{"paper_id":"2998cc5e-b2fc-487f-979d-2b40261cbd09","body_text":"Comparison of Clinical and Cost-Effectiveness Between Amplatzer Vascular Plug and Coil Embolization for Prophylactic Internal Iliac Artery Embolization During EVAR | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Clinical and Cost-Effectiveness Between Amplatzer Vascular Plug and Coil Embolization for Prophylactic Internal Iliac Artery Embolization During EVAR Satoshi Takaki, Yoshiko Tani, Hiroyuki Hirahara, Masaaki Sugawara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9174649/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objective: This study is a retrospective, single-center study comparing the effectiveness of Amplatzer vascular plug (AVP) with coil embolization in prophylactic internal iliac artery embolization during endovascular aortic aneurysm repair (EVAR). Materials and Methods: We reviewed 146 embolization procedures performed during EVAR from 2009 to 2024. We compared technical success, adverse events (including type II endoleak and buttock claudication), procedure time, and embolization-related costs between the coil embolization group and the AVP embolization group. We also performed multivariate analyses on factors influencing gluteal claudication, procedure time, and procedure costs. Results: Technical success was achieved in all procedures. No significant differences were observed between groups in type II endoleaks and intraoperative vascular injuries. Compared to the coil embolization group, the AVP group had a lower incidence of buttock claudication at 6 months (10% vs. 30%), shorter procedure time, and lower embolization-related costs. Multivariate analysis identified embolic material as an independent factor associated with buttock claudication, procedure time, and procedure cost. Conclusion: Prophylactic internal iliac artery embolization using AVP during EVAR is safe and effective, potentially reducing buttock claudication and lowering procedure time and cost compared to coil embolization while maintaining comparable clinical outcomes. Figures Figure 1 Figure 2 Figure 3 Introduction Endovascular abdominal aortic repair (EVAR) for abdominal aortic aneurysms (AAA) is commonly accepted as a safe alternative to open surgery. Cases involving aneurysmal dilatation of at least one of the left and right common iliac arteries, which account for 20% of AAAs 1) , or cases with the relatively short and thick common iliac arteries often observed in Asian populations, may require extending the iliac branch of the stent graft to the external iliac artery 2) , posing a risk of type 2 endoleak due to retrograde flow from the occluded internal iliac artery. To prevent such type 2 endoleaks, prophylactic internal iliac artery embolization using metal coils, which involves embolizing the internal iliac artery with metal coils simultaneously with or in stages with EVAR, is widely performed 2–4) . Recently, a new technique called iliac branch stent grafting has made it possible to perform EVAR with external iliac artery landing while maintaining blood flow in the internal iliac artery 2) . However, this device has various anatomical requirements and lacks versatility. Therefore, in selected cases, prophylactic internal iliac artery embolization remains an important strategy. The Amplatzer Vascular Plug (Abbott Vascular, Redwood City, California, USA) is a nitinol-based, self-expanding cylindrical occlusion device known as a suitable alternative to coil embolization 5–12) . At our hospital, we have been primarily using AVP for prophylactic internal iliac artery embolization since 2014. The purpose of this study was to compare the clinical outcomes of prophylactic internal iliac artery embolization using Amplatzer vascular plugs (AVPs) during endovascular abdominal aortic repair (EVAR) with those of conventional embolization. Materials and Methods This study is a single-center retrospective study. Patient characteristics: This study included 120 cases and 146 procedures performed at Nagaoka Red Cross Hospital between September 2009 and January 2024, where prophylactic embolization of the internal iliac artery was carried out before or simultaneously with EVAR procedures. There were 97 males and 23 females, the age ranged from 46 to 90 years, and the average age was 75.8 years. The median observation period was 88.7 months (95% C.I. 78.5 months to 98.9 months). The lesion sites were abdominal aortic aneurysm + common iliac artery aneurysm in 67 procedures, localized iliac artery aneurysm in 44 procedures, and localized abdominal aortic aneurysm (insufficient distal landing zone) in 35 procedures. Additionally, 56 procedures were accompanied by aneurysmal dilation of the internal iliac artery. At our institution, in cases requiring bilateral embolization, we first performed staged embolization on one side, followed by simultaneous embolization on the remaining side during EVAR surgery. For cases where only unilateral embolization was performed, simultaneous embolization was generally carried out. Therefore, there were 100 unilateral embolization procedures and 46 bilateral embolization procedures. Regarding the timing of embolization, 124 embolization procedures were performed simultaneously with EVAR surgery, while 22 embolization procedures were performed in stages. Regarding the embolization site, embolization at the level of the main internal iliac artery was defined as proximal embolization, and embolization at the branch of the internal iliac artery was defined as distal embolization. The breakdown was 78 proximal procedures and 68 distal procedures. The devices used were Cook Zenith (Medtronic Cardiovascular, Santa Rosa, California) in 8 procedures, Gore Excluder (W. L. Gore & Associates, Inc., Newark, Delaware) in 118 procedures, ENDURANT (Medtronic Cardiovascular, Santa Rosa, California) in 10 procedures, Endologix Powerlink/AFX/AFX2 (Endologix Inc., Irvine, California) in 8 procedures, and Aorfix stent graft (Lombard Medical Technologies Inc., Tempe, Arizona) in 2 procedures (Table 1). For insertion into the internal iliac artery, the standard procedure involved approaching from the contralateral femoral artery, over the aortic bifurcation, inserting a rigid guidewire (diameter: 0.035 inches, length: 180–300 cm) distal to the superior or inferior gluteal artery, guiding a long 6Fr sheath (Destination Terumo, Tokyo, Japan) distal to the internal iliac artery trunk, and positioning the AVP from the internal iliac artery trunk to the origin level proximal to the superior/inferior gluteal artery bifurcation using the pullback technique described in the instruction manual (Fig. 1). When necessary, we also used an approach via the ipsilateral femoral artery. The breakdown of approaches was as follows: 115 procedures (79%) were contralateral approaches, 30 procedures (21%) were ipsilateral approaches, and 1 procedure (0.6%) was brachial approach. The brachial approach was used only once in the initial stages, but due to a lack of suitable devices and concerns about the risk of stroke, it has not been selected as an access route for prophylactic internal iliac artery embolization since then. The snare-assisted pull-through method was used in three embolization procedures (1 procedure with coils and 2 procedures with AVP). Patient information, radiological data, and surgical data were obtained from our hospital's paper and electronic medical records. Patient names and other Health Insurance Portability and Accountability Act (HIPAA) identifiers were removed from all manuscripts, including supplementary information, and no other information that could potentially identify subjects (such as clinical images or videos) was included in this study. The Nagaoka Red Cross Hospital Ethics Committee exempted this study from ethical review and informed consent requirements because it was a retrospective study. All methods were carried out in accordance with relevant guidelines and regulations. [Investigated Items] ( 1 ) Embolization success rate and breakdown of procedures and embolization details for all procedures ( 2 ) Comparison between the coil group and AVP group for adverse events (type 2 endoleak, intraoperative vascular injury, frequency of buttock claudication), procedural time, and cost incurred for the procedures ( 3 ) Three types of subgroup analysis Comparison of buttock claudication, procedure time, and procedure cost based on the presence or absence of internal iliac artery aneurysm Comparison of buttock claudication, procedure time, and procedure cost between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm Comparison of buttock claudication with unilateral embolization and bilateral embolization ( 4 ) Multivariate analysis of factors influencing buttock claudication, procedure time, and procedure cost All analyses were performed for each embolization procedure, and each embolization procedure was analyzed as an independent event. The evaluation of type 2 endoleaks was conducted using contrast-enhanced CT scans targeting the internal iliac artery and the common iliac artery where preventive embolization was performed. Regarding buttock claudication, as a general rule, the presence or absence of symptoms and whether they have improved were evaluated through interviews at the vascular surgery outpatient clinic at 1 month, 6 months, 1 year, and then every year thereafter. If the symptoms persisted at 6 months post-surgery, it was evaluated as having buttock claudication. Buttock claudication was also evaluated after each embolization procedure and analyzed for each treatment. In the case of staged bilateral embolization, the symptoms were considered to be attributable to the corresponding procedure. At our institution, during EVAR surgery, the anesthesia department administers systemic heparinization at the time of inserting short sheaths into both groins. Therefore, regarding the procedure time for embolization, in the case of simultaneous embolization with EVAR, the start time was defined as the time of systemic heparinization as recorded in the anesthesiology records. If a preceding interventional radiology (IVR) procedure (including 1 renal artery stent placement, 14 prophylactic IMA embolization procedures, and 2 type 1b interventions immediately following EVAR placement, totaling 17 procedures) had been performed, the start time was defined as the time of confirmation imaging for the preceding IVR procedure. In the case of staged embolization, the start time was defined as the time of arterial puncture. For all procedures, the completion time was defined as the time when confirmation images were taken at the end of the embolization procedure. Furthermore, since introducing AVP at our hospital, our policy is to first attempt embolization using AVP in all procedures, and only switch to embolization using other devices such as coils if it proves difficult. Therefore, to ensure fairness, 8 procedures that were switched to coil embolization due to difficulties with AVP embolization after AVP introduction were excluded from the analysis of procedure time. Additionally, for the 7 coil embolization procedures and 1 AVP embolization procedure performed in the operating room, the confirmation imaging time at the end of the embolization procedure could not be determined from the imaging equipment records, so these procedures were excluded from the analysis of procedure time. Regarding the costs associated with the procedure, we referred to the documentation from the radiology department and the details of the surgical procedures, as well as our institution's medical billing claims. We accounted for the costs of items used solely for internal iliac artery embolization. The cost was calculated using both Japanese yen and US dollars converted at the average dollar-yen exchange rate for January 2026 (1 USD = 156 yen). The number of variables included in the multivariate model was limited to avoid overfitting. The analysis was performed using SPSS software (IBM Corp., Armonk, New York, USA). The frequency of type 2 endoleaks and buttock claudication at 6 months postoperatively was determined by the chi-square test, and the frequency of intraoperative vascular injury was determined by Fisher's exact test. The procedure time and cost were analyzed using the t-test. For multivariate analysis, buttock claudication was analyzed using logistic regression analysis, while procedure time and cost were analyzed using multiple regression analysis. In all analyses, a P-value of less than 0.05 was considered statistically significant. Regarding gonadal dysfunction, which is generally considered one of the adverse events associated with internal iliac artery embolization, it was not considered in this study due to the high proportion of elderly patients in the target group and the absence of postoperative complaints from the patients. Similarly, severe pelvic ischemia, such as bowel ischemia, which is also considered a common adverse event, was not observed in any of the procedures. Results ( 1 ) Success Rate of Embolization and Breakdown of Embolization Content in All Procedures The success rate of embolization was 100%, with no perioperative deaths or non-target embolizations observed. However, during one embolization procedure, an F-F bypass surgery was performed due to thrombotic occlusion of the common iliac artery. Another embolization procedure required conservative treatment due to the formation of a femoral artery pseudoaneurysm. Furthermore, thrombus removal surgery was performed after one embolization procedure due to lower limb arterial thrombosis. The breakdown of embolization procedures was as follows: 42 procedures using metal coils alone, 11 procedures using metal coils and NBCA in combination, 87 procedures using AVP alone, 4 procedures using AVP and metal coils in combination, and 2 procedures using AVP and NBCA in combination. In the metal coil embolization group, an average of 18.4 ± 2.5 coils were used, consisting of 10.2 ± 2.4 pushable coils (0.035), 7.5 ± 3.0 pushable coils (0.018), 0.06 ± 0.1 detachable coils (0.035), and 0.7 ± 0.6 detachable coils (0.018). In the AVP embolization group, an average of 1.3 ± 0.1 AVPs and 0.1 ± 0.1 coils were used. The breakdown of the coils used was 0.08 ± 0.1 pushable coils (0.018) and 0.07 ± 0.08 detachable coils (0.035). No re-intervention related to internal iliac artery embolization was required for all of the procedures. No dilation of the internal iliac artery sac was observed. No secondary embolization was performed. No deaths due to rupture of aneurysms in the treated area were observed. ( 2 ) Comparison of Coil Group and AVP Group: Adverse Events (Type 2 Endoleak, Intraoperative Vascular Injury, Frequency of Buttock Claudication), Procedure Time, and Procedure Cost Regarding patient background factors in the coil group and AVP group, the frequency of bilateral embolization was significantly higher in the AVP group on the embolization side (P = .001). However, no significant differences were observed in other factors (Table 2). Additionally, the brachial approach was excluded from the analysis of patient background factors, as previously mentioned. Regarding type 2 endoleak, the frequency was 2 cases (3.8%) in the coil group and 4 cases (4.5%) in the AVP group, with no significant difference between the two groups (P = 0.862). Additionally, there were no type 2 endoleaks that required additional treatment. Furthermore, in 1 procedure in the coil group and 5 procedures in the AVP group, postoperative contrast-enhanced CT scans could not be performed due to renal function decline, making it impossible to evaluate type 2 endoleaks. Regarding intraoperative vascular injury, there were no cases (0%) in the coil group, whereas the AVP group had 3 cases (3.3%) of vascular injury caused by migration of stiff guidewire tip, which were managed with intraoperative TAE. There was no significant difference in the frequency of vascular injury between the two groups (P = 0.191). At 6 months postoperatively, the frequency of buttock claudication was 15 procedures (30%) in the coil group and 9 procedures (10%) in the AVP group, with a significantly lower frequency of buttock claudication in the AVP group (P = 0.003) (Table 3). Additionally, evaluations of buttock claudication could not be performed for 3 procedures in the coil group and 1 procedure in the AVP group due to the destruction of medical records, and for 2 procedures in the AVP group due to early postoperative discharge. In the analysis of procedure time, the average procedure time was 105.1 ± 41.6 minutes in the coil group, compared to 50.8 ± 23.5 minutes in the AVP group, indicating that the AVP group had a significantly shorter procedure time (P = 0.000) (Table 3, Fig. 2). Regarding costs of procedure, the average cost for the coil group was 310,273 ± 185,697 yen (1,989 ± 1,192 US dollars), while for the AVP group it was 183,044 ± 62,950 yen (1,174 ± 406 US dollars), indicating that the AVP group was significantly lower cost (P = 0.000) (Table 3, Fig. 3). ( 3 ) Three Types of Subgroup Analysis Comparison of buttock claudication frequency, procedure time, and procedure cost based on the presence or absence of internal iliac artery aneurysm. The frequency of buttock claudication in patients with and without internal iliac artery aneurysm was 16 procedures (18.6%) in the group without aneurysm and 8 procedures (14.8%) in the group with aneurysm, with no significant difference between the two groups (P = 0.562). Regarding the procedure time based on the presence or absence of internal iliac artery aneurysm, the group without aneurysm needed 63.1 ± 35.4 minutes, while the group with aneurysm needed 75.0 ± 44.3 minutes. Although the group without aneurysm tended to have a shorter procedure time, no significant difference between the two groups (P = .098). The cost of the procedure differed significantly between the group without internal iliac artery aneurysm and the group with aneurysm: the group without aneurysm cost 206,810 ± 121,299 yen (1,326 ± 777 US $ ), while the group with aneurysm cost 265,688 ± 153,031 yen (1,704 ± 982 US $ ). The group without aneurysm was significantly lower cost (P = .011). Comparison of buttock claudication frequency, procedure time, and procedure cost between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm. In the absence of internal iliac artery aneurysm, buttock claudication occurred in 10 procedures (33.5%) in the coil group and 6 procedures (10.7%) in the AVP group. Procedure time was 97.2 ± 33.0 minutes in the coil group and 48.1 ± 24.5 minutes in the AVP group. Procedure costs were 297,361 ± 166,121 yen (1,906 ± 1,064 US $ ) in the coil group and 158,412 ± 36,716 yen (1,016 ± 235 US $ ) in the AVP group. The AVP group was significantly superior in all categories: buttock claudication (P = .008), procedure time (P < .001), and procedure costs (P < .001). In the group with internal iliac artery aneurysm, buttock claudication occurred in 5 procedures (22.7%) in the coil group and 3 procedures (9.1%) in the AVP group. Procedure time was 119.3 ± 52.0 minutes in the coil group and 55.6 ± 21.0 minutes in the AVP group. Procedure costs were 328,468 ± 213,437 yen (2,106 ± 1,368 US $ ) in the coil group and 225,065 ± 75,587 yen (1,445 ± 489 US $ ) in the AVP group. While buttock claudication tended to be better in the AVP group, there was no significant difference (P = .160). However, the AVP group was significantly better in both procedure time (P < .001) and procedure cost (P = .011). Comparison of buttock claudication frequency between unilateral and bilateral embolization. The frequency of buttock claudication in unilateral and bilateral embolization was 18 procedures (18.8%) for unilateral embolization and 12 procedures (14.0%) for bilateral embolization, with no significant difference between the two groups (P = .489). ( 4 ) Multivariate Analysis of Factors Influencing Buttock Claudication, Procedure Time, and Procedure Cost The following factors were identified as significant influences on buttock claudication: embolic material (P = .002), location of embolization (P = .034), indication (P < .001), and procedure time (P = .048) (Table 4). The following factors were identified as significant influencing the procedure time: embolic material (P < .001), procedure cost (P = .027), and buttock claudication (P = .042) (Table 5). The following factors were identified as significant influencing the cost of the procedure: embolic material (P = .046), location of embolization (P = .020), and procedure time (P = .027). In the univariate analysis, the timing of embolization (synchronous or metachronous) was not significantly associated with the procedure time (P = .503) or the cost of embolization (P = .524). The timing of embolization was strongly correlated with bilateral embolization, so it was not included in the multivariate model to avoid multicollinearity. Discussion Buttock claudication is one of the important adverse events in prophylactic internal iliac artery embolization, with a reported frequency of 13% to 67% 5),7–8),12–19),22–25),27–28) . On the other hand, some reports suggest that embolization of the proximal internal iliac artery 9),18–19),24–25) and the use of AVP 5–12) reduce the frequency of buttock claudication. In this study, a statistically significant increase in proximal embolizations and a decrease in the frequency of buttock claudication were observed in the AVP group. AVP embolization may be associated with a reduction in the frequency of buttock claudication. Dierk et al 26) . reported that proximal occlusion of asymptomatic IIA and distal occlusion of aneurysmal IIA prior to EVAR were equivalent in terms of clinical outcomes. In this study as well, there was no significant difference in the frequency of buttock claudication between the presence or absence of internal iliac artery aneurysm in the subgroup analysis. Similarly, there was no significant difference in the location of embolization between the group without aneurysm (39 procedures, 43.3%) and the group with aneurysm (29 procedures, 51.8%) (P = .319), suggesting that the incidence of buttock claudication is similar regardless of the presence or absence of aneurysm. In a subgroup analysis of the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm, the frequency of buttock claudication was significantly lower in the AVP group compared to the group without aneurysm, and although there was no significant difference in the group with aneurysm, there was a tendency for the frequency to be lower in the AVP group. This suggests that one possible reason for this is insufficient analytical power due to the small number of cases of internal iliac artery aneurysm. Regarding unilateral and bilateral embolization, some reports indicate that bilateral embolization has adverse effects on buttock claudication 21) , while others suggest that serious complications are rare even with bilateral embolization and that it can be performed with a similar level of risk as unilateral embolization 13–14),22),29) . Our subgroup analysis showed no significant difference between the two groups in the frequency of buttock claudication. This suggests that the AVP group had a significantly higher rate of bilateral embolization, and that the increased frequency of AVP use in bilateral embolization procedures may have reduced the frequency of buttock claudication, resulting in no significant difference observed. It has already been reported that using AVP in prophylactic internal iliac artery embolization leads to a reduction in procedure time 10,16,26) . This study also showed a reduction in procedure time with AVP, suggesting that AVP embolization may contribute to reducing procedure time in prophylactic internal iliac artery embolization. In a subgroup analysis of procedure time based on the presence or absence of internal iliac artery aneurysm, there was no significant difference between the two groups. This suggests that the technical difficulty of cannulation due to internal iliac artery aneurysm may have been relatively underestimated, as the number of procedures excluded from the procedure time analysis due to difficulties in cannulation after AVP introduction and subsequent transition to coil embolization was significantly higher in the group with aneurysm (11.5%) compared to the group without aneurysm (2 procedures, 2.3%) (P = .025). In a subgroup analysis of procedure time between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm, the AVP group had significantly shorter procedure time regardless of the presence or absence of aneurysm, suggesting that the use of AVP may contribute to reducing procedure time. Several reports indicate that the cost of prophylactic internal iliac artery embolization using AVP is significantly lower than that of coil embolization 5,7),10–11) . However, these reports generally estimate the cost of AVPs to be around 300 US $ , but in Japan, the cost per AVP is 131,000 yen (approximately 879 US $ at the average dollar-yen exchange rate in January 2026), so this does not accurately reflect the procurement cost of AVPs. Ryer et al. 15) also reported in a similar study that the cost of embolization procedures tended to be lower in the AVP group, but there was no significant difference between the AVP group and the coil group. Kotoku et al. 20) reported that a special technique called coil-in-plug (CIP), in which coils are inserted into AVP, reduces costs compared to conventional coil embolization, but their report does not simply compare AVP embolization with coil embolization. This study demonstrated that the cost of AVP embolization was significantly lower compared to coil embolization. No reliable studies on prophylactic internal iliac artery embolization that reflect the formal procurement costs of AVP based on a certain number of cases have reported similar results. To our knowledge, there are very few studies that have evaluated embolization-related costs using AVP while reflecting actual procurement costs in relatively large cohorts. In this study, a subgroup analysis of procedural costs between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm revealed that procedural costs were significantly lower in the AVP group, regardless of the presence or absence of aneurysm. The impact of AVP embolization on the overall cost of EVAR surgery is an interesting factor, but Ryer et al. 15) reported no significant difference in this regard. On the other hand, it is well known that the cost of EVAR surgery varies greatly depending on the treatment plan. Therefore, it is unlikely that meaningful results can be obtained by simply calculating the mean values ​​of cases collected retrospectively without considering the plan, as in the case group of this study. Prospective comparative studies using standardized EVAR strategies and randomized embolic materials may further clarify these results. Many reports suggest that AVP embolization is generally superior to coil embolization in internal iliac artery embolization 5–12),16),26) . In this study, particularly in the multivariate analysis, the embolic material was identified as a significant factor that commonly affects buttock claudication, procedure time, and procedure cost, suggesting that the selection of the embolic material is an important element in embolization. However, selection bias and temporal changes in technique may have influenced these results. Conclusion The use of AVP in prophylactic internal iliac artery embolization during EVAR may offer benefits such as a reduced incidence of buttock claudication, shorter procedure time, and lower embolization costs, with no serious adverse events observed. [Limitations] The limitations of this study include the following: The study is a single-center retrospective analysis. Since the study involves a single operator, there is an element of learning curve that may influence the results. The study spans a long patient enrollment period, which introduces potential bias due to advancements in device technology over time. Because multiple procedures were performed in some patients, the assumption of independence may have been violated, which could introduce bias into the statistical analysis. References Armon MP, Wenham PW, Whitaker SC, Gregson RHS, Hopkinson BR (1998) Common iliac artery aneurysms in patients with abdominal aortic aneurysms. 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J Vasc Surg 37(5):943–948 Bratby MJ, Munneke GM, Belli A-M, Loosemore TM, Loftus I, Thompson MM (2008 Mar-Apr) R A Morgan How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol. 31(2):246–253 Alexander Dierk A, Sauer F, Wolfshmidt N, Hassold R, Kellersmann T, Abley (2017) Ralph Kickuth Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome. Br J Radiol 90(1072):20160527 Shunichiro Fujioka SH, Morimura H, Chen K, Wang ZC, Toguchi K, Fukuda S (2017), Koki Takizawa, Hiroshi Osawa Outcomes of Extended Endovascular Aortic Repair for Aorto-Iliac Aneurysm with Internal Iliac Artery Occlusion. Ann Vasc Dis ;10(4):359–363 Manish Mehta, Frank J, Veith R, Clement Darling SP, Roddy T, Ohki EC, Lipsitz PSK, Paty PB, Kreienberg, Kathleen J, Ozsvath, Benjamin B, Chang (2004) Dhiraj M Shah Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 40(4):698–702 Tables Tables are available in the Supplementary Files section. Supplementary Files renamed74f2a.ppt Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 08 Apr, 2026 Reviewers invited by journal 07 Apr, 2026 Editor invited by journal 07 Apr, 2026 Editor assigned by journal 07 Apr, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9174649\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":619017502,\"identity\":\"41a73f17-9ce7-469d-b676-a4bdede0ddb1\",\"order_by\":0,\"name\":\"Satoshi Takaki\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIie3RMWsCMRTA8RcC1yX01nc49Cs8ODgciv0qBiFuRSgUxxyCLoJrPsaBH6ARwUnsetBC49LZ7gd6Fju45HSTkv+QIfDjvRCAUOgGe/p6txZp34mB6d3psuslBGvp2gPeSzTLjb2QpDTccVZYYH/EH7GpwpIinn6M8tHPGJ5jgG/nfQuPV4khcZ99LnK9GMNLoqFP3imRUC0k5FkpJ64mst5QoZcIkbUqIjY38neKfGskKFJC6rICT6SAZiIdku1hWZP1BqVZNr3l4fiVle3Epr/Vw9dHOZtMlfOR81hUr8SFulwAVMfjbnUNCYVCof/fARfDUHB9fe5mAAAAAElFTkSuQmCC\",\"orcid\":\"https://orcid.org/0009-0005-5060-1925\",\"institution\":\"Nagaoka Red Cross Hospital: Nagaoka Sekijuji Byoin\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Satoshi\",\"middleName\":\"\",\"lastName\":\"Takaki\",\"suffix\":\"\"},{\"id\":619017503,\"identity\":\"c7ba4917-df0b-421e-bc83-96589f72c887\",\"order_by\":1,\"name\":\"Yoshiko Tani\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nagaoka Red Cross Hospital: Nagaoka Sekijuji Byoin\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yoshiko\",\"middleName\":\"\",\"lastName\":\"Tani\",\"suffix\":\"\"},{\"id\":619017504,\"identity\":\"611ce1eb-9727-4df6-a48e-615d281ccf3f\",\"order_by\":2,\"name\":\"Hiroyuki Hirahara\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nagaoka Red Cross Hospital: Nagaoka Sekijuji Byoin\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hiroyuki\",\"middleName\":\"\",\"lastName\":\"Hirahara\",\"suffix\":\"\"},{\"id\":619017505,\"identity\":\"84237a8f-efa4-41a9-bc99-a0502778edac\",\"order_by\":3,\"name\":\"Masaaki Sugawara\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nagaoka Red Cross Hospital: Nagaoka Sekijuji Byoin\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Masaaki\",\"middleName\":\"\",\"lastName\":\"Sugawara\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-20 04:11:13\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9174649/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9174649/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106922766,\"identity\":\"3b453cf7-cf68-447f-849d-07daaa3fe0e4\",\"added_by\":\"auto\",\"created_at\":\"2026-04-14 20:34:23\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":399747,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e(a) Approach from the contralateral femoral artery across the aortic bifurcation, insert a stiff wire at the periphery of the SGA or IGA, and guide the 6Fr long sheath (arrow head) distal to the main trunk of the IIA.\\u003c/p\\u003e\\n\\u003cp\\u003e(b) AVP (arrow) is placed in the main trunk of the IIA, proximal to the SGA or IGA bifurcation.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9174649/v1/6f55fd8bd5f6624beaeca5a0.jpg\"},{\"id\":106961313,\"identity\":\"23ec36a7-febc-4428-8ae9-4e387b674789\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 09:24:59\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":20730,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComparison of the required procedure time between coils group vs AVP group.\\u003c/p\\u003e\\n\\u003cp\\u003eThe procedure time of AVP group were more shorterthan those of coils group, and there was the significant difference (P \\u0026lt; .001) between both groups .\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9174649/v1/aa5d21cf99349a0dc8731feb.jpg\"},{\"id\":106922769,\"identity\":\"790ecebd-864a-4a77-a858-877536e0b53a\",\"added_by\":\"auto\",\"created_at\":\"2026-04-14 20:34:23\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":24717,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComparison of the cost of embolization between coils group vs AVP group.\\u003c/p\\u003e\\n\\u003cp\\u003eThe AVP group had lower costs than the coils group, and there was the significant difference (P \\u0026lt; .001) between both groups .\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture3.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9174649/v1/98ab645d092aa876c8df363f.jpg\"},{\"id\":106963276,\"identity\":\"b890ae5d-be85-4c8b-b5d7-27dfae14530a\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 09:43:18\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":820125,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9174649/v1/617af51f-cabd-492b-bf9c-560e453cbaf7.pdf\"},{\"id\":106961770,\"identity\":\"26e4f1ee-f854-4246-97eb-4717d244f46a\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 09:26:58\",\"extension\":\"ppt\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":279040,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"renamed74f2a.ppt\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9174649/v1/b4f66ecd1ce2ce1e9cb67171.ppt\"}],\"financialInterests\":\"\",\"formattedTitle\":\"Comparison of Clinical and Cost-Effectiveness Between Amplatzer Vascular Plug and Coil Embolization for Prophylactic Internal Iliac Artery Embolization During EVAR\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eEndovascular abdominal aortic repair (EVAR) for abdominal aortic aneurysms (AAA) is commonly accepted as a safe alternative to open surgery. Cases involving aneurysmal dilatation of at least one of the left and right common iliac arteries, which account for 20% of AAAs \\u003csup\\u003e1)\\u003c/sup\\u003e, or cases with the relatively short and thick common iliac arteries often observed in Asian populations, may require extending the iliac branch of the stent graft to the external iliac artery \\u003csup\\u003e2)\\u003c/sup\\u003e, posing a risk of type 2 endoleak due to retrograde flow from the occluded internal iliac artery. To prevent such type 2 endoleaks, prophylactic internal iliac artery embolization using metal coils, which involves embolizing the internal iliac artery with metal coils simultaneously with or in stages with EVAR, is widely performed \\u003csup\\u003e2\\u0026ndash;4)\\u003c/sup\\u003e. Recently, a new technique called iliac branch stent grafting has made it possible to perform EVAR with external iliac artery landing while maintaining blood flow in the internal iliac artery \\u003csup\\u003e2)\\u003c/sup\\u003e. However, this device has various anatomical requirements and lacks versatility. Therefore, in selected cases, prophylactic internal iliac artery embolization remains an important strategy.\\u003c/p\\u003e \\u003cp\\u003eThe Amplatzer Vascular Plug (Abbott Vascular, Redwood City, California, USA) is a nitinol-based, self-expanding cylindrical occlusion device known as a suitable alternative to coil embolization \\u003csup\\u003e5\\u0026ndash;12)\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eAt our hospital, we have been primarily using AVP for prophylactic internal iliac artery embolization since 2014.\\u003c/p\\u003e \\u003cp\\u003eThe purpose of this study was to compare the clinical outcomes of prophylactic internal iliac artery embolization using Amplatzer vascular plugs (AVPs) during endovascular abdominal aortic repair (EVAR) with those of conventional embolization.\\u003c/p\\u003e\"},{\"header\":\"Materials and Methods\",\"content\":\"\\u003cp\\u003eThis study is a single-center retrospective study.\\u003c/p\\u003e \\u003cp\\u003ePatient characteristics: This study included 120 cases and 146 procedures performed at Nagaoka Red Cross Hospital between September 2009 and January 2024, where prophylactic embolization of the internal iliac artery was carried out before or simultaneously with EVAR procedures. There were 97 males and 23 females, the age ranged from 46 to 90 years, and the average age was 75.8 years.\\u003c/p\\u003e \\u003cp\\u003eThe median observation period was 88.7 months (95% C.I. 78.5 months to 98.9 months).\\u003c/p\\u003e \\u003cp\\u003eThe lesion sites were abdominal aortic aneurysm\\u0026thinsp;+\\u0026thinsp;common iliac artery aneurysm in 67 procedures, localized iliac artery aneurysm in 44 procedures, and localized abdominal aortic aneurysm (insufficient distal landing zone) in 35 procedures. Additionally, 56 procedures were accompanied by aneurysmal dilation of the internal iliac artery.\\u003c/p\\u003e \\u003cp\\u003eAt our institution, in cases requiring bilateral embolization, we first performed staged embolization on one side, followed by simultaneous embolization on the remaining side during EVAR surgery. For cases where only unilateral embolization was performed, simultaneous embolization was generally carried out. Therefore, there were 100 unilateral embolization procedures and 46 bilateral embolization procedures. Regarding the timing of embolization, 124 embolization procedures were performed simultaneously with EVAR surgery, while 22 embolization procedures were performed in stages.\\u003c/p\\u003e \\u003cp\\u003eRegarding the embolization site, embolization at the level of the main internal iliac artery was defined as proximal embolization, and embolization at the branch of the internal iliac artery was defined as distal embolization. The breakdown was 78 proximal procedures and 68 distal procedures.\\u003c/p\\u003e \\u003cp\\u003eThe devices used were Cook Zenith (Medtronic Cardiovascular, Santa Rosa, California) in 8 procedures, Gore Excluder (W. L. Gore \\u0026amp; Associates, Inc., Newark, Delaware) in 118 procedures, ENDURANT (Medtronic Cardiovascular, Santa Rosa, California) in 10 procedures, Endologix Powerlink/AFX/AFX2 (Endologix Inc., Irvine, California) in 8 procedures, and Aorfix stent graft (Lombard Medical Technologies Inc., Tempe, Arizona) in 2 procedures (Table\\u0026nbsp;1).\\u003c/p\\u003e \\u003cp\\u003eFor insertion into the internal iliac artery, the standard procedure involved approaching from the contralateral femoral artery, over the aortic bifurcation, inserting a rigid guidewire (diameter: 0.035 inches, length: 180\\u0026ndash;300 cm) distal to the superior or inferior gluteal artery, guiding a long 6Fr sheath (Destination Terumo, Tokyo, Japan) distal to the internal iliac artery trunk, and positioning the AVP from the internal iliac artery trunk to the origin level proximal to the superior/inferior gluteal artery bifurcation using the pullback technique described in the instruction manual (Fig.\\u0026nbsp;1). When necessary, we also used an approach via the ipsilateral femoral artery. The breakdown of approaches was as follows: 115 procedures (79%) were contralateral approaches, 30 procedures (21%) were ipsilateral approaches, and 1 procedure (0.6%) was brachial approach. The brachial approach was used only once in the initial stages, but due to a lack of suitable devices and concerns about the risk of stroke, it has not been selected as an access route for prophylactic internal iliac artery embolization since then.\\u003c/p\\u003e \\u003cp\\u003eThe snare-assisted pull-through method was used in three embolization procedures (1 procedure with coils and 2 procedures with AVP).\\u003c/p\\u003e \\u003cp\\u003ePatient information, radiological data, and surgical data were obtained from our hospital's paper and electronic medical records. Patient names and other Health Insurance Portability and Accountability Act (HIPAA) identifiers were removed from all manuscripts, including supplementary information, and no other information that could potentially identify subjects (such as clinical images or videos) was included in this study. The Nagaoka Red Cross Hospital Ethics Committee exempted this study from ethical review and informed consent requirements because it was a retrospective study. All methods were carried out in accordance with relevant guidelines and regulations.\\u003c/p\\u003e \\u003cp\\u003e[Investigated Items]\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Embolization success rate and breakdown of procedures and embolization details for all procedures\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) Comparison between the coil group and AVP group for adverse events (type 2 endoleak, intraoperative vascular injury, frequency of buttock claudication), procedural time, and cost incurred for the procedures\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) Three types of subgroup analysis\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication, procedure time, and procedure cost based on the presence or absence of internal iliac artery aneurysm\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication, procedure time, and procedure cost between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication with unilateral embolization and bilateral embolization\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) Multivariate analysis of factors influencing buttock claudication, procedure time, and procedure cost\\u003c/p\\u003e \\u003cp\\u003eAll analyses were performed for each embolization procedure, and each embolization procedure was analyzed as an independent event.\\u003c/p\\u003e \\u003cp\\u003eThe evaluation of type 2 endoleaks was conducted using contrast-enhanced CT scans targeting the internal iliac artery and the common iliac artery where preventive embolization was performed.\\u003c/p\\u003e \\u003cp\\u003eRegarding buttock claudication, as a general rule, the presence or absence of symptoms and whether they have improved were evaluated through interviews at the vascular surgery outpatient clinic at 1 month, 6 months, 1 year, and then every year thereafter. If the symptoms persisted at 6 months post-surgery, it was evaluated as having buttock claudication. Buttock claudication was also evaluated after each embolization procedure and analyzed for each treatment. In the case of staged bilateral embolization, the symptoms were considered to be attributable to the corresponding procedure.\\u003c/p\\u003e \\u003cp\\u003eAt our institution, during EVAR surgery, the anesthesia department administers systemic heparinization at the time of inserting short sheaths into both groins. Therefore, regarding the procedure time for embolization, in the case of simultaneous embolization with EVAR, the start time was defined as the time of systemic heparinization as recorded in the anesthesiology records. If a preceding interventional radiology (IVR) procedure (including 1 renal artery stent placement, 14 prophylactic IMA embolization procedures, and 2 type 1b interventions immediately following EVAR placement, totaling 17 procedures) had been performed, the start time was defined as the time of confirmation imaging for the preceding IVR procedure. In the case of staged embolization, the start time was defined as the time of arterial puncture. For all procedures, the completion time was defined as the time when confirmation images were taken at the end of the embolization procedure. Furthermore, since introducing AVP at our hospital, our policy is to first attempt embolization using AVP in all procedures, and only switch to embolization using other devices such as coils if it proves difficult. Therefore, to ensure fairness, 8 procedures that were switched to coil embolization due to difficulties with AVP embolization after AVP introduction were excluded from the analysis of procedure time. Additionally, for the 7 coil embolization procedures and 1 AVP embolization procedure performed in the operating room, the confirmation imaging time at the end of the embolization procedure could not be determined from the imaging equipment records, so these procedures were excluded from the analysis of procedure time.\\u003c/p\\u003e \\u003cp\\u003eRegarding the costs associated with the procedure, we referred to the documentation from the radiology department and the details of the surgical procedures, as well as our institution's medical billing claims. We accounted for the costs of items used solely for internal iliac artery embolization. The cost was calculated using both Japanese yen and US dollars converted at the average dollar-yen exchange rate for January 2026 (1 USD\\u0026thinsp;=\\u0026thinsp;156 yen).\\u003c/p\\u003e \\u003cp\\u003eThe number of variables included in the multivariate model was limited to avoid overfitting.\\u003c/p\\u003e \\u003cp\\u003eThe analysis was performed using SPSS software (IBM Corp., Armonk, New York, USA). The frequency of type 2 endoleaks and buttock claudication at 6 months postoperatively was determined by the chi-square test, and the frequency of intraoperative vascular injury was determined by Fisher's exact test. The procedure time and cost were analyzed using the t-test. For multivariate analysis, buttock claudication was analyzed using logistic regression analysis, while procedure time and cost were analyzed using multiple regression analysis.\\u003c/p\\u003e \\u003cp\\u003eIn all analyses, a P-value of less than 0.05 was considered statistically significant.\\u003c/p\\u003e \\u003cp\\u003eRegarding gonadal dysfunction, which is generally considered one of the adverse events associated with internal iliac artery embolization, it was not considered in this study due to the high proportion of elderly patients in the target group and the absence of postoperative complaints from the patients. Similarly, severe pelvic ischemia, such as bowel ischemia, which is also considered a common adverse event, was not observed in any of the procedures.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Success Rate of Embolization and Breakdown of Embolization Content in All Procedures\\u003c/p\\u003e \\u003cp\\u003eThe success rate of embolization was 100%, with no perioperative deaths or non-target embolizations observed. However, during one embolization procedure, an F-F bypass surgery was performed due to thrombotic occlusion of the common iliac artery. Another embolization procedure required conservative treatment due to the formation of a femoral artery pseudoaneurysm. Furthermore, thrombus removal surgery was performed after one embolization procedure due to lower limb arterial thrombosis.\\u003c/p\\u003e \\u003cp\\u003eThe breakdown of embolization procedures was as follows: 42 procedures using metal coils alone, 11 procedures using metal coils and NBCA in combination, 87 procedures using AVP alone, 4 procedures using AVP and metal coils in combination, and 2 procedures using AVP and NBCA in combination.\\u003c/p\\u003e \\u003cp\\u003eIn the metal coil embolization group, an average of 18.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.5 coils were used, consisting of 10.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.4 pushable coils (0.035), 7.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.0 pushable coils (0.018), 0.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.1 detachable coils (0.035), and 0.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.6 detachable coils (0.018). In the AVP embolization group, an average of 1.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.1 AVPs and 0.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.1 coils were used. The breakdown of the coils used was 0.08\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.1 pushable coils (0.018) and 0.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.08 detachable coils (0.035).\\u003c/p\\u003e \\u003cp\\u003eNo re-intervention related to internal iliac artery embolization was required for all of the procedures.\\u003c/p\\u003e \\u003cp\\u003eNo dilation of the internal iliac artery sac was observed.\\u003c/p\\u003e \\u003cp\\u003eNo secondary embolization was performed.\\u003c/p\\u003e \\u003cp\\u003eNo deaths due to rupture of aneurysms in the treated area were observed.\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) Comparison of Coil Group and AVP Group: Adverse Events (Type 2 Endoleak, Intraoperative Vascular Injury, Frequency of Buttock Claudication), Procedure Time, and Procedure Cost\\u003c/p\\u003e \\u003cp\\u003eRegarding patient background factors in the coil group and AVP group, the frequency of bilateral embolization was significantly higher in the AVP group on the embolization side (P = .001). However, no significant differences were observed in other factors (Table\\u0026nbsp;2). Additionally, the brachial approach was excluded from the analysis of patient background factors, as previously mentioned.\\u003c/p\\u003e \\u003cp\\u003eRegarding type 2 endoleak, the frequency was 2 cases (3.8%) in the coil group and 4 cases (4.5%) in the AVP group, with no significant difference between the two groups (P\\u0026thinsp;=\\u0026thinsp;0.862). Additionally, there were no type 2 endoleaks that required additional treatment. Furthermore, in 1 procedure in the coil group and 5 procedures in the AVP group, postoperative contrast-enhanced CT scans could not be performed due to renal function decline, making it impossible to evaluate type 2 endoleaks.\\u003c/p\\u003e \\u003cp\\u003eRegarding intraoperative vascular injury, there were no cases (0%) in the coil group, whereas the AVP group had 3 cases (3.3%) of vascular injury caused by migration of stiff guidewire tip, which were managed with intraoperative TAE. There was no significant difference in the frequency of vascular injury between the two groups (P\\u0026thinsp;=\\u0026thinsp;0.191).\\u003c/p\\u003e \\u003cp\\u003eAt 6 months postoperatively, the frequency of buttock claudication was 15 procedures (30%) in the coil group and 9 procedures (10%) in the AVP group, with a significantly lower frequency of buttock claudication in the AVP group (P\\u0026thinsp;=\\u0026thinsp;0.003) (Table\\u0026nbsp;3). Additionally, evaluations of buttock claudication could not be performed for 3 procedures in the coil group and 1 procedure in the AVP group due to the destruction of medical records, and for 2 procedures in the AVP group due to early postoperative discharge.\\u003c/p\\u003e \\u003cp\\u003eIn the analysis of procedure time, the average procedure time was 105.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;41.6 minutes in the coil group, compared to 50.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23.5 minutes in the AVP group, indicating that the AVP group had a significantly shorter procedure time (P\\u0026thinsp;=\\u0026thinsp;0.000) (Table\\u0026nbsp;3, Fig.\\u0026nbsp;2).\\u003c/p\\u003e \\u003cp\\u003eRegarding costs of procedure, the average cost for the coil group was 310,273\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;185,697 yen (1,989\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1,192 US dollars), while for the AVP group it was 183,044\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;62,950 yen (1,174\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;406 US dollars), indicating that the AVP group was significantly lower cost (P\\u0026thinsp;=\\u0026thinsp;0.000) (Table\\u0026nbsp;3, Fig.\\u0026nbsp;3).\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) Three Types of Subgroup Analysis\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication frequency, procedure time, and procedure cost based on the presence or absence of internal iliac artery aneurysm.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe frequency of buttock claudication in patients with and without internal iliac artery aneurysm was 16 procedures (18.6%) in the group without aneurysm and 8 procedures (14.8%) in the group with aneurysm, with no significant difference between the two groups (P\\u0026thinsp;=\\u0026thinsp;0.562).\\u003c/p\\u003e \\u003cp\\u003eRegarding the procedure time based on the presence or absence of internal iliac artery aneurysm, the group without aneurysm needed 63.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;35.4 minutes, while the group with aneurysm needed 75.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;44.3 minutes.\\u003c/p\\u003e \\u003cp\\u003eAlthough the group without aneurysm tended to have a shorter procedure time, no significant difference between the two groups (P = .098).\\u003c/p\\u003e \\u003cp\\u003eThe cost of the procedure differed significantly between the group without internal iliac artery aneurysm and the group with aneurysm: the group without aneurysm cost 206,810\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;121,299 yen (1,326\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;777 US\\u003cspan\\u003e$\\u003c/span\\u003e), while the group with aneurysm cost 265,688\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;153,031 yen (1,704\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;982 US\\u003cspan\\u003e$\\u003c/span\\u003e). The group without aneurysm was significantly lower cost (P = .011).\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication frequency, procedure time, and procedure cost between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn the absence of internal iliac artery aneurysm, buttock claudication occurred in 10 procedures (33.5%) in the coil group and 6 procedures (10.7%) in the AVP group. Procedure time was 97.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;33.0 minutes in the coil group and 48.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;24.5 minutes in the AVP group. Procedure costs were 297,361\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;166,121 yen (1,906\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1,064 US\\u003cspan\\u003e$\\u003c/span\\u003e) in the coil group and 158,412\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;36,716 yen (1,016\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;235 US\\u003cspan\\u003e$\\u003c/span\\u003e) in the AVP group. The AVP group was significantly superior in all categories: buttock claudication (P = .008), procedure time (P \\u0026lt; .001), and procedure costs (P \\u0026lt; .001).\\u003c/p\\u003e \\u003cp\\u003eIn the group with internal iliac artery aneurysm, buttock claudication occurred in 5 procedures (22.7%) in the coil group and 3 procedures (9.1%) in the AVP group. Procedure time was 119.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;52.0 minutes in the coil group and 55.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.0 minutes in the AVP group. Procedure costs were 328,468\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;213,437 yen (2,106\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1,368 US\\u003cspan\\u003e$\\u003c/span\\u003e) in the coil group and 225,065\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;75,587 yen (1,445\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;489 US\\u003cspan\\u003e$\\u003c/span\\u003e) in the AVP group. While buttock claudication tended to be better in the AVP group, there was no significant difference (P = .160). However, the AVP group was significantly better in both procedure time (P \\u0026lt; .001) and procedure cost (P = .011).\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eComparison of buttock claudication frequency between unilateral and bilateral embolization.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe frequency of buttock claudication in unilateral and bilateral embolization was 18 procedures (18.8%) for unilateral embolization and 12 procedures (14.0%) for bilateral embolization, with no significant difference between the two groups (P = .489).\\u003c/p\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) Multivariate Analysis of Factors Influencing Buttock Claudication, Procedure Time, and Procedure Cost\\u003c/p\\u003e \\u003cp\\u003eThe following factors were identified as significant influences on buttock claudication: embolic material (P = .002), location of embolization (P = .034), indication (P \\u0026lt; .001), and procedure time (P = .048) (Table\\u0026nbsp;4).\\u003c/p\\u003e \\u003cp\\u003eThe following factors were identified as significant influencing the procedure time: embolic material (P \\u0026lt; .001), procedure cost (P = .027), and buttock claudication (P = .042) (Table\\u0026nbsp;5).\\u003c/p\\u003e \\u003cp\\u003eThe following factors were identified as significant influencing the cost of the procedure: embolic material (P = .046), location of embolization (P = .020), and procedure time (P = .027).\\u003c/p\\u003e \\u003cp\\u003eIn the univariate analysis, the timing of embolization (synchronous or metachronous) was not significantly associated with the procedure time (P = .503) or the cost of embolization (P = .524). The timing of embolization was strongly correlated with bilateral embolization, so it was not included in the multivariate model to avoid multicollinearity.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eButtock claudication is one of the important adverse events in prophylactic internal iliac artery embolization, with a reported frequency of 13% to 67% \\u003csup\\u003e5),7\\u0026ndash;8),12\\u0026ndash;19),22\\u0026ndash;25),27\\u0026ndash;28)\\u003c/sup\\u003e. On the other hand, some reports suggest that embolization of the proximal internal iliac artery\\u003csup\\u003e9),18\\u0026ndash;19),24\\u0026ndash;25)\\u003c/sup\\u003e and the use of AVP\\u003csup\\u003e5\\u0026ndash;12)\\u003c/sup\\u003e reduce the frequency of buttock claudication. In this study, a statistically significant increase in proximal embolizations and a decrease in the frequency of buttock claudication were observed in the AVP group. AVP embolization may be associated with a reduction in the frequency of buttock claudication. Dierk et al\\u003csup\\u003e26)\\u003c/sup\\u003e. reported that proximal occlusion of asymptomatic IIA and distal occlusion of aneurysmal IIA prior to EVAR were equivalent in terms of clinical outcomes. In this study as well, there was no significant difference in the frequency of buttock claudication between the presence or absence of internal iliac artery aneurysm in the subgroup analysis. Similarly, there was no significant difference in the location of embolization between the group without aneurysm (39 procedures, 43.3%) and the group with aneurysm (29 procedures, 51.8%) (P = .319), suggesting that the incidence of buttock claudication is similar regardless of the presence or absence of aneurysm. In a subgroup analysis of the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm, the frequency of buttock claudication was significantly lower in the AVP group compared to the group without aneurysm, and although there was no significant difference in the group with aneurysm, there was a tendency for the frequency to be lower in the AVP group. This suggests that one possible reason for this is insufficient analytical power due to the small number of cases of internal iliac artery aneurysm. Regarding unilateral and bilateral embolization, some reports indicate that bilateral embolization has adverse effects on buttock claudication\\u003csup\\u003e21)\\u003c/sup\\u003e, while others suggest that serious complications are rare even with bilateral embolization and that it can be performed with a similar level of risk as unilateral embolization\\u003csup\\u003e13\\u0026ndash;14),22),29)\\u003c/sup\\u003e. Our subgroup analysis showed no significant difference between the two groups in the frequency of buttock claudication. This suggests that the AVP group had a significantly higher rate of bilateral embolization, and that the increased frequency of AVP use in bilateral embolization procedures may have reduced the frequency of buttock claudication, resulting in no significant difference observed.\\u003c/p\\u003e \\u003cp\\u003eIt has already been reported that using AVP in prophylactic internal iliac artery embolization leads to a reduction in procedure time\\u003csup\\u003e10,16,26)\\u003c/sup\\u003e. This study also showed a reduction in procedure time with AVP, suggesting that AVP embolization may contribute to reducing procedure time in prophylactic internal iliac artery embolization. In a subgroup analysis of procedure time based on the presence or absence of internal iliac artery aneurysm, there was no significant difference between the two groups. This suggests that the technical difficulty of cannulation due to internal iliac artery aneurysm may have been relatively underestimated, as the number of procedures excluded from the procedure time analysis due to difficulties in cannulation after AVP introduction and subsequent transition to coil embolization was significantly higher in the group with aneurysm (11.5%) compared to the group without aneurysm (2 procedures, 2.3%) (P = .025). In a subgroup analysis of procedure time between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm, the AVP group had significantly shorter procedure time regardless of the presence or absence of aneurysm, suggesting that the use of AVP may contribute to reducing procedure time.\\u003c/p\\u003e \\u003cp\\u003eSeveral reports indicate that the cost of prophylactic internal iliac artery embolization using AVP is significantly lower than that of coil embolization\\u003csup\\u003e5,7),10\\u0026ndash;11)\\u003c/sup\\u003e. However, these reports generally estimate the cost of AVPs to be around 300 US\\u003cspan\\u003e$\\u003c/span\\u003e, but in Japan, the cost per AVP is 131,000 yen (approximately 879 US\\u003cspan\\u003e$\\u003c/span\\u003e at the average dollar-yen exchange rate in January 2026), so this does not accurately reflect the procurement cost of AVPs. Ryer et al. \\u003csup\\u003e15)\\u003c/sup\\u003e also reported in a similar study that the cost of embolization procedures tended to be lower in the AVP group, but there was no significant difference between the AVP group and the coil group. Kotoku et al. \\u003csup\\u003e20)\\u003c/sup\\u003e reported that a special technique called coil-in-plug (CIP), in which coils are inserted into AVP, reduces costs compared to conventional coil embolization, but their report does not simply compare AVP embolization with coil embolization. This study demonstrated that the cost of AVP embolization was significantly lower compared to coil embolization. No reliable studies on prophylactic internal iliac artery embolization that reflect the formal procurement costs of AVP based on a certain number of cases have reported similar results.\\u003c/p\\u003e \\u003cp\\u003eTo our knowledge, there are very few studies that have evaluated embolization-related costs using AVP while reflecting actual procurement costs in relatively large cohorts. In this study, a subgroup analysis of procedural costs between the coil group and the AVP group based on the presence or absence of internal iliac artery aneurysm revealed that procedural costs were significantly lower in the AVP group, regardless of the presence or absence of aneurysm.\\u003c/p\\u003e \\u003cp\\u003eThe impact of AVP embolization on the overall cost of EVAR surgery is an interesting factor, but Ryer et al.\\u003csup\\u003e15)\\u003c/sup\\u003e reported no significant difference in this regard. On the other hand, it is well known that the cost of EVAR surgery varies greatly depending on the treatment plan. Therefore, it is unlikely that meaningful results can be obtained by simply calculating the mean values ​​of cases collected retrospectively without considering the plan, as in the case group of this study. Prospective comparative studies using standardized EVAR strategies and randomized embolic materials may further clarify these results.\\u003c/p\\u003e \\u003cp\\u003eMany reports suggest that AVP embolization is generally superior to coil embolization in internal iliac artery embolization \\u003csup\\u003e5\\u0026ndash;12),16),26)\\u003c/sup\\u003e. In this study, particularly in the multivariate analysis, the embolic material was identified as a significant factor that commonly affects buttock claudication, procedure time, and procedure cost, suggesting that the selection of the embolic material is an important element in embolization.\\u003c/p\\u003e \\u003cp\\u003eHowever, selection bias and temporal changes in technique may have influenced these results.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe use of AVP in prophylactic internal iliac artery embolization during EVAR may offer benefits such as a reduced incidence of buttock claudication, shorter procedure time, and lower embolization costs, with no serious adverse events observed.\\u003c/p\\u003e \\u003cp\\u003e[Limitations]\\u003c/p\\u003e \\u003cp\\u003eThe limitations of this study include the following:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eThe study is a single-center retrospective analysis.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eSince the study involves a single operator, there is an element of learning curve that may influence the results.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eThe study spans a long patient enrollment period, which introduces potential bias due to advancements in device technology over time.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eBecause multiple procedures were performed in some patients, the assumption of independence may have been violated, which could introduce bias into the statistical analysis.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eArmon MP, Wenham PW, Whitaker SC, Gregson RHS, Hopkinson BR (1998) Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 15:255\\u0026ndash;257\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAnders Wanhainen F, Verzini IV, Herzeele E, Allaire M, Bown T, Cohnert F, Dick J, van Herwaarden C, Karkos M, Koelemay T, K\\u0026ouml;lbel I, Loftus K, Mani G, Melissano J, Powell D, Reviewers M, Bj\\u0026ouml;rck S, Cheng R, Dalman (2019) Lazar Davidovic, Konstantinos Donas, Jonothan Earnshaw, Hans-Henning Eckstein, Jonathan Golledge, Stephan Haulon, Tara Mastracci, Ross Naylor, Jean-Baptiste Ricco, Hence Verhagen Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. ;57(1):8\\u0026ndash;93\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYano OJ, Morrissey N, Eisen L, Faries PL, Soundararajan K, Wan S et al (2001) Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 34:204\\u0026ndash;211\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee CW, KaufmanJA, Fan CM, Geller SC, Brewster DC, Cambria RP et al (2000) Clinical outcome of internal iliac artery occlusions during endo vascular treatment of aortoiliac aneurysmal diseases. J Vasc Interv Radiol 11:567\\u0026ndash;571\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHa CD, Calcagno D (2005) Amplatzer vascular plug to occlude the internal iliac arteries in patients undergoing aortoiliac aneurysm repair. J Vasc Surg 42:1058\\u0026ndash;1062\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKickuth R, Dick F, Triller J, Ludwig K, Schmidli J, Do DD (2007) Internal iliac artery embolization before endovascular repair of aortoiliac aneurysms with a nitinol vascular occlusion plug. J Vasc Interv Radiol 18:1081\\u0026ndash;1087\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVandy F, Criado E, Upchurch GR Jr, Williams DM, Rectenwald J, Eliason J (2008) Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair. J Vasc Surg 48:1121\\u0026ndash;1124\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWu Z, Raith el D, Ritter W et al (2011. Feb) Preliminary embolization of the hypogastric artery to expand the applicability of endovascular aneurysm repair. J Endovasc Ther 18(1):114\\u0026ndash;120\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBosanquet a DC, Wilcox a C, Whitehurst L et al (2017) Systematic Review and Meta-analysis of the Effect of Internal Iliac Artery Exclusion for Patients Undergoing EVAR. Eur J Vasc Endovasc Surg 53:534\\u0026ndash;548\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKaren Wong P, Johnson Z, Chen J, Newsome Z, Bercu LK, Findeiss S, Dariushnia (2020) Ravi Rajani, Nima Kokabi A Meta-analysis of Comparative Outcome and Cost-Effectiveness of Internal Iliac Artery Embolization with Vascular Plug Versus Coil. Cardiovasc Intervent Radiol 43(5):706\\u0026ndash;713\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUmberto M, Bracale A, Petrone M, Provenzano N, Ielapi L, Ferrante D, Turchino LD, Guercio D, Pakeliani M, Andreucci (2022) Raffaele Serra The use of the Amplatzer Vascular Plug in the prevention of endoleaks during abdominal endovascular aneurysm repair: A systematic literature review on current applications. Vascular 30(4):681\\u0026ndash;689\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWarein E, Feugier P, Chaufour X, Molin V, Malikov S, Bartoli MA, Coscas R, Picquet J, Peyrot H, Favre J-P, Steinmetz E, Ben Ahmed S (2016) Rosset Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study. Eur J Vasc Endovasc Surg 51:641\\u0026ndash;646\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZander T, Baldi S, Rabellino M et al (2007) Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance. J Vasc Iterv Radiol 18(12):1481\\u0026ndash;1486\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEngelke C, Elford J, Morgan RA et al (2002) Internal iliac artery embolization with bilateral occlusion before endovascular aortoiliac aneurysm repair-clinical outcome of simultaneous and sequential intervention. J Vasc Interv Radiol 13(7):667\\u0026ndash;676\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRyer EJ, Garvin RP, Webb TP et al (2012) Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair. J Vasc Surg 56(5):1239\\u0026ndash;1245\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLibicher M, Pavlidis D, Bangard C et al (2012) Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs. Vasc Endovasc Surg 46(1):34\\u0026ndash;39\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRayt HS, Bown MJ, Lambert KV et al (2008 Jul-Aug) Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 31(4):728\\u0026ndash;734\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChun JY, Mailli L, Abbasi MA et al (2014) Embolization of the Internal Iliac Artery Before EVAR: Is It Effective? Is It Safe? Which Technique Should Be Used? Cardiovasc Intervent Radiol 37(2):329\\u0026ndash;336\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChoi HR (June 2016) Ki Hyuk Park, and Jae Hoon Lee Risk Factor Analysis for Buttock Claudication after Internal Iliac Artery Embolization with Endovascular Aortic Aneurysm Repair Vasc Spec Interna. 32(2):44\\u0026ndash;50\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKotoku A, Ogawa Y, Chiba K et al Clinical Utility of Coil in Plug Method (CIP) for Internal Iliac Artery Embolization during Endovascular Aortic Aneurysm Repair. Ann Vasc Dis 2020 Vol, 13, 3: 269\\u0026ndash;272\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShunya Suzuki D, Akamatsu H, Goto T, Kakihana H, Sugawara K, Tsuchida Y, Yoshida M, Umetsu (2022) Takashi Kamei, Michiaki Unno Prospective clinical study for claudication after endovascular aneurysm repair involving hypogastric artery embolization. Surg Today 52(11):1645\\u0026ndash;1652\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim HJ, Hwang D, Kim H-K, Huh S (2023 Jul) Woo-Sung Yun Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair. Vasc Specialist Int 21:3919\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJihee Kang B-H, Chung D-H, Hyun Y-J, Park (2020) Dong-Ik Kim Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair. Int Angiol 39(4):323\\u0026ndash;329\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBoonprasit Kritpracha JP, Pigott CI, Price TE, Russell (2003) Mary Jo Corbey, Hugh G Beebe Distal internal iliac artery embolization: a procedure to avoid. J Vasc Surg 37(5):943\\u0026ndash;948\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBratby MJ, Munneke GM, Belli A-M, Loosemore TM, Loftus I, Thompson MM (2008 Mar-Apr) R A Morgan How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol. 31(2):246\\u0026ndash;253\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlexander Dierk A, Sauer F, Wolfshmidt N, Hassold R, Kellersmann T, Abley (2017) Ralph Kickuth Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome. Br J Radiol 90(1072):20160527\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShunichiro Fujioka SH, Morimura H, Chen K, Wang ZC, Toguchi K, Fukuda S (2017), Koki Takizawa, Hiroshi Osawa Outcomes of Extended Endovascular Aortic Repair for Aorto-Iliac Aneurysm with Internal Iliac Artery Occlusion. Ann Vasc Dis ;10(4):359\\u0026ndash;363\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eManish Mehta, Frank J, Veith R, Clement Darling SP, Roddy T, Ohki EC, Lipsitz PSK, Paty PB, Kreienberg, Kathleen J, Ozsvath, Benjamin B, Chang (2004) Dhiraj M Shah Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 40(4):698\\u0026ndash;702\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"cvir-endovascular\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cire\",\"sideBox\":\"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/cire/default.aspx\",\"title\":\"CVIR Endovascular\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9174649/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9174649/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study is a retrospective, single-center study comparing the effectiveness of Amplatzer vascular plug (AVP) with coil embolization in prophylactic internal iliac artery embolization during endovascular aortic aneurysm repair (EVAR).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMaterials and Methods:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe reviewed 146 embolization procedures performed during EVAR from 2009 to 2024. We compared technical success, adverse events (including type II endoleak and buttock claudication), procedure time, and embolization-related costs between the coil embolization group and the AVP embolization group. We also performed multivariate analyses on factors influencing gluteal claudication, procedure time, and procedure costs.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTechnical success was achieved in all procedures. No significant differences were observed between groups in type II endoleaks and intraoperative vascular injuries. Compared to the coil embolization group, the AVP group had a lower incidence of buttock claudication at 6 months (10% vs. 30%), shorter procedure time, and lower embolization-related costs. Multivariate analysis identified embolic material as an independent factor associated with buttock claudication, procedure time, and procedure cost.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eProphylactic internal iliac artery embolization using AVP during EVAR is safe and effective, potentially reducing buttock claudication and lowering procedure time and cost compared to coil embolization while maintaining comparable clinical outcomes.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Comparison of Clinical and Cost-Effectiveness Between Amplatzer Vascular Plug and Coil Embolization for Prophylactic Internal Iliac Artery Embolization During EVAR\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-14 20:34:19\",\"doi\":\"10.21203/rs.3.rs-9174649/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2026-04-08T10:07:34+00:00\",\"index\":0,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-07T14:08:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"CVIR Endovascular\",\"date\":\"2026-04-07T12:06:19+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-07T11:38:12+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"CVIR Endovascular\",\"date\":\"2026-03-26T09:35:14+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"cvir-endovascular\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cire\",\"sideBox\":\"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/cire/default.aspx\",\"title\":\"CVIR Endovascular\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"23f1b988-8b48-4ca0-a56e-3dec18d08688\",\"owner\":[],\"postedDate\":\"April 14th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-14T20:34:19+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-14 20:34:19\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9174649\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9174649\",\"identity\":\"rs-9174649\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}