Outcomes of Hypogastric Coverage and Occlusion during Endovascular Treatment of Aortoiliac Occlusive Disease

Andrew H Smith; Siddhartha Dash; Erin C Driscoll; Levester Kirksey; Jarrad Rowse; David Hardy; Sean P Lyden; Francis J Caputo; Christopher J Smolock

doi:10.1016/j.avsg.2021.05.020

Outcomes of Hypogastric Coverage and Occlusion during Endovascular Treatment of Aortoiliac Occlusive Disease

Ann Vasc Surg. 2021 Nov:77:116-126. doi: 10.1016/j.avsg.2021.05.020. Epub 2021 Aug 16.

Authors

Andrew H Smith¹, Siddhartha Dash¹, Erin C Driscoll¹, Levester Kirksey¹, Jarrad Rowse¹, David Hardy¹, Sean P Lyden¹, Francis J Caputo¹, Christopher J Smolock²

Affiliations

¹ Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH.
² Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH. Electronic address: smolocc@ccf.org.

PMID: 34411668
DOI: 10.1016/j.avsg.2021.05.020

Abstract

Background: The risk of hypogastric occlusion (HO) following bare-metal stent (BMS) coverage of the hypogastric origin during endovascular treatment of aortoiliac occlusive disease (AIOD) is unclear. This study sought to determine the rate and clinical significance of HO following BMS coverage during iliac stenting for complex AIOD.

Methods: Consecutive patients undergoing elective iliac stenting for AIOD from 2010-2018 at Cleveland Clinic were reviewed. Patients with BMS coverage of a patent hypogastric origin were included. Rate of HO were determined by review of intraoperative angiography and follow up imaging. Predictors of HO were identified by univariable and multivariable logistic regression. Outcomes were compared between those who did and did not develop HO.

Results: There were 251 patients (338 limbs) with BMS coverage of the hypogastric origin during treatment of AIOD. Lesion severity was classified as TASC C/D in 249/338 (73.7%) of cases. Bilateral hypogastric coverage occurred in 93/251 (37.1%) patients. Hypogastric patency was 78.1% at 24-months following coverage. Recanalization of an ipsilateral external iliac artery (EIA) occlusion was predictive of HO (HR 3.12, 95% CI: 1.33, 7.34; P= 0.009). Increased luminal diameter of the hypogastric origin protected against HO (HR 0.64; 95% CI: 0.47, 0.88; P= 0.006). Perioperative outcomes were no different between patients with and without HO. There were no cases of gluteal necrosis, spinal cord ischemia, or pelvic organ ischemia. Four-year mortality and limb salvage were not affected by HO. HO was associated with decreased primary patency of ipsilateral iliac stents and increased risk of ipsilateral reintervention (HR 5.49; 95% CI: 1.82, 16.58; P= 0.002).

Conclusions: HO is relatively infrequent following BMS coverage during treatment of AIOD. Luminal diameter of the hypogastric origin and ipsilateral EIA occlusion are associated with occlusion. HO is well tolerated in AIOD, though it is potentially associated with increased risk iliac stent occlusion and reintervention.

MeSH terms

Aged
Aortic Diseases / diagnostic imaging
Aortic Diseases / physiopathology
Aortic Diseases / therapy*
Endovascular Procedures / adverse effects*
Endovascular Procedures / instrumentation
Female
Humans
Iliac Artery* / diagnostic imaging
Iliac Artery* / physiopathology
Male
Middle Aged
Pelvis / blood supply*
Peripheral Arterial Disease / diagnostic imaging
Peripheral Arterial Disease / physiopathology
Peripheral Arterial Disease / therapy*
Retrospective Studies
Risk Assessment
Risk Factors
Stents
Time Factors
Treatment Outcome
Vascular Patency