Volume 35, Issue 4 , Pages 429-435, April 2008
Is Hypogastric Artery Embolization during Endovascular Aortoiliac Aneurysm Repair (EVAR) Innocuous and Useful?
Article Outline
Introduction
We hypothesized that the coverage of the hypogastric artery with a stent-graft causes an occlusion of the artery in its proximal segment, allowing collateral network formation in distal segments of the artery. In contrast, hypogastric embolisation may cause the formation of microthrombi that tend to disseminate leading to embolic occlusion of secondary branches and collaterals. This phenomenon worsens pelvic ischemia.
To answer this question we compared two groups of patients with aortoiliac aneurysms treated with or without coil embolization to assess 1) The occurrence and evolution of buttock ischemia and 2) the effect on endoleak.
Materials/Methods
Between October 1995 and January 2007, 147 out of 598 EVAR patients (24.6%) required occlusion of one or both hypogastric arteries. 101 were available for over one year of follow-up. Group A included 76 patients (75%) who underwent coil embolization before EVAR and group B 25 patients (25%) who had their hypogastric artery covered by the sole limb of the stent.
Patient demographics, aneurysm characteristics, operative details, immediate and long term clinical outcomes, and CT-scan evaluation were stored prospectively in a specific data base and analyzed retrospectively.
Results
They were 96 males (95%). Mean age was 72.1
±9.5 years. One month postoperatively, 51 patients (50.0%) suffered from buttock claudication. After six months, 34 patients were still disabled (34%), 32 in Group A (42%) and 2 in Group B (8%) (p=0.001). Post-operative sexual dysfunction occurred in 19 (19.6%) without statistical difference between the two groups.
Type 2 endoleaks occurred in 12 patients (16.0%) in group A and 4 patients (16.0%) in group B (p=1). Endoleak from the hypogastric artery occurred in one patient in each group.
Univariate analysis showed that predictive factors of long term (over six months) buttock claudication were embolization (p<0.001), younger age (p<0.03), coronary disease (p=0.06) and left ventricular dysfunction (p<0.01). The logistic regression analysis showed that buttock claudication was independently associated with embolization OR=9.1[95%CI=1.9-44] and left ventricular dysfunction OR=4.1[95%CI=1.3-12.7].
Conclusions
Coil embolization of hypogastric artery during EVAR is not an innocuous procedure and may not reduce the rate of type II endoleak.
Keywords: Abdominal aortic aneurysm, Hypogastric embolization, Endovascular procedure, Buttock claudication
Introduction
Endovascular treatment of abdominal aortic aneurysms is an attractive alternative to open repair.1 It reduces the post-operative mortality and morbidity rates and shortens the patient's length of stay in hospital. Whilst long term results are being investigated, mid term analysis showed that aneurysm exclusion is currently obtained in 68 to 89% of cases.2, 3, 4, 5, 6, 7, 8
Success of EVAR is highly dependent on anatomical features of the aneurysm, including infra renal neck length and shape and iliac arteries diseases.
Twenty percent of abdominal aortic aneurysms (AAA) involves the common iliac arteries9 and occasionally the hypogastric and the external iliac artery as well. In these cases, with the lack of branched grafts, the usual choice is to place the distal tip of the limb of the graft at the level of the external iliac artery.10, 11, 12 To prevent type II endoleak13, 14, 15, 16, 17, 18, 19 from the hypogastric artery, coil embolization is frequently performed.20, 21
We hypothesized that the coverage of the hypogastric artery with a stent-graft causes an occlusion of the artery in its proximal segment, allowing collateral network formation in distal segments of the artery. In contrast, hypogastric embolisation may cause the formation of microthrombi that tend to disseminate leading to embolic occlusion of secondary branches and collaterals. This phenomenon worsens pelvic ischemia.
Unfortunately, the blockage of the hypogastric artery may lead to pelvic ischemia, with more or less severe clinical consequences such as buttock claudication (BC), erectile dysfunction, sciatic nerve ischemia and/or colonic necrosis.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32
In order to avoid complications related to hypogastric artery occlusion, hypogastric revascularization by means of bypass33 and branched endograft designed to perfuse the hypogastric artery34 have been successfully employed but with an increased complexity of the procedure that extents the length of intervention which may induce more complications and asks more experience from the surgeon.
Little data is available to assess long term evolution of BC and sexual dysfunction as well as to determine whether coil embolization is useful and innocuous as compare to coverage of the ostium of the hypogastric artery alone.35, 36, 37
The aim of the current study was 1) to determine the predictive factors of BC and 2) to compare two groups of EVAR patients in whom the hypogastric artery was blocked with or without coil embolization to assess the rate and evolution of buttock ischemia, and the effect on endoleak.
Materials/Methods
Between October 1995 and January 2007, 598 AAA or iliac aneurysms were treated by EVAR in the department of vascular surgery at Henri-Mondor Hospital, Créteil, France.
All patients had a pre-operative abdominal CT scan with contrast medium. Intra operatively, measurements of the different length and diameter were checked by angiography.
For AAA, we used preferentially bifurcated stent-graft. Iliac or aorto-mono-iliac grafts were used for unilateral iliac aneurysm or for unfavorable unilateral iliac anatomy or emergency cases.
All the stent-grafts were commercially available.
Decision to cover the hypogastric artery was made when the aneurysm was close or involved the iliac bifurcation, when the hypogastric artery was aneurysmal, or when the common iliac artery was too large to fit the available stent-grafts.
Coil embolization was performed the day before stent-graft implantation for cases expected to be difficult or at the beginning of the procedure for the technically easy ones. When bilateral embolization was deemed necessary patients were treated in a three steps procedure with a period of three months between each embolization, and EVAR.
Selective catheterization of the hypogastric artery was performed via ipsilateral or contralateral femoral access, depending on the vascular iliac anatomy.
The main trunk of the hypogastric artery was catheterized with use of a 5-F Cobra or Simmons 2 catheter (W. Cook Europe).
After the catheter was stabilized in the post-ostial segment of the hypogastric main trunk, we placed five to ten 0.035 inches by 5 or 10cm long coils (MR-eye stainless-steel coils; William Cook Europe). Heparin was not used during this step of the procedure.
The coils were positioned in the main trunk of hypogastric artery when it was healthy. In case of hypogastric aneurysm, we placed the coils downstream at the level of the anterior and the posterior divisions of the hypogastric trunk.
We strove to stop any residual anterograde flow through coils as checked by final angiography.
For those patients without coil embolization, the hypogastric artery was covered by the sole limb of the graft. This was done either accidentally following miscalculation of the length of the limb, or by mistake during deployment, or on purpose. This later case included failed attempt of coil embolization.
Patient demographics, aneurysm characteristics, operative details, immediate and long term clinical outcomes, and CT-scan evaluation were stored prospectively in a specific data base and analyzed retrospectively.
Out of the 598 EVAR, 147 (24.6%) required unilateral or bilateral occlusion of hypogastric arteries.
For the purpose of this study we excluded patients who did not reach six months follow-up, those who were lost to follow-up or died, and those who were unable to answer the specific questionnaire.
The current study included 101 patients. They were divided into two groups: Group A included 76 patients (75%) who underwent hypogastric artery coil embolization before or during EVAR and group B included 25 patients (25%) who had their hypogastric artery covered by the sole limb of the stent.
Follow-up
Patients were followed according to recommendations of the French Agency for Sanitary Security of Health Products (AFSSAPS:Agence Française de Sécurité Sanitaire des Produits de Santé) with a clinical exam at one month, six months and one year and then every year. Consultations were done by senior physicians. They included an interview for new complications, clinical examination, Doppler-ultrasound and contrast medium CT scan of the abdominal aorta. Patients unable to attend the visit were asked to send their imaging and were submitted to a telephone interview.
Analysis of buttock claudication and sexual dysfunction (Table 1)
Walking distance was assessed by questioning. Tread-mill test were not used. Any impairment of the walking was carefully assessed. Buttock claudication was defined as a new pain in the buttock which appeared immediately following EVAR. It was also referred to the side of hypogastric occlusion. It was graded as severe when it prohibited the patient from performing daily tasks. BC was defined as “persistent” when it lasted more than six months.
Table 1. Specific questionnaire for buttock claudication and sexual dysfunction
| Buttock claudication 1.Date of intervention 2.Follow-up respected? 3.Last visit 4.Buttock claudication after surgery: pain in the buttock or in the posterior side of the hip 5.Side of hypogastric interruption 6.Side of buttock claudication 7.Disability related to the pain 8.Walking distance 9.Improvement during the time. When did it stop? 10.Activity during the day Sexual dysfunction 1.What was the sexual activity before the operation 2.History of prostate cancer or surgery 3.Sexual activity after operation 4.Any difference felt between before and after 5.Residual activity or none activity |
Sexual dysfunction was considered to be linked to the intervention if the patient mentioned a clear difference of sexual activity before and immediately after the intervention.
Statistical analysis
They were performed with SPSS 13.0 and BPDP softwares in the Department of Biostatistics (Dr Roudot-Thoraval).
Statistical comparisons between groups were made by means of by the χ2 test or the Fischer's exact test for qualitative variables, and by the T-test or the non-parametric Mann-Whitney test for continuous variables.
All variables associated with persistent BC, with a p-value less than or equal to 0.10 in univariate analysis were tested in a stepwise logistic regression analysis. Adjusted Odds ratios (OR) with 95% confidence intervals were estimated from the model. P-values<0.05 were considered significant.
Results
Among 101 patients, there were 96 males (95%). Mean age was 72.1±9.5 years.
Eleven patients were operated in emergency, four of them for a painful aneurysm, and seven for a ruptured aneurysm. Ninety patients were treated electively.
The average of aortic aneurysms diameter was 57.1mm (range 46–100mm).
The average follow-up was 32.4±22.2 months (from 5.6 to 100.6 months).
Eleven patients died during the follow-up.
Table 2 shows anatomical features of AAA or iliac aneurysm with hypogastric blockage.
Table 2. Anatomical features of AAA or Iliac aneurysms treated by EVAR with hypogastric blockage
| Anatomical Features | Patients (n) % |
|---|---|
| AAA | 8 |
| AAA+unilateral CIA∗ | 33 |
| AAA+bilateral CIA | 19 |
| AAA+unilateral HA∗∗ | 12 |
| AAA+bilateral HA | 2 |
| Isolated unilateral CIA | 14 |
| Bilateral CIA | 3 |
| Unilateral HA | 9 |
| Bilateral HA | 1 |
∗CIA Common Iliac Aneurysm. |
∗∗HA Hypogastric Aneurysm. |
Group A included 76 patients (75%) in whom coils embolization was effectively performed.
There were 73 unilateral embolizations among which 71 unilateral embolizations with a non stenotic contralateral hypogastric artery and 2 unilateral embolizations with a stenotic contralateral hypogastric artery. There were also 3 bilateral hypogastric embolizations.
Group B included 25 patients (25%) in whom the hypogastric artery was blocked by the sole limb of the graft. Twelve were unintentional: in nine cases, the limb was placed too low, in two cases the hypogastric artery was blocked by the occluder of aorto-uniiliac graft, and in the remaining cases the common iliac artery was dissected by the guide wire preventing embolization. Thirteen cases were done on purpose. In these later cases coil embolization was not technically feasible: in eight cases it was due to major tortuosity of the iliac arteries, in four cases stenosis of the hypogastric artery hindered catheterization and in one ruptured case to avoid wasting time.
Table 3 shows the comparison of the pre-operative risk factors in group A and B. There is no statistical difference between the two groups.
Table 3. Comparison of group A (coil embolization) and group B (blockage by the graft limb alone)
| Risk Factors | Group B (n=25) | Group A (n=76) | Total | P value |
|---|---|---|---|---|
| Male | 22(88%) | 74(97%) | 96 | 0.96 |
| Diabetes | 3(12%) | 7(9%) | 10 | 0.70 |
| Smoking history | 11(44%) | 30(39%) | 41 | 0.81 |
| Hypertension | 14(56%) | 36(47%) | 50 | 0.50 |
| Dyslipidemia | 9(36%) | 27(36%) | 36 | 1 |
| CAD∗ | 9(36%) | 21(28%) | 30 | 0.46 |
| LVD∗∗ | 5(20%) | 16(21%) | 21 | 1 |
| Pulmonary insufficiency | 9(36%) | 14(18%) | 23 | 0.10 |
| Obesity | 5(20%) | 24(32%) | 29 | 0.31 |
| Renal insufficiency | 3(12%) | 11(14%) | 14 | 1 |
| Age | 73.00±7.42 | 71.75±10.09 | 0.57 |
∗CAD |
∗∗LVD |
Evolution of buttock claudication and sexual dysfunction
Fifty-one patients (50%) suffered BC post-operatively. In 34 patients (33%) BC did not improve during follow-up.
In seven patients (6.9%) BC was severe and lasted for the entire follow-up. In one of these patients, removal of the coils and bypass to the hypogastric artery from the external iliac artery was attempted. The bypass occluded within a few days.
Nineteen patients (19.6%) complained of post-operative erectile dysfunction. None improved during follow-up. Five of them (4.9%) qualified erectile dysfunction as extremely disabling.
Incidence of buttock complications and sexual dysfunction in Group A and B
In group A and in group B, BC was noted respectively in 44 patients (58%) and in seven patients (28%) (p=0.01). Persistent BC was noted in Group A in 32 patients (42%) and in group B in two patients (8%) (p=0.001).
In Group A, 15 patients (21%) presented with post-operative erectile dysfunction, whereas in group B it was only in four patients (19%), (ns).
Among the 3 patients with a bilateral hypogastric embolization, one presented a persistent bilateral BC, one presented a persistent unilateral BC associated with a severe sexual dysfunction and the last one was asymptomatic.
Pre-operative risk factors of post-operative and persistent BC
Univariate analysis of predictive factors is summarized in Table 4 for immediate post-operative BC and in Table 5 for the persistent ones.
Table 4. Univariate analysis of pre-operative risk factors of post-operative BC
| Parameters | No BC (n=50) | BC (n=51) | Total | P |
|---|---|---|---|---|
| Diabetes | 8 (16%) | 2(4%) | 10 | 0.007 |
| Tobacco | 19(38%) | 22(43%) | 41 | 0.06 |
| Hypertension | 23(46%) | 27(53%) | 50 | 0.60 |
| Dyslipidemia | 13(26%) | 23(45%) | 36 | 0.04 |
| CAD | 15(30%) | 15(29%) | 30 | 1 |
| LV dysfunction | 8(16%) | 13(25%) | 21 | 0.20 |
| Pulmonary insufficiency | 14(28%) | 9(17%) | 23 | 0.06 |
| Obesity | 15(30%) | 14(27%) | 29 | 0.77 |
| Renal insufficiency | 5(10%) | 9(17%) | 14 | 0.27 |
| Painful aneurysm | 6(12%) | 5(10%) | 11 | 0.74 |
| Group A | 32(64%) | 44(86%) | 76 | 0.01 |
| Group B | 18(36%) | 7(14%) | 25 | |
| Age | 74.72±7.97 | 69.45±10.17 | 0.005 |
Table 5. Univariate analysis of pre-operative risk factors of persistent BC
| Parameters | No persistent BC (n=67) | Persistent BC (n=34) | Total | P |
|---|---|---|---|---|
| Diabetes | 8 (12%) | 2(6%) | 10 | 0.49 |
| Tobacco | 26(39%) | 15(44%) | 41 | 0.67 |
| Hypertension | 30(55%) | 20(58%) | 50 | 0.21 |
| Dyslipidemia | 21(31%) | 15(44%) | 36 | 0.27 |
| CAD | 16(24%) | 14(42%) | 30 | 0.07 |
| LV dysfunction | 9(13%) | 12(38%) | 21 | 0.009 |
| Pulmonary insufficiency | 18(27%) | 5(15%) | 23 | 0.21 |
| Obesity | 18(27%) | 11(32%) | 29 | 0.64 |
| Renal insufficiency | 8(12%) | 6(18%) | 14 | 0.54 |
| Painful aneurysm | 8(12%) | 3(9%) | 11 | 0.74 |
| Group A | 44(66%) | 32(94%) | 76 | 0.001 |
| Group B | 23(34%) | 2(6%) | 25 | |
| Age | 73.50±8.32 | 69.20±11.01 | 0.03 |
The logistic regression analysis showed that immediate post-operative BC was independently associated with embolization OR=3.65[95%CI=1.24-10.8], diabetes OR=0.127[95%CI=0.0223-0.724] and age OR=0.925[95%CI=0.877-0.976].
Persistent BC was independently associated with embolization OR=9.1[95%CI=1.9-44] and LV dysfunction OR=4.1[95%CI=1.3-12.7]. The younger age did not reach statistical significance with the multivariate analysis for the persistent BC but the p=0.085.
Endoleaks
They were 16 type II endoleaks (16%). Their origins were the lumbar arteries (n=6), the inferior mesenteric artery (n=5) and the hypogastric artery (n=2). In three cases the origin remained uncertain.
Endoleak was observed in twelve patients (16.0%) in group A and four patients (16.0%) in group B (ns). Endoleak from the hypogastric artery occurred in one patient in each group.
Contralateral hypogastric artery patency
Two patients had a significant stenosis of the contralateral hypogastric artery.
The first had a persistent buttock claudication, the other one had no buttock claudication during follow-up.
Discussion
Previous reports have underlined that a significant number of patients experience complications after hypogastric artery embolization. These complications include BC, sexual dysfunction, skin necrosis of the buttock and ischemic sciatic nerve deficit. The more severe ones, however infrequent, include colonic ischemia and/or paraplegia.14, 23, 28, 31, 37
The current study confirms that hypogastric occlusion is not benign. Buttock claudication was observed in 50% of cases; it lasted more than six months in 34% of these cases and was severe in 7% of cases. Coil embolization was a significant factor of both early and late claudication. Post-operative sexual dysfunction was similar with the two treatment modalities. Finally the rate of type II endoleak was not reduced by the use of coil embolization.
Previous reports (Table 6) stated that post operative BC was in the range of 18 to 45%.14, 23, 27, 28, 30, 31, 37, 38, 39 In our study we noticed a higher rate of BC of 50%, comparable to the rate reported by Lee et al.33 Although thorough screening of BC may account for the higher rate of BC, we looked for other factors which may intervene in the development of BC.
Table 6. Literature review of the incidence of buttock claudication following hypogastric occlusions as part of EVAR
| Authors | Mean follow-up (months) | No. IIA occluded | No. coil | No. no coil | Post-operative BC∗ | Hypogastric endoleak |
|---|---|---|---|---|---|---|
| Rhee et al. (2002) | 4.6 | 49 | 35 | 6 | 14(28%) | 0 |
| Lee W et al. (2001) | 14.4 | 23 | 10 | 13 | 9(39%) | 0 |
| Karch et al. (2000) | 13.4 | 24 | 15 | 9 | 7(32%) | 0 |
| Lee C et al. (2000) | 7.3 | 28 | 13 | 18 | 5(18%) | 0 |
| Wolpert et al. (2001) | nr | 18 | 18 | nr | 8(44%) | 0 |
| Criado et al. (2000) | 11.5 | 39 | 39 | nr | 5(13%) | 0 |
| Cynamon et al. (2000) | 18 | 34 | 34 | nr | 13(38%) | 0 |
| Wyers et al. (2002) no coil | 18.5 | 33 | 11 | 22 | 6(27%) | 1 |
| Wyers et al. (2002) coil | 10.2 | 5(45%) | 0 | |||
| Farahmand et al. (2007) no coil | 36.3 | 101 | 76 | 25 | 7(28%) | 1 |
| Farahmand et al. (2007) coil | 31.2 | 44(58%) | 1 |
∗Buttock claudication. |
Among predictive factor linked to the patient's conditions, we found that younger age and left ventricular dysfunction were significant. These findings are logical; young patients are more active and more prone to suffer from claudication, while older patients may not be active enough to declare symptoms. Age should then be taken into account when hypogastric occlusion is an option during EVAR. Of note also is that younger patients were more prone to suffer lasting claudication. Patients with left ventricular dysfunction had 4.5 times more chance to develop persistent claudication. Low cardiac outflow may play a role on pelvic circulation when one hypogastric artery is blocked. Again, this factor should be taken into account when deciding for hypogastric blockage. Patients with diabetes had a lower rate of buttock claudication. Reasons are unclear but we could hypothesize that this subgroup of patient were less active.
In our series, the way hypogastric artery was blocked played a major role in the development of BC. We found much less claudication when the hypogastric was simply covered by the limb of the graft (28% versus 58%). Persistent BC concerned 42% of embolized patients and only 8% of non-embolized patients. The multivariate analysis showed that the persistent claudication was nine times more frequent in the embolized patients.
This finding is in agreement with Wyers et al.39 and Terefa et al.40 who supported not embolizing the hypogastric artery when the sealing between the stent and the iliac artery was correct.
Some have advocated placing coils at the origin of the hypogastric artery rather than in the second or even tertiary tributaries. This technique allows collateral circulation between anterior and posterior arteries, limiting ischemia of the buttock muscle.
Since we did not precisely record where the coils were placed we cannot draw conclusions on this statement. However, aware of these complications, we always strove to place the coils as proximal as technically feasible. For the same reasons we tended to use larger and longer coils (10cm) to avoid their drifting distally into the tributaries of the hypogastric artery. However, when dealing with a large hypogastric artery or hypogastric aneurysms there are few other choices left than blocking the distal arteries arising from the pouch.
While coil embolization produced more buttock claudication, the rate of type II endoleak was similar in both patients with or without embolization. In the current series, the majority of type II endoleak were from the lumbar arteries and the inferior mesenteric artery. It is fairly understandable that coil embolization of one hypogastric artery could not prevent type II endoleak. Ascending lumbar arteries coming from the contralateral hypogastric artery, anastomosis with diaphragmatic arteries and collateral pathway with the superior mesenteric artery were sufficient to feed the aneurysm sac with a retrograde flow.
The main goal of hypogastric coils embolization is to prevent back flow in the ipsilateral common iliac artery. This was achieved in 99% (75/76) cases. One patient had a retrograde flow from the hypogastric artery into a large common iliac artery due to improper coils embolization. Redo embolization was performed from the groin with success. Of note in the group without embolization, the success rate was quite acceptable: 96% (24/25). One patient had a retrograde flow which required ligation of the hypogastric artery. After this redo procedures, no buttock claudication nor sexual dysfunction was noticed.
The sexual dysfunction is another important issue. Occlusion of the hypogastric artery is a well recognized cause of erectile dysfunction in male patients. The relationship between therapeutic hypogastric occlusion and sexual dysfunction is difficult to evaluate in this subset of patients. The average age is 72 years old, many have a reduced level of sexual activity, they often have had surgery for prostate pathology or anti-cancer chemotherapy, 25% are diabetic and many takes drugs such as beta blockers which may also alter sexual performance. In our study, we found a 20% rate of new erectile dysfunction after a unilateral embolization and 33% rate after bilateral embolization. This is in the range of previous series where the rate of sexual dysfunction was between 10 and 50%.23, 38, 41 In the current series, we were unable to find a difference of new sexual dysfunction whether the hypogastric artery was embolized or not. However, those evaluations were made by interviewand no objective data could be collected.
Our study has several limitations. It was a retrospective study, the groups were not randomized, and site of embolization was not precisely noted nor analyzed. However the pre-operative parameters were divided in a homogeneous way between the two groups without significant association of one of the parameters with one of the two groups, suggesting a sufficient comparability between the two groups. Given the severity of BC, hypogastic revascularization by means of bypass33 or branched endograft designed to perfuse the hypogastric artery34 should be strongly advocated. However they are not always feasible and they add complexity to the procedure with its inherent own risk.
Conclusion
Hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) is not an innocuous procedure, leaving a significant number of patients with severe and lasting buttock claudication. We then advocate limiting hypogastric embolization to the older patients when the size of the common iliac artery does not fit the size of the current stent-graft or in patients with associated hypogastric aneurysm requiring treatment.
Acknowledgements
Thanks to Ms Alexandra Mason, ND, for her voluntary assistance in the translation and the writing of this article. No conflict of interest.
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PII: S1078-5884(07)00750-2
doi:10.1016/j.ejvs.2007.12.001
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Volume 35, Issue 4 , Pages 429-435, April 2008
