Complex solutions to minimise vascular access complications during iliac branch device implantation after EVAR: a narrative review focusing on planning and technical aspects
DOI:
https://doi.org/10.48750/acv.667Keywords:
Iliac branch device, endoleak, vascular access, brachial access, steerable sheath, endovascular, abdominal aortic aneurysmAbstract
INTRODUCTION: Secondary implantation of iliac branch devices (IBDs) after endovascular aortic repair (EVAR) for type Ib endoleak poses unique technical challenges due to altered aortoiliac anatomy and prior femoral access. Selecting an optimal access strategy is critical to minimize complications and ensure procedural success. This review summarizes contemporary transfemoral and upper extremity access techniques, with a focus on modern endovascular solutions that facilitate safe and effective reinterventions.
METHODS: A narrative review of the literature published between 2010 and 2025 was conducted using PubMed, focusing on studies reporting technical strategies, outcomes, and complications of secondary IBD implantation after EVAR. Only original research, including technical notes, was included.
RESULTS: Across the reviewed studies, upper extremity access was associated with neurologic events, longer operative times, and higher access-site complication rates. Transfemoral "up-and-over" techniques consistently demonstrated technical success rates over 95%, shorter procedural times, and reduced complication rates. Steerable sheath systems enable complete IBD implantation from a single femoral access, with promising safety and efficacy. Technical refinements, including special attention to the prior graft bifurcation and meticulous technique, appear to be key elements to optimising immediate and late outcomes.
CONCLUSION: Transfemoral strategies, particularly "up-and-over" techniques using steerable sheaths, appear to be safe and effective alternatives to upper-extremity access for secondary IBD implantation following EVAR. Access strategy should be tailored to patient anatomy and prior graft configuration, with emphasis on minimising vascular trauma, neurologic risk, and procedural complexity.
Downloads
References
Powell JT, Sweeting MJ, Ulug P, Blankenstein JD, Lederle FA, Becquemin JP, et al. Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg. 2017;104:166-78.
Donas KP, Inchongolo M, Cao P, Pratesi C, Pratesi G, Torsello G, et al. Secondary Procedures Following Iliac Branch Device Treatment of Aneurysms Involving the Iliac Bifurcation: The pELVIS Registry. J Endovasc Ther. 2017;24:405-10.
Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg. 2014;59:89-94.
Gronert C, Panuccio G, Eleshra A, Rohlffs F, Debus ES, Tsilimparis N, et al. Feasibility and Preliminary Patency of Prophylactic Hypogastric Artery Stenting for Prevention of Spinal Cord Ischemia in Complex Endovascular Aortic Repair. Ann Vasc Surg. 2022;80:241-9.
Simonte G, Parlani G, Farchioni L, Isernia G, Cieri E, Lenti M, et al. Lesson Learned with the Use of Iliac Branch Devices: Single Centre 10 Year Experience in 157 Consecutive Procedures. Eur J Vasc Endovasc Surg. 2017;54:95-103.
Verzini F, Parlani G, Varetto G, Gibello L, Boero M, Torsello GF, et al. Late outcomes of different hypogastric stent grafts in aortilioi endografting with iliac branch device: Results from the pELVIS Registry. J Vasc Surg. 2020;72:549-55.
Wanhainen A, Van Herzele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Illic Artery Aneurysms. Eur J Vasc Endovasc Surg. 2024;67:192-331.
Eilenberg W, Kolbel T, Rohlffs F, Oderich G, Eleshra A, Tsilimparis N, et al. Comparison of transfemoral versus upper extremity access to antegrade branches in branched endovascular aortic repair. J Vasc Surg. 2021;73:1498-503.
Mastracci TM, Eagleton MJ, Kuramochi Y, Bathurst S, Wolski K. Twelve- year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms. J Vasc Surg. 2015;61:355-64.
Mirza AK, Oderich GS, Sandri GA, Tenorio ER, Davila VJ, Karkkainen JM, et al. Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair. J Vasc Surg. 2019;69:635-43.
Rancic Z, Pfammatter T, Lachat M, Hechelhammer L, Oberkofler C, Veith FJ, et al. Pull-down technique to allow complete endovascular relining of failed AAA Vanguard endografts with Excluder bifurcated endografts. Eur J Vasc Endovasc Surg. 2009;38:54-60.
Redfors B, Watson BM, McAndrew T, Palisaitis E, Francese DP, Razavi M, et al. Mortality, Length of Stay, and Cost Implications of Procedural Bleeding After Percutaneous Interventions Using Large-Bore Catheters. JAMA Cardiol. 2017;2:798-802.
Mastrorilli D, Mezzetto L, Antonello M, D'Oria M, Simonte G, Isernia G, et al. Results of iliac branch devices for hypogastric salvage after previous aortic repair. J Vasc Surg. 2023;78:963-72.
Gittinger M, Nguyen T, Jokisch C, Parikh RS, Shames M, Arnaoutakis DJ. Endovascular Salvage of Type Ia and Ib Endoleaks Using a Physician-Modified Fenestrated/Branched Endograft and an Iliac Branch Device Via Unilateral Transfemoral Arterial Access. J Endovasc Ther. 2024;15266028241249571.
Bellandi G, Ventoruzzo G. Endovascular bilateral evolutive common iliac artery aneurysm repair using a zenith branch graft through a combined femoro-brachial approach in a patient with previous EVAR. Eur J Vasc Endovasc Surg. 2010;40:596-8.
Tenorio ER, Oderich GS, Sandri GA, Karkkainen JM, Kalra M, DeMartino RR, et al. Outcomes of an iliac branch endoprosthesis using an "up-and-over" technique for endovascular repair of failed bifurcated grafts. J Vasc Surg. 2019;70:497-508.
Spath P, Cardona-Gloria Y, Torsello G, Gallitto E, Öz T, Beropoulos E, et al. Use of Secondary Iliac Branch Devices after Previous Endovascular Abdominal and Thoraco-Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg. 2023;65:819-26.
Bisdas T, Weiss K, Donas KP, Schwindt A, Torsello G, Austermann M. Use of iliac branch devices for endovascular repair of aneurysmal distal seal zones after EVAR. J Endovasc Ther. 2014;21:579-86.
Mesnard T, Patterson BO, Azzaoui R, Pruvot L, Haulon S, Sobocinski J. Iliac branch device to treat type Ib endoleak with a brachial access or an "up-and-over" transfemoral technique. J Vasc Surg. 2022;76:1537-47.
Dawson DL, Sandri GA, Tenorio E, Oderich GS. Up-and-Over Technique for Implantation of Iliac Branch Devices After Prior Aortic Endograft Repair. J Endovasc Ther. 2018;25:21-7.
Tadros RO, Power JR, Wengerter SP, Png CYM, Marin ML, Faries PL, et al. Femoral Access for Iliac Branched Endoprosthesis Deployment in Patients with a Prior Bifurcated Aortic Stent Graft. Ann Vasc Surg. 2018;53:262-5.
Oberhuber A, Duran M, Ertas N, Simon F, Schelzig H. Implantation of an Iliac Branch Device After EVAR via a Femoral Approach Using a Steerable Sheath. J Endovasc Ther. 2015;22:610-2.
Ferrer C, Venturini L, Grande R, Raccagni K, Giannini Corradini L, Corona M, et al. A Steerable Sheath to Deploy Hypogastric Bridging Stent by Contralateral Femoral Approach in an Iliac Branch Procedure after Endovascular Aneurysm Repair. Ann Vasc Surg. 2017;44:415.
Vaccarino R, Karelis A, Sonesson B, Dias NV. Steerable sheath for exclusively femoral bilateral extension of previous fenestrated endovascular aneurysm repair with iliac branch devices. J Vasc Surg Cases Innov Tech. 2021;7:322-5.
Rieß HC, Kölbel T, Diener H, Heidemann F, Debus ES, Rohlffs F, et al. Complete Ipsilateral Femoral Approach Using an Iliac Branch Device to Preserve a Sole Internal Iliac Artery After Aortic Stent-Graft Placement. J Endovasc Ther. 2016;23:800-2.
Panuccio G, Rohlffs F, Makaloski V, Eleshra A, Tsilimparis N, Kölbel T. Through-and-Through Suture Technique to Stabilize a Sheath in Branched Endovascular Aortic Repair. J Endovasc Ther. 2019;26:805-9.
