Balloon-Expandable Covered Stents as Iliac Limbs During Complex EVAR

Calcified, stenotic, or occluded iliac and femoral arteries can pose a challenge for iliac limb delivery and deployment during endovascular repair of aortic aneurysms (EVAR). The purpose of this study is to evaluate the feasibility and outcomes of balloon-expandable covered stents used as iliac limbs during complex EVAR.

From 2017 to 2025, BECS (VBX; W.L. Gore & Associates, Flagstaff, AZ) were used as an iliac limb for eighty-nine iliac arteries in sixty-four patients undergoing complex EVAR in a prospective, nonrandomized, investigator-sponsored Investigational Device Exemption (IDE) study. A BECS was used as an iliac limb when the iliac landing-zone diameter was <16 mm in patients with occlusive disease or tortuosity that was deemed unfavorable for treatment using a standard self-expanding EVAR limb. Cases in which a BECS was used with an iliac-branch-device or to reinforce or extend commercially available iliac limbs were excluded.

The mean age of patients treated with a BECS as an iliac limb was 74.0 years (range: 61-89 years), and 54.7% were women. The mean iliac landing zone diameter was 10.6 mm (range: 5.6-15.6 mm). BECS were delivered via axillary artery access for 15 iliac arteries (16.9%) and were delivered via femoral artery access for the remaining 74 (83.1%). A single BECS was used in 57 iliac arteries (64%), 2 BECS were used in 29 iliac arteries (32.6%), and 3 BECS were used in 3 iliac arteries (3.4%). The most commonly used BECS size was 11 mm in diameter (62 iliac arteries; 69.7%). BECS were implanted into 71 native iliac arteries and into 18 iliac limbs from prior EVARs or prosthetic surgical grafts. The median follow-up was 19.7 months (range: 0.8-60.2). Primary patency was 98.9%, and freedom from reintervention was 93.8%. Three patients (3.4%) had a type 1b endoleak, and one patient (1.6%) had a type III endoleak on follow-up imaging.

Balloon-expandable covered stents can serve as a feasible and promising alternative iliac limb strategy during EVAR in selected patients with small or diseased iliac arteries or unfavorable femoral access. In this series, the use of BECS was associated with high, intermediate-term limb patency, low reintervention rates, and favorable distal sealing despite challenging iliac anatomy. The low-profile delivery system, precise deployment, favorable flexibility, and strong radial force of the VBX platform make it particularly well-suited for this application. Longer follow-up and comparative studies are needed to further define long-term durability and optimal patient selection.