artery diameter at 10mm intervals, presence and severity of common iliac artery stenosis, common iliac artery length, presence and thickness of circumferencial thrombus and calcium, aortic and iliac artery tortuosity, and iliac limb endograft oversizing. Aortic and iliac tortuosity was characterized as absent, mild, moderate or severe. Univariate regression analysis was used to model the relationship between the complications and the anatomic variables.
Results: Fifteen patients (3.56%) developed 18 iliac complications during the follow up period. There were 9 type Ib endoleaks and 9 limb occlusions identified. Moderate and severe aortic tortuosity was associated with increased incidence of type Ib endoleaks (p=0.002) and limb occlusion (p=0.021). Increased incidence of type Ib endoleak was also seen more frequently in patients with endograft limb overisizing >10% compared to the control group (55.5% vs 23.7%) without reaching statistical significance (p=0.071). Moderate and severe iliac tortuosities were more frequent in the complications group (27.7% vs 13%), without reaching statistical significance as well.
Conclusions: Moderate and severe aortic tortuosity predisposes EVAR patients to type Ib endoleaks. Endograft limb oversizing and iliac vessel tortuosity may also be associated with a higher rate of iliac complications requiring intervention, but our patient sample was likely not large enough to achieve statistical significance.


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