The Bell-Bottom Technique Versus Branched Stent Grafts in Endovascular Treatment of Diseased Common Iliac Artery: A Systematic Review and Meta-Analysis

To evaluate whether the use of iliac branched endoprosthesis reduces perioperative complications compared to the bell-bottom technique (BBT) in patients with common iliac artery aneurysm or ectasia. We conducted a systematic search of studies in the PubMed, Embase, and Cochrane databases up to March 2024. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol, 91 articles were analyzed. A restricted maximum likelihood model with random effects with odds ratios and 95% confidence intervals was applied for binary outcomes. Heterogeneity was assessed using the Cochrane Q test and Higgins and Thompson’s I2 statistic. Significance was defined as a P value < 0.05. Six cohort studies involving 2,899 patients were included, of which 863 underwent repair with branched endoprosthesis. There was no statistically significant difference observed for endoleaks: of any type (odds ratio [OR] 0.41; 95% confidence interval [CI] 0.10–1.60; P = 0.20), type 1a (OR 1.12; 95% CI 0.20–6.40; P = 0.90), type 1b (OR 0.63; 95% CI 0.20–1.97; P = 0.42), and type 2 (OR 0.52; 95% CI 0.10–2.71; P = 0.44). However, type 3 endoleaks were less frequent in the bell-bottom group (OR 9.00; 95% CI 1.09–74.17; P = 0.04). Additionally, perioperative mortality (OR 0.73; 95% CI 0.41–1.27; P = 0.26), mesenteric ischemia (OR 0.14; 95% CI 0.01–2.54; P = 0.18), iliac artery injury (P = 0.06), and buttock claudication (OR 0.14; 95% CI 0.02–1.08; P = 0.06) also did not statistically differ between the 2 groups. Branched endoprosthesis and BBTs did not differ regarding perioperative mortality rates, internal iliac artery occlusion, and mesenteric ischemia rates. However, the use of branched endoprostheses was associated with a higher incidence of type 3 endoleaks compared to the BBT.