Challenges associated with chronic aortic dissections: single-center experience of iliac branch devices in chronic aortic dissections.

Background: Chronic aortic dissections extending into the iliac arteries present unique anatomical and procedural challenges. Iliac branch devices (IBDs) offer the potential to preserve pelvic perfusion and achieve distal false lumen exclusion, yet their use in dissected anatomies remains off-label and insufficiently studied. This study evaluates the safety, technical success, and mid-term outcomes of IBDs in patients with chronic post-dissection aneurysms.

Methods: This retrospective single-center study included all patients treated with IBDs (Zenith Branch Endovascular Graft-Iliac Bifurcation, Cook Medical Bloomington, IN, USA) for chronic aortoiliac dissections between 2016 and 2024. Preoperative anatomy, procedural details, and clinical outcomes were analyzed. Primary endpoints were technical success and aneurysm shrinkage. Secondary endpoints included mortality, IBD-related endoleaks, occlusions and reinterventions.

Results: A total of 38 IBDs were implanted in 28 patients (mean age 59±11 years, 89% male). In 53% of cases, IBD implantation was performed simultaneously with f/bEVAR. Technical success was achieved in 100% of procedures. Aneurysm shrinkage was observed in all measured segments, with a mean reduction of 4.9 mm in the aorta, 5.4 mm at the aortic bifurcation, and 6.7 mm in the CIA (each P≤0.004). Estimated overall survival was 96% at 12 months and 86% at 36 months, declining to 62% at 60 months. Freedom from IBD-related endoleaks was 76%, from occlusion 91%, and from reintervention 75% at 36 months, with most adverse events clustering in the first year and event curves plateauing thereafter. A total of four IBD-related occlusions and eight reinterventions were recorded during follow-up. One early case of spinal cord ischemia after acute complicated type B dissection with contained rupture and one late case following embolic IIA branch occlusion were observed. General clinical complications occurred in 39% of patients, mainly due to hospital-acquired infections and acute kidney injury. Exploratory regression identified age, chronic kidney disease, aortic diameter, and pelvic tortuosity as predictors of overall mortality; custom-made IBDs predicted sac shrinkage, while self-expanding bridging stents and distal IIA relining were associated with occlusion.

Conclusions: In anatomically complex and predominantly younger patients, IBDs offer high technical success, favorable aneurysm remodeling and sustained preservation of pelvic perfusion. Despite their off-label use, endoleak, occlusion and reintervention rates remain acceptable when performed in experienced centers. The high rate of clinical complications reflects the complexity of simultaneous multilevel aortic repair and underscores the importance of meticulous perioperative care in this high-risk population. Further prospective multicenter studies are needed to validate these findings and optimize patient selection and device design for this complex pathology.