Management of the Iliac Bifurcation During Endovascular Aneurysm Repair: A Systematic Review and Network...

This study aimed to assess safety and efficacy of endovascular strategies for management of iliac bifurcation during endovascular aneurysm repair.

A systematic search was conducted of PubMed, Web of Science, and Scopus.

A systematic review and Bayesian network meta-analysis were undertaken in accordance with PRISMA 2020 guidelines. Primary endpoints were incidence of iliac related reinterventions and type Ib/Ic endoleaks. Risk of bias was assessed via ROBINS-I tool. Certainty of evidence was evaluated using the GRADE framework.

Twenty one studies were included, comprising 6291 patients and 7008 iliac bifurcations. The interventions evaluated were iliac branch devices (IBD), bell bottom technique, coil and cover, internal iliac artery (IIA) coverage with external iliac artery (EIA) extension, and the sandwich technique. IBD emerged as the only treatment reducing reinterventions compared with IIA coverage with EIA extension (risk ratio [RR] 0.46, 95% credible intervals [CrI] 0.15 - 0.93; Certainty of evidence: Moderate). For type Ib/Ic endoleaks, IBD ranked first according to the surface under the cumulative ranking curve (SUCRA) with modest separation from coil and cover (51.91 vs. 45.45) and was associated with a lower risk than bell bottom (RR 0.02, 95% CrI 0.00 - 0.15; Certainty of evidence: High). IBD (RR 0.07, 95% CrI 0.02 - 0.21; Certainty of evidence: Low), IIA coverage with EIA extension (RR 0.11, 95% CrI 0.03 - 0.30; Certainty of evidence: High) and bell bottom (RR 0.01, 95% CrI 0.00 - 0.06; Certainty of evidence: Low) reduced the risk of buttock claudication compared with coil and cover.

IBD demonstrated fewer iliac related reinterventions than coil and cover, fewer type Ib/Ic endoleaks than bell bottom, and less buttock claudication than coil and cover. Overall, IBD demonstrated the most consistently favourable outcome profile among the evaluated strategies when anatomically suitable.