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Occlusion of the IIA using a vascular plug. A, Angiography of the iliac bifurcation. B, Successful vessel occlusion after deployment of the AVP II (arrow head) within the proximal trunk of the IIA. IIA indicates internal iliac artery.
Source publication
We compared occlusion of the internal iliac artery (IIA) using coils or the Amplatzer vascular plug (AVP) II prior to endovascular aortic aneurysm repair.
Occlusion of the IIA was performed in 32 patients (aged 74 ± 8 years) using coils (N = 17) or the AVP II (N = 15). We retrospectively compared procedural data, initial success, and clinical outco...
Context in source publication
Context 1
... the plug was released by rotating the delivery wire counterclockwise until separation from the device. The plug was placed within the proximal segment of the IIA. After deployment of the plug, contrast medium was applied over the sheath to demonstrate complete vessel occlusion for the evalua- tion of technical success ( Figure ...
Similar publications
Interventional occlusion of the hypogastric artery (HA) can be used for endovascular aneurysm repair (EVAR) in the iliac arteries. Most frequent ischemic complication is buttock claudication (BC).
To investigate the frequency and progression of BC after interventional occlusion of the HA prior to EVAR.
A retrospective analysis was performed in pati...
Citations
... Coils have been used for over twenty years with numerous retrospective reviews reporting on their use [10][11][12][13]. More recently, vascular embolization plugs have provided an alternative with similar results reported peri-procedure and through three months [6,[14][15][16]. On average, however, more coils are needed per patient compared to plugs and 30% of patients treated with coils needed additional embolization at the time of the endograft procedure [6]. ...
Purpose
To assess occlusion success and adverse events associated with the use of a self-expanding device for peripheral artery embolization.
Methods
This prospective, single-arm, feasibility study was conducted using the Caterpillar™ Arterial Embolization Device composed of opposing nitinol fibers and a flow-occluding membrane. Twenty patients (24 embolization sites) were treated at four investigational centers in New Zealand and Australia and followed for 30 days. Embolization sites included mesenteric, accessory renal, and iliac arteries and their branches. Primary outcome measures were peri-procedural occlusion confirmed by angiography and freedom from device-related serious adverse events (SAEs) at 30 days. Secondary observations included time to occlusion and assessment of adverse events.
Results
Peri-procedural occlusion was 100%, and freedom from a device-related SAE was 94.7% at 30 days. One patient had abdominal bloating that required hospitalization deemed possibly related to the device or procedure. Twenty-two of 24 embolization sites were occluded with one device (91.7%). Mean procedure duration was 11.7 ± 8.6 min (device deployment time: 1.8 ± 1.0 min), and mean fluoroscopy time was 241 ± 290.7 s. All embolization sites occluded during the procedure with 62.5% occluded within three minutes and 91.6% occluded within ten minutes. No devices migrated or required re-embolization. Freedom from device- and procedure-related adverse events was 84.2%. One patient died from aortic rupture during a subsequent adjunctive abdominal aortic endovascular procedure deemed unrelated to the embolization device or procedure.
Conclusions
This first-in-human study of the Caterpillar embolization device achieved peri-procedural occlusion in all patients with a 94.7% freedom from device-related SAE at 30 days.
Level of Evidence
Level 2b—prospective, multicenter, single-arm, first-in-human clinical study. Pre-specified endpoints were analyzed using descriptive statistics.
... Buttock claudication, the most common complications, is likely reversible after a short period with persistent buttock claudication in less than half of patients. Similarly, reports of the devastating complications, bowel and spinal cord ischemia, seem to be exaggerated and true occurrence seem to be exceedingly rare in the literature [13,17,19,20] . ...
Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during endovascular abdominal aortic aneurysm repair (EVAR). Methods: A retrospective observational study was conducted in patients managed with EVAR for the aorto-iliac aneurysmal disease. The IIA was sacrificed by extension of the stent-graft into the external iliac artery in the absence of the distal landing zone, while it was preserved if the landing zone was available. Results: From 2002 to 2018, 540 patients underwent EVAR for aorto-iliac aneurysmal disease in our center. Sixty-five (12.04%, n = 65/540) had iliac aneurysm extension. Among these 65 cases, the IIA was not covered in 32 patients (IIA salvage/spared group), while they were covered in 33 patients (IIA sacrifice group). The IIA sacrifice group consisted of 25 unilateral and 8 bilateral coverages. There was 100% technical success and no 30-day mortality in both groups. The IIA sacrifice group had more postoperative complications in general when compared to the IIA salvage group, but they were not significant (P < 0.05). There were one patient with buttock claudication (P = 1.000) with bilateral IIA coverage, two cases of lower limb microembolization (P = 0.492) and one case of erectile dysfunction (P = 1.000) in IIA sacrifice group, while they were not seen in IIA salvage group. There was no ruptured iliac access, device-related malfunction, spinal cord ischemia or bowel ischemia in either group.
Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.
... The distal location of the embolization material leads to blockage of the collateral circulation and more frequent occurrence of claudication 17,18,27 compared to the embolization in the proximal segment. The occlusion of the proximal segment of the IIA is practically always possible with the use of vascular plugs and the incidence of claudication is reported to be lesser with vascular plugs compared to that of metal coils [28][29][30] . In addition the use of vascular plugs also reduces the duration of the procedure and is cheaper compared with metal coils [28][29][30] . ...
... The occlusion of the proximal segment of the IIA is practically always possible with the use of vascular plugs and the incidence of claudication is reported to be lesser with vascular plugs compared to that of metal coils [28][29][30] . In addition the use of vascular plugs also reduces the duration of the procedure and is cheaper compared with metal coils [28][29][30] . All these facts could be confirmed by our own results and experience. ...
Aims: The coverage / occlusion of internal iliac artery (IIA) during endovascular treatment of aorto-iliac aneurysms (AIA) can be associated with risk of ischemic complications. To reduce these complications, unilateral or bilateral iliac branch device implantation (IBDI) has been reported. This study aims at evaluating the efficacy of simultaneous unilateral IBDI in the treatment of AIAs and comparing our results with literature.
Materials: and Methods. From March 2010 to December 2019, 27 patients (25 men, 2 women, range 54-84 years) were treated for aorto-iliac/isolated common iliac aneurysms with simultaneous unilateral revascularization of IIA and surgical / endovascular occlusion of contralateral IIA. 27 iliac-branched devices were implanted in 27 patients. The results including ischemic complications were evaluated and compared with literature.
Results: The technical success was 100% with no perioperative mortality and morbidity of 3.7%. Primary internal iliac branch patency at a median follow-up of 52 months (range 1-118 months) was 96.42%. Secondary endoleak was observed in 6 patients (Type 1a [1], Type 1b [1], Type II [4]) and inflammatory complication in 1 patient. The incidence of buttock claudication one year after the procedure was 11.1%. Except for buttock claudication no other ischemic complications occurred.
Conclusion: Unilateral flow preservation in the IIA territory using IBDI is associated with a lesser, but a certain risk of ischemic complications. Bilateral IBDI with bilateral flow preservation of IIAs increases the complexity, procedure -/ fluoroscopy times, contrast agent volume and cost, however, may further reduce these ischemic complications.
... This device allows a more precise proximal embolization (ProxEmbX) in comparison with embolization with several coils. 1 Recent studies demonstrated that the AVP is a suitable alternative to coil embolization to achieve successful occlusion of the IIA before EVAR. [9][10][11][12] Isolated AVP embolization seems to be reasonable in case of an unaffected IIA. Otherwise, the combined use of multiple coils and/or AVPs seems to be inevitable, as embolization of both afferent and efferent arteries of the IIA aneurysm is necessary. ...
... 13,14 A few studies have been published comparing proximal plug embolization vs distal embolization (DistEmbX) with coils and/or plugs. 11,12,15 However, no study has set a special focus on presence of distal aneurysmatic disease. The aim of this retrospective single centre study was to compare ProxEmbX strategies in unaffected IIAs with DistEmbX procedures performed in cases of aneurysmatic IIAs. ...
... During the past years, plug embolization of non-aneurysmatic IIA became more and more common. Previous studies have shown that precise proximal IIA occlusion can be achieved with only one AVP I. 9,11,12 The AVP is an established embolic device nowadays. For Prox-EmbX of non-aneurysmatic IIA, we used AVP I, which was successfully used in 2004 for the first time. ...
Objective:
Occlusion of the internal iliac artery (IIA) may be necessary prior to endovascular aortoiliac aneurysm repair (EVAR) to prevent endoleak type II. We compared efficacy and clinical outcome after proximal occlusion of an unaffected IIA (ProxEmbx) using an Amplatzer vascular plug I (AVP) vs. distal occlusion of aneurysmatic IIA with coils and plugs (DistEmbx).
Methods:
Between 2009 and 2012 22 patients underwent EVAR. In 9 patients with unaffected IIA occlusion was performed by a single AVP. In 13 patients with aneurysmatic IIA more distal embolization was conducted by using several coils and additional AVPs. Retrospectively, technical success, clinical outcome and complications were evaluated.
Results:
Embolization of the IIA was successful in all patients. Three patients with more distal embolization of aneurysmatic IIAs suffered from new onset of sexual dysfunction after occlusion without statistically significant difference (p>0.05). Transient buttock claudication was observed in three patients in each group. Bowel ischemia did not occur. The procedure time (p=0.013) and fluoroscopy time (p=0.038) was significantly lower in the ProxEmbx group than in the DistEmbx group.
Conclusion:
Proximal occlusion of an unaffected IIA and more distal occlusion of an aneurysmatic IIA prior to EVAR had the same technical and clinical outcome. However, proximal plug embolization of an unaffected IIA prior to EVAR was associated with shorter procedure and fluoroscopy time in comparison to more distal embolization of aneurysmatic IIAs. Advances in knowledge: Proximal embolization of unaffected IIA and distal embolization of aneurysmatic IIA before EVAR are both effective in preventing typ II endoleaks and have the same technical and clinical outcome.
... 23 These rates seem to be even higher in patients treated with coil embolization. [24][25][26] In contrast, only 4.3% of patients with IBD failure demonstrated buttock claudication in the current series. ...
Purpose:
To evaluate the efficacy, feasibility, and long-term outcomes of the Zenith ZBIS iliac branch device (IBD) to preserve internal iliac artery (IIA) perfusion in a large Dutch multicenter cohort.
Methods:
Between September 2004 and August 2015, 140 patients (mean age 70.9±7.4 years; 130 men) with 162 IBD implantations were identified in 7 vascular centers. The indication for IBD implantation was an abdominal aortic aneurysm >55 mm with a concomitant common iliac artery (CIA) aneurysm >20 mm (n=40), a CIA aneurysm with a diameter >30 mm (n=89), or revision of a type Ib endoleak after endovascular aneurysm repair (n=11).
Results:
Technical success (aneurysm exclusion, no type I or III endoleak, and a patent IIA) was obtained in 157 (96.9%) of 162 IBD implantations. Six (4.3%) patients developed major complications; 2 (1.4%) died. Mean follow-up was 26.6±24.1 months, during which 17 (12.1%) IBD-associated secondary interventions were performed. Including technical failures and intentional IIA embolizations, 15 (9.3%) IIA branch occlusions were identified; buttock claudication developed in 6 of these patients. The freedom from secondary intervention estimate was 75.9% (95% confidence interval 59.7 to 86.3) at 5 years.
Conclusion:
CIA aneurysms can be treated safely and effectively by IBDs with preservation of antegrade flow to the IIA. Secondary interventions are indicated in >10% of patients during follow-up but can be performed endovascularly in most.
... 4 In the case of a short landing zone, such as in a hypogastric artery occlusion before an endovascular aneurysm repair (EVAR), an AVPI is the ideal device to occlude the hypogastric artery at its origin, in order to avoid type II endoleaks and to preserve the distal gluteal vessels, further reducing the risk of buttock claudication. 5,6 The AVPII and the AVPIII reduce the time to occlusion by creating multiple occlusive planes, and are therefore indicated for use in high-flow situations, such as occlusion of hemodialysis fistulas. 7 The AVP4 can be used without needing to exchange the catheter ( Figure 1A-C). ...
Endoluminal occlusion has been performed since the early beginning of interventional radiology. Over recent decades, major technological advances have improved the techniques used and different devices have been developed for changing conditions. Most of these occlusion devices have been implemented in the vascular territory. Early embolization materials included glass particles, hot contrast, paraffin, fibrin, and tissue fragments such as muscle fibers and blood clots; today, occlusion materials include metallic devices, particles, and liquid materials, which can be indicated for proximal or distal occlusion, high-flow and low-flow situations, and in large-caliber and small-caliber vessels, based on need. Technological progress has led to a decreased size of delivery catheters, and an increase in safety due to release systems that permit the withdrawing and replacement of embolization material. Furthermore, bioactive embolization materials have been developed to increase the efficacy of embolization or the biological effect of medication. Finally, materials have been modified for changing indications. Intravascular stents were initially developed to keep an artery open; however, by adding a covering membrane, these stents can be used to occlude the wall of a vessel or other endoluminal structures. This article gives an overview of the devices most utilized for occlusion of endoluminal structures, as well as their major purpose in the endovascular territory.
... In our study, most cases (12 cases, 92%) had diameters greater than 6.5 mm, so these were not suitable for the AVP 4. The AVP 4 was launched in Korea in late 2012, but our procedures were done between 2010 and 2012; so, we were unable to use the AVP 4. Buttock claudication rates of AVPs embolization are reported in 9% to 33% of the cases, and erectile dysfunctions were essentially unreported (2,8,16,26). Libicher et al. (28) reported that embolization of internal iliac arteries with either coils or AVPs was safe and effective. Initial buttock claudication was more severe with coils, but there was no significant difference after 12 months of follow-up (28). ...
... Libicher et al. (28) reported that embolization of internal iliac arteries with either coils or AVPs was safe and effective. Initial buttock claudication was more severe with coils, but there was no significant difference after 12 months of follow-up (28). AVPs embolization is connected with a significant reduction of procedure time and radiation dose compared to coils (28). ...
... Initial buttock claudication was more severe with coils, but there was no significant difference after 12 months of follow-up (28). AVPs embolization is connected with a significant reduction of procedure time and radiation dose compared to coils (28). ...
Objective
The purpose of this study was to evaluate the effectiveness of detachable interlock microcoils for an embolization of the internal iliac artery during an endovascular aneurysm repair (EVAR).
Materials and Methods
A retrospective review was conducted on 40 patients with aortic aneurysms, who had undergone an EVAR between January 2010 and March 2012. Among them, 16 patients were referred for embolization of the internal iliac artery for the prevention of type II endoleaks. Among 16 patients, 13 patients underwent embolization using detachable interlock microcoils during an EVAR. Computed tomographic angiographies and clinical examinations were performed during the follow-up period. Technical success, clinical outcome, and complications were reviewed.
Results
Internal iliac artery embolizations using detachable interlock microcoils were technically successful in all 13 patients, with no occurrence of procedure-related complications. Follow-up imaging was accomplished in the 13 cases. In all cases, type II endoleak was not observed with computed tomographic angiography during the median follow-up of 3 months (range, 1-27 months) and the median clinical follow-up of 12 months (range, 1-27 months). Two of 13 (15%) patients had symptoms of buttock pain, and one patient died due to underlying stomach cancer. No significant clinical symptoms such as bowel ischemia were observed.
Conclusion
Internal iliac artery embolization during an EVAR using detachable interlock microcoils to prevent type II endoleaks appears safe and effective, although this should be further proven in a larger population.
... The Amplatzer plug is a nitinol-based self-expanding device that ensures rapid secure occlusion at the origin of the artery after precise placement. [12][13][14][15] Locking by means of an endograft to the CIA and EIA provided extra reassurance of exclusion of the ruptured aneurysm as well as ensuring good inline flow to the external iliac system. Bilateral femoral cannulations facilitated access to the right iliac system by ipsilateral as well as by contralateral means. ...
This case represents the first report of multiple arterial aneurysms including aortic, iliac, visceral, and coronary aneurysms associated with hypereosinophilic syndrome. It presents an interesting case of epinephrine abuse and the unfortunate sequelae. This case illustrates novel approaches in emergency repair of internal iliac artery aneurysm rupture and the management of visceral artery aneurysms and exemplifies how multiple endovascular technologies can be utilized even in the high-risk polymorbid patient.
... Occasionally when both IIAs are aneurysmal and there is a lack of IIA main trunk distal neck length, the application of EVAR is challenging [5]. In such situations, simple or more complex techniques have to act together in order to provide perfusion to the legs and to pelvic organs, sigmoid bed and gluteal muscles [11,12]. Salvage of both, previously patent, IIAs is welcome, while unilateral main trunk or even branch preservation is suggested by many authors [3]. ...
... Pure endovascular or combined techniques have been used in such settings aiming at preserving the whole or a part of the pelvic arterial bed. Although unilateral IIA embolization and extension of the endograft limb to the EIA has been proposed as a safe method for expanding the feasibility of EVAR [11], it is commonly asserted that fl ow to at least one IIA should be preserved [1]; identifi cation of those patients at high risk for pelvic ischemic complications remains obscure. In our case, as both IIAs were aneurismal we decided to embolize the right IIA -for anatomic reasons -and to perfuse a major branch of the left IIA which could also support sigmoid circulation for future bowel continuity restoration. ...
... 3,13,14 While both coil embolization (COIL) and Amplatzer plug embolization (PLUG) have been shown to be successful techniques, limited data directly comparing the two treatment modalities are available. 15,16 The aim of this study was to evaluate the safety (including radiation expo-sure), efficacy, outcomes, and financial cost of COIL vs PLUG when associated with EVAR. ...
To compare the safety and efficacy of coil embolization (COIL) to Amplatzer vascular plug embolization (PLUG) to achieve internal iliac artery (IIA) occlusion prior to endovascular aortiliac aneurysm repair (EVAR).
Data from consecutive patients who underwent IIA embolization prior to EVAR over a 6-year period (2004-2010) were retrospectively reviewed. Patient demographics, treatment modalities, and outcomes were compared.
From January 1, 2004 to December 31, 2010, a total of 53 patients underwent percutaneous embolization of 57 IIAs prior to EVAR. Twenty-nine IIAs underwent COIL and 28 IIAs underwent PLUG embolization. Patient demographics and risk factors were similar between the two groups. Patients underwent repair for aneurysmal dilation of the infrarenal aorta in conjunction with the common or internal iliac arteries (n = 35, 62%) or isolated iliac artery aneurysms (n = 19, 38%). A significantly greater number of embolization devices were used in the COIL group (5.8 ± 3.8 vs 1.1 ± 0.4; P < .0001). Patients undergoing PLUG embolization demonstrated significantly shorter procedure times (118.4 ± 64.7 minutes vs 72.6 ± 22.4 minutes; P = .008) and fluoroscopy times (32.6 ±14.6 vs 14.4 ± 8.6 minutes; P = .002). However, radiation dose between the groups did not differ (COIL: 470,192.7 ± 190,606.6 vs PLUG: 300,972.2 ± 191,815.7 mGycm(2); P = .10). Overall periprocedural morbidity did not differ between the groups (COIL: 11% vs PLUG: 6%; P = 1.0), and there were no perioperative mortalities or severe complications. Nontarget embolization occurred in two COIL and no PLUG cases (COIL: 6.9% vs PLUG: 0%; P = .49). Patient-reported buttock claudication at 1 month was 17.2% for COIL and 39.3% for PLUG patients (P = .08). At last follow-up, persistent buttock claudication was reported in 13.8% of COIL and in 14.3% of PLUG embolizations (P = 1.0). There was no significant difference in charges for the embolization material, operating room, or overall hospital charges (COIL: 44,720 ± 19,153 vs 37,367 ± 10,915; P = .22). Lastly, zero endoleaks in the COIL group and three in the PLUG group (P = .40) were detected on the most recent follow-up computed tomography imaging. No endoleak was related to the site of IIA embolization.
COIL and PLUG embolization both provide effective IIA embolization with low complication rates when used for EVAR. Buttock claudication did occur in approximately one-third of patients but resolved in half of those affected. PLUG embolization took significantly less time to perform and required decreased fluoroscopy times. Based on outcomes and cost-analysis, COIL and PLUG embolization are equivalent methods to achieve IIA occlusion during EVAR.
