Outcomes of an iliac branch endoprosthesis using an “up-and-over” technique for endovascular repair of failed bifurcated grafts

Objective: Type IB endoleak after endovascular aneurysm repair may be treated by an iliac branch endoprosthesis (IBE) through brachial access for internal iliac artery (IIA) stenting. The aim of this study was to evaluate outcomes of the IBE using an “up-and-over” transfemoral technique in patients with prior aortic repair compared with the standard technique in patients with de novo iliac aneurysms. Methods: We reviewed the clinical data of patients treated for aortoiliac aneurysms using Gore IBE (W. L. Gore & Associates, Flagstaff, Ariz) between 2014 and 2017. The up-and-over technique was indicated in patients with type IB endoleak or common iliac aneurysms after prior aortic repair with bifurcated endografts or surgical grafts. End points were technical success, mortality, major adverse events, IIA patency, freedom from IIA branch instability (composite end point of any IIA branch-related complication leading to aneurysm rupture, death, occlusion, component separation, or reintervention to maintain branch patency or to treat a branch-related separation or endoleak), and freedom from secondary interventions or new-onset buttock claudication. Results: There were 53 patients (51 male; 74 ± 8 years old) treated by 62 IBEs (9 bilateral). Standard technique was used in 36 patients (43 IBEs) and up-and-over technique in 17 (19 IBEs). Three patients had contralateral IIA embolization. Total procedure time, contrast material volume, and radiation dose averaged 168 ± 98 minutes, 140 ± 50 mL, and 1096 ± 1009 mGy, with no difference between techniques. Technical success was achieved in 98% of patients. Eleven patients had extension of IIA bridging stent into the posterior branch (eight standard, three up-and-over). Four patients (8%) had major adverse events due to estimated blood loss >1000 mL in all patients. There was no 30-day mortality after a median follow-up of 7 months (interquartile range, 3-12 months). There were two IIA stent occlusions (all standard), three iliac-related type I endoleaks (one standard, two up-and-over), and four secondary interventions (three standard, one up-and-over). At 1 year, patients treated by standard or up-and-over technique had similar primary patency (94% ± 4% vs 100%; P =.38) and secondary patency (97% ± 3% vs 100%; P =.54) and freedom from IIA branch instability (90% ± 6% vs 93% ± 7%; P =.48), secondary intervention (84% ± 8% vs 90% ± 9%; P =.63), and new-onset buttock claudication (90% ± 6% vs 100%; P =.35). Conclusions: Endovascular repair using IBE was associated with high technical success, no mortality, and low rate of complications using either the standard technique for de novo aneurysms or an up-and-over technique for patients with failed bifurcated endografts or grafts. The up-and-over technique should be considered a suitable alternative to brachial access in patients who require distal extension using IBEs.