REVIEW  LATEST UPDATE AND EVIDENCE OF OFF-THE-SHELF TREATMENT OPTIONS FOR COMPLEX AAAS Free access

The Journal of Cardiovascular Surgery 2024 April;65(2):85-98

DOI: 10.23736/S0021-9509.24.12987-4

Copyright © 2024 EDIZIONI MINERVA MEDICA

language: English

Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm

Paolo SPATH ^{1, 2} ✉, Federica CAMPANA ¹, Enrico GALLITTO ^{1, 3}, Rodolfo PINI ^{1, 3}, Chiara MASCOLI ³, Gemmi SUFALI ¹, Stefania CAPUTO ¹, Alessia SONETTO ³, Gianluca FAGGIOLI ^{1, 3}, Mauro GARGIULO ^{1, 3}

¹ Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; ² Unit of Vascular Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy; ³ Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy

Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.

KEY WORDS: Aortic aneurysm, abdominal; Endovascular aneurysm repair; Iliac artery; Endovascular aneurysm repair