Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair

Purpose: Most endografts for an endoluminal AAA repair cannot achieve an adequate hemostatic seal in ectatic common iliac arteries larger than 14 mm. The extension of the endograft into the external iliac artery can alleviate this problem but requires sacrifice of the internal iliac artery. We have used the larger diameter aortic extension cuff to obtain adequate endograft to arterial wall apposition in patients with ectatic, nonaneurysmal common iliac arteries. Because of the resultant flared configuration of the iliac limb, the technique is termed bell-bottom. However, it is unknown whether subsequent enlargement of these ectatic common iliac arteries that will lead to endoleaks or endograft migration will occur. Methods: The records of all 96 patients who have undergone endoluminal abdominal aortic aneurysm repair at our institution were reviewed. Fourteen patients were identified in whom aortic extension cuffs were placed into 18 ectatic (>14 mm, but <20 mm) common iliac arteries. The mean follow-up time was 14 months (range, 6-24 months). The maximal diameter of the common iliac artery on computed tomography scan before endograft placement was compared with the maximal diameter at the most recent follow-up. The incidence of endoleaks, ruptures, and endograft migration related to the "bell-bottom" technique were recorded. Results: The mean preoperative common iliac artery diameter was 18 mm (range, 15-20 mm). Aortic extension cuffs of 20-mm diameter and 24-mm diameter were used in 14 and 4 common iliac arteries, respectively. The diameter did not change in 11 common iliac arteries (61%), increased by 1 mm in 4 common iliac arteries (22%), and decreased by 1 mm in 3 common iliac arteries (17%). No endoleaks, ruptures, or endograft migration related to this technique was identified. Conclusion: The use of aortic extension cuffs for ectatic common iliac arteries expands the number of patients who can be treated endoluminally without sacrifice of the internal iliac artery. Most common iliac arteries do not increase in diameter. When enlargement occurs, the degree of dilation is minimal. Therefore, the "bell-bottom" technique appears to be an acceptable option in the management of large, nonaneurysmal iliac vessels during endoluminal abdominal aortic aneurysm repair.