Few internal iliac artery aneurysms rupture under 4 cm

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Complicated left isolated internal iliac artery aneurysm (IIIAA) in a young man - An unusual presentation in a Tertiary Hospital in Ghana: Case report

Generally, an aneurysm is a disease of the elderly due to the degenerative aetiological factor. Isolated internal iliac artery aneurysm (IIIAA) is rare, representing 0.3-0.5 % of all intra-abdominal aneurysms. It is a focal dilatation of the internal iliac artery alone with a threshold for surgical intervention set at 8 mm. Herein, we present an unusual presentation of a rare condition of a huge left internal iliac artery aneurysm in a young man with no identifiable risk factor complicated by left ilio-femoral deep vein thrombosis. Even though this is an interesting case study, the lack of facilities to do anaerobic cultures remains a major limitation in our setting.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Endovascular coil-embolization of an unruptured, true UAA during early pregnancy- a case report

BACKGROUND

True uterine artery aneurysms, especially during pregnancy, are a rare entity and not well understood. Clinical symptoms are unspecific pelvic pain and pressure. Diagnosis can be confirmed by transvaginal color-coded-sonography and/or magnetic resonance imaging. Because of potential risk of rupture, immediate interdisciplinary discussion and treatment planning in the best interests of both mother and child is crucial.

CASE PRESENTATION

We present a 31-year-old pregnant woman with increasing pelvic pain and pressure. Diagnosis of an unruptured uterine artery aneurysm was confirmed by color-coded-sonography and magnetic resonance angiography. After interdisciplinary consultation, successful endovascular super-selective coil-embolization was performed by using X-ray fluoroscopy. Thus, fetal radiation dose during treatment with 4.33 mGy (VirtualDoseTM) was as low as possible with no immediate harm to the fetus.

CONCLUSIONS

Unruptured true uterine artery aneurysms can be successfully treated by endovascular super-selective coil-embolization during early pregnancy with no immediate harm to the fetus.

Internal iliac artery aneurysm in a patient with proximal occlusion at its origin

We present the case of an 87-year-old man with a ruptured right internal iliac artery aneurysm with hemoperitoneum. The right internal iliac artery aneurysm appeared to fill from the retrograde profunda femoris artery in the setting of a previously repaired abdominal aortic aneurysm with aorta-bi-iliac bypass with ligation of the bilateral internal iliac arteries. Abdominal computed tomography revealed an aneurysm of the right internal iliac artery measuring 8.9 cm, with filling through the collateral vessels. Open repair was performed, leading to complete exclusion of the aneurysm with no perioperative complications.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Outcome of endovascular treatment of internal iliac artery aneurysms: a single center retrospective review

PURPOSE

To evaluate the technical feasibility and clinical outcomes of endovascular treatment for internal iliac artery (IIA) aneurysms.

MATERIAL AND METHODS

This was a retrospective analysis of 25 patients with 32 IIA aneurysms (mean diameter: 39.1 ± 12.6 mm) who underwent endovascular treatment over a 10-year period, and were available for follow-up. Univariate analysis was used to determine the association between variables (including aortoiliac involvement and technique) and outcome.

RESULTS

The IIA inflow was covered with an iliac stent graft (N = 29) or embolized with a plug (N = 3). The IIA outflow was embolized in all but one case in which there was thrombotic occlusion of outflow branches. Outflow embolization using plugs or coils was performed in the distal IIA or anterior/posterior trunks in 9 cases and distal IIA branches in 22 cases. During a mean follow-up period of 39.9 months, 31.2% of aneurysms demonstrated endoleak and 12.5% demonstrated enlargement. Univariate analysis revealed that endoleak was associated with technical failure (p = 0.01) and that endoleak rate was higher in patients who underwent distal IIA branch embolization (p = 0.03). No variable was associated with sac expansion. Major complication occurred in one patient who died from aneurysm rupture. Minor complications were reported in six patients who developed femoral pseudoaneurysm (N = 2, 8%), buttock claudication (N = 3, 12%), and limb graft occlusion (N = 1, 4%).

CONCLUSION

Endovascular treatment of IIA aneurysms effectively prevents sac expansion. Endoleak was more frequently observed in cases of technical failure and those in which distal IIA branches were embolized.

LEVEL OF EVIDENCE

Level 3b, retrospective cohort study.

Natural history and growth rates of isolated common iliac artery aneurysms

OBJECTIVE

The natural history of isolated common iliac artery aneurysms (CIAAs) has not been well-studied. The optimal size threshold for elective repair of isolated CIAAs is also not well-defined. We sought to determine the natural history and growth rates of isolated CIAAs to justify a surveillance protocol and size for elective repair.

METHODS

Isolated CIAAs (>2 cm) identified from January 1, 2008, through February 29, 2020, at a single center were reviewed. Patient demographics, comorbidities, and details of CIAA operative repairs were retrospectively collected. All available duplex ultrasound and computed tomography scans were reviewed from time of CIAA identification through June 2020.

RESULTS

There were 244 isolated CIAAs found in 167 patients. The cohort was 94% male with an average age of 68.1 ± 8.8 years at the time of CIAA detection. CIAAs were identified with ultrasound examination 69% of the time with a mean CIAA diameter of 2.3 cm. Operative repair of a CIAA was performed in 11.4% of the cohort at an average diameter of 3.30 ± 1.02 cm. The majority of these repairs were performed via an endovascular approach (73.7%; n = 14). There were no symptomatic or ruptured isolated CIAAs. Concurrent aortic growth that led to an abdominal aortic aneurysm with diameter of at least 3 cm occurred in 10.6% (n = 26) of isolated CIAAs. The average length of time from CIAA diagnosis to repair was 65.7 ± 47.1 months. The overall CIAA growth rate was 0.4 mm/y. A subgroup analysis based on CIAA size demonstrated a growth rate of 0.2 mm/y fore CIAAs 2.00 to 2.49 cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 1.3 mm/y for CIAAs 3.0 cm or larger. There were two CIAAs greater than 3.0 cm with extreme growth, which significantly impacted the CIAA growth rate on sensitivity analysis. After excluding those two CIAAs from the model, the overall CIAA growth rate was 0.3 mm/y. The subgroup analysis then demonstrated a growth rate of 0.2 mm/y for CIAAs 2.00 to 2.49cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 0.5 mm/y for CIAAs 3 cm or larger.

CONCLUSIONS

Isolated CIAAs are typically slow growing aneurysms that expectedly grow faster as they enlarge. Given the rare occurrence of rapid isolated CIAA growth, we recommend surveillance at 3 years for 2.00 to 2.49 cm isolated CIAAs, 2 years for 2.50 to 2.99 cm isolated CIAAs, and yearly for isolated CIAAs greater than 3.0 cm. The lack of symptomatic or ruptured isolated CIAAs in this study supports delaying elective repair until an isolated CIAA diameter reaches at least 3.5 cm. These recommendations should be considered for isolated CIAA practice guidelines.

[Isolated iliac artery aneurysm : Clinical background and interventional treatment strategies]

BACKGROUND

Isolated iliac artery aneurysms are less frequent than abdominal aortic aneurysms, with the same, predominantly atherosclerotic-degenerative etiology, but patients present more frequently with symptoms or at the stage of rupture. The majority of those affected are men over the age of 65. The ideal imaging technique for diagnosis, treatment planning and follow-up is computed tomography (CT) angiography. Below a diameter of 4 cm, the risk of rupture is 6.3%, and then increases significantly with increasing diameter. Today, treatment is recommended from a size of 3.5 cm at the earliest.

THERAPY

Because of the lower mortality, endovascular therapy is the leading treatment for the elective and emergency situation. The quality of the landing zones, which are important for sealing, is decisive for elimination of the aneurysm. The elimination is carried out by means of stent grafts, often in combination with embolization. Due to the risk of buttock claudication and erectile dysfunction, the preservation of ipsilateral pelvic perfusion is recommended in cases of insufficient collateralization. Special iliac branch devices or various parallel endograft techniques are available for this purpose.

FOLLOW-UP

The main problem of endovascular treatment are endoleaks and the associated need for reintervention. Imaging control by means of CT angiography is crucial for timely endoleak detection, especially in the early phase.

Application of a Novel Common-Iliac-Artery Skirt Technology (CST) in Treating Challenge Aorto-Iliac or Isolated Iliac Artery Aneurysms

Purpose: To report a novel common-iliac-artery skirt technology (CST) in treating challenge iliac artery aneurysms. Methods: When required healthy landing zone of common iliac artery (CIA) is not available, CST is a strategy to exclude the internal iliac artery (IIA) and prevent IIA reflux without need of embolization. Patients who received endovascular aneurysm repair (EVAR) in our center from 2014 to 2020 were retrospectively screened, and patients treated with CST or with IIA embolization (IIAE) were enrolled. Results: After retrospective screen of 524 EVAR patients, 39 CST patients, 26 IIAE patients, and 7 CST + IIAE patients were enrolled in this study. CST group suggested to have more aged, hyperlipemia, and smoking patients than IIAE group. Two groups had comparable maximal diameter of abdominal aorta (AA), CIA, EIA, but larger diameter of IIA (CST 19.82 ± 2.281 vs. IIAE 27.82 ± 3.401, p = 0.048), and CIA bifurcation (CST 25.01 ± 1.316 vs. IIAE 29.76 ± 2.775, p = 0.087) was found in IIAE group. Anatomy of 79.5% of CST patients and 92.3% of IIAE patients (p = 0.293) was not suitable for potential use of iliac branch device. CST group had significant shorter surgery time (CST 97.42 ± 3.891 vs. IIAE 141.0 ± 8.010, p < 0.001), shorter hospital stay (CST 15.35 ± 0.873 vs. IIAE 19.32 ± 1.067, p = 0.009), lower in-hospital [CST 0% (0/39) vs. IIAE 11.5% (3/26), p = 0.059] and 1-year follow-up stent related MAEs [CST 6.7% (2/30) vs. IIAE 28.6% (6/21), p = 0.052], but comparable mortality and stent related MAEs for all-cohort follow-up analysis comparing to IIAE group. In our study, a lower in-hospital buttock claudication (BC) rate for CST (CST 20.5% vs. IIAE 46.2%, p = 0.053) and a comparable erectile dysfunction (ED) rate (CST 10.3% vs. IIAE 23.1%, p = 0.352) were found between CST and IIAE groups. After 1 year, both groups had about one third relief of BC symptoms [CST 33.3% (4/12) vs. IIAE 30.7% (4/13), p = 1.000]. Subgroup analysis of 14 patents concomitant with IIA aneurysm in CST group and the 7 CST + IIAE patients were carried out, and no difference was found in mortality, stent MAEs, sac dilation, or reintervention rate. Last, illustration of seven typical CST cases was presented. Conclusion: In selected cases, the CST is a safe, feasible-and-effective choose in treating challenge iliac artery aneurysms and preventing IIA endoleak.

Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms

INTRODUCTION

Isolated iliac artery aneurysms (IAA), accounting for 2-7 percent of all abdominal aneurysms, are nowadays often treated with the use of iliac branched endografts. Although outside of the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an EVAR device, for the treatment of isolated IAA. In this study we aim to describe the outcomes of the use of the Gore IBE device, without support of an infrarenal EVAR device, for the exclusion of isolated IAA.

DESIGN

This study is an international multicenter retrospective cohort analysis.

METHOD

All patients that were treated with a solitary IBE for IAA exclusion from 11-01-2013 up to 31-12-2018 were retrospectively reviewed. The primary outcome was technical success. Secondary outcomes included mortality, intraoperative and postoperative complications, and re-interventions.

RESULTS

In total 18 European and American centers participated, including 51 patients in which 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. There was no 30-day mortality and a 98.1% patency of both the internal and external iliac artery was found at 24-months follow-up. At 24-months follow-up, 81.5% of patients were free of complications and 90% were free of a secondary intervention.

CONCLUSION

Treatment with a solitary IBE is a safe and, at midterm, effective treatment strategy in selected patients with a solitary IAA.

Modalities of endovascular management for internal iliac artery aneurysms

BACKGROUND

Internal iliac artery aneurysms (IIAA) are uncommon. Open repair is technically challenging and has been associated with increased morbidity and mortality compared with repair of abdominal aortic aneurysms. The aim of this study is to assess the outcomes of endovascular treatment of IIAA and incidence of postoperative pelvic ischaemia.

METHODS

A single-centre retrospective analysis was performed for IIAAs treated with endovascular repair between January 2005 and December 2017. Aneurysm morphology, mode of presentation and operative technique were evaluated. Primary outcomes were 30-day mortality and incidence of pelvic ischaemia. Secondary outcomes were technical success, major complications and reintervention.

RESULTS

Twenty-nine IIAAs were treated in 23 patients with a mean age of 74 */- 9 years. Six patients had isolated IIAAs (26%); the remaining 17 patients had aortoiliac aneurysms. Five patients (22%) required emergent repair for ruptured IIAAs. Mean IIAA size was 4.1 cm */- 1.8 and ruptures occurred at mean 6.1 cm */- 2.6. Endovascular techniques used: stent graft occlusion of the internal iliac artery (IIA) ostium (n = 16), deployment of iliac branch device (n = 9), and other endovascular techniques (n = 4). The 30-day mortality was zero. Three patients (13%) experienced post-operative pelvic ischemia which were all minor chronic gluteal claudication after IIA occlusion. Primary technical success was achieved in 27 repairs (93%). There was one late reintervention (3%).

CONCLUSION

IIAAs are often asymptomatic and diagnosed incidentally, however, a significant proportion present emergently. Endovascular treatment is feasible for both ruptured and non-ruptured aneurysms with low perioperative morbidity, mortality and reintervention rates.

Bladder Scan Misleading a Vascular Emergency as Urinary Retention

A middle-aged man arrives from a nursing facility to the emergency department with urinary retention and abdominal pain. A bladder scan was performed to identify the amount of urine in the bladder. Multiple attempts were made to place a urinary catheter without difficulty, but no urine was identified. When several attempts are made to insert a urinary catheter without success of urinary output, one must stop and rule out other causes. This case study outlines the etiology, diagnostics tests, and management of a patient with urinary retention.

Therapeutic effect of and mechanisms underlying the effect of miR-195-5p on subarachnoid hemorrhage-induced vasospasm and brain injury in rats

Objectives

There is much evidence suggesting that inflammation contributes majorly to subarachnoid hemorrhage (SAH)-induced cerebral vasospasm and brain injury. miRNAs have been found to modulate inflammation in several neurological disorders. This study investigated the effect of miR-195-5p on SAH-induced vasospasm and early brain injury in experimental rats.

Methods

Ninety-six Sprague-Dawley male rats were randomly and evenly divided into a control group (no SAH, sham surgery), a SAH only group, a SAH + NC-mimic group, and a SAH + miR-195-5p group. SAH was induced using a single injection of blood into the cisterna magna. Suspensions containing NC-mimic and miR-195-5p were intravenously injected into rat tail 30 mins after SAH was induced. We determined degree of vasospasm by averaging areas of cross-sections the basilar artery 24h after SAH. We measured basilar artery endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κ B), phosphorylated NF-κ B (p-NF-κ B), inhibitor of NF-κ B (Iκ Bα) and phosphorylated-Iκ Bα (p-Iκ Bα). Cell death assay was used to quantify the DNA fragmentation, an indicator of apoptotic cell death, in the cortex, hippocampus, and dentate gyrus. Tumor necrosis factor alpha (TNF-α) levels were measured using sample protein obtained from the cerebral cortex, hippocampus and dentate gyrus.

Results

Prior to fixation by perfusion, there were no significant physiological differences among the control and treatment groups. SAH successfully induced vasospasm and early brain injury. MiR-195-5p attenuated vasospasam-induced changes in morphology, reversed SAH-induced elevation of iNOS, p-NF-κ B, NF-κ B, and p-Iκ Bα and reversed SAH-induced suppression of eNOS in the basilar artery. Cell death assay revealed that MiR-195-5p significantly decreased SAH-induced DNA fragmentation (apoptosis) and restored TNF-α level in the dentate gyrus.

Conclusion

In conclusion, MiRNA-195-5p attenuated SAH-induced vasospasm by up-regulating eNOS, down-regulating iNOS and inhibiting the NF-κ B signaling pathway. It also protected neurons by decreasing SAH-induced apoptosis-related cytokine TNF-α expression in the dentate gyrus. Further study is needed to elucidate the detail mechanism underlying miR-195-5p effect on SAH-induced vasospasm and cerebral injury. We believe that MiR-195-5p can potentially be used to manage SAH-induced cerebral vasospasm and brain injury.

[Endovascular treatment of common iliac artery aneurisms]

OBJECTIVE

To demonstrate endovascular management of common iliac artery aneurysms with iliac branch devices and to discuss some technical aspects of these interventions including bilateral procedures.

MATERIAL AND METHODS

Endovascular abdominal aortic aneurysm repair with concomitant implantation of iliac branch devices was performed in 9 patients at the Petrovsky National Research Center of Surgery for the period from January 2019 to December 2020. Mean age of patients was 64.8± years (min 52; max 72 years). Preoperative planning and morphometric analysis were based on CT data with a slice thickness of 1 mm. Angiographic reconstruction was made using Osirix 3D software (OsiriX Foundation, Geneva, Switzerland). Abdominal aortic aneurysm was combined with common iliac artery aneurysm in 7 patients (77.7%). Three (33.3%) patients had isolated common iliac artery aneurysm without significant abdominal aorta enlargement (Reber type I). Bilateral common iliac artery aneurysms were detected in 1 (11.1%) patient. All patients had iliac artery aneurysms over 4 cm. Iliac branch device implantation was accompanied by endovascular abdominal aneurysm repair in all patients.

RESULTS

Technical success rate was 100%. Six-month results were followed-up in 5 patients (55.5%), annual outcomes - in 2 patients (22.2%). Control examination consisted of a telephone interview, ultrasound of abdominal aorta, pelvic and lower limb arteries and computed tomography. All patients had no endoleaks, stent-graft thrombosis, as well as signs of ischemia of pelvic organs and lower extremities. Incidence of iliac artery aneurysm combined with abdominal aortic aneurysms is about 20%. Until recently, treatment of these patients was performed exclusively with covering of internal iliac artery. Improvement of technologies and development of iliac branch devices made it possible to preserve blood flow in internal iliac artery after endovascular management. This approach allowed avoiding of ischemic complications associated with embolization of internal iliac arteries.

A systematic review on endovascular repair of isolated common iliac artery aneurysms and suggestions regarding diameter thresholds for intervention

OBJECTIVE

Our aim was to systematically review results of endovascular aneurysm repair for isolated common iliac artery aneurysms (CIAA) regarding outcomes and to determine if changes should be made to current diameter threshold recommendations for intervention.

METHODS

A comprehensive systematic review was performed according to the PRISMA guidelines. PubMed, Scopus, and the Cochrane Central databases were searched.

RESULTS

Twenty-one studies were deemed eligible and provided data for 879 patients and 981 isolated CIAA treated with endovascular repair. The majority of the patients (90.8%) were males. The weighted mean age of the patients was 71.7 years (range, 37-91 years). The weighted mean diameter for the CIAA was 41. mm 1 (range, 15-110 mm) and for ruptured aneurysms 58.4 mm. The overall technical success rate was 97.6%. The perioperative mortality rate was 0.7%. Secondary patency rates were reported in only four studies and varied between 96.7% and 100%. The overall morbidity rate was 14%, ranging from 0% to 25%. Most of the studies did not report long-term or adequate follow-up data. Rupture of an isolated CIAA at <4 cm diameter was extremely low.

CONCLUSIONS

Endovascular treatment of isolated CIAA is feasible and safe with a low mortality and excellent technical success rates. Consideration of increasing the diameter threshold for intervention of CIAA to 4 cm should be considered. Studies with longer follow-up and reliable long-term results are needed.

Cross-over Deployment of a Tapered Stent Graft to Repair a Ruptured Isolated Internal Iliac Aneurysm

We report the case of a 72-year-old man who presented with a left ruptured internal iliac aneurysm (IIA). A percutaneous cross-over approach was used to coil-embolize the 3 distal branches of the IIA. A tapered endograft limb was then delivered via the right common femoral artery using a femorofemoral through-and-through cross-over approach. The widest part of the graft was deployed in the common iliac artery and the smallest in the external iliac artery. This percutaneous endovascular technique opens up new perspectives in emergency care for ruptured internal iliac artery aneurysms.

A Case of Chronic Right Hip Pain Revealing an Insidious, Incidental Eight-Centimeter Internal Aneurysm Among Multiple Diffuse Aneurysms

The prevalence of internal iliac artery aneurysms (IIAA) is very low. Existing data on IIAA are scarce and mainly based on case reports and small retrospective series. We present the case of a 55-year-old African American man with a past medical history of HIV, hypertension, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), coronary artery disease, polysubstance abuse, schizophrenia, depression, and bipolar disorder who presented to the emergency department with dyspnea on exertion. He was admitted for COPD exacerbation. He reported concerns of ambulatory chronic right hip pain, for which he underwent a CT, which revealed the presence of a partially visible right IIAA. A CT of his abdomen/pelvis revealed multiple aneurysms, including a partially thrombosed 8-cm fusiform right IIAA. Due to the presence of multiple aneurysms, the vascular surgery team was consulted, and elective repair was recommended. IIAA should be considered in the differential diagnosis of patients with significant smoking history and hip pain and acted upon immediately.

[Endoprosthetic repair of iliac artery aneurysm with a branch of the Anaconda stent graft]

An iliac artery aneurysm is characterized by arterial lumen dilatation which is more than 1.5 times greater than the normal diameter of the artery. In clinical practice, this pathology is rarely encountered, being associated with arterial hypertension and smoking, and more often observed in men. Its natural course inevitably leads to aneurysmal rupture. Treatment is only operative. Is admissible to use both open and endovascular techniques, with preference given to endovascular interventions using special linear endografts. Presented herein are two clinical case reports concerning endoprosthetic repair of an iliac artery aneurysm with a branch of the bifurcated stent graft Terumo Aortic Anaconda. The operative interventions had no complications in either peri- or postoperative periods. Our experience shows that endoprosthetic repair of an isolated aneurysm of the common iliac artery with a branch of the bifurcated stent graft Terumo Aortic Anaconda combines safety and efficacy and may be used by a wide range of vascular and roentgenoendovascular surgeons.

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes.

METHODS

We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model.

RESULTS

Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I² 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I² 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I² 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I² 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I² 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I² 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I² 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I² 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I² 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I² 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I² 0%, P = .622).

CONCLUSIONS

IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication.

Systematic Review of the Co-Prevalence of Arterial Aneurysms Within the Vasculature

OBJECTIVE

Aneurysms are considered focal manifestations of a systemic vascular condition, and various studies report co-prevalence of aneurysms in different vascular beds. Insight into profiles of patients at risk of multiple aneurysms is lacking, and few clinical algorithms exist if additional screening is indicated. This systematic review assessed the co-prevalence of aneurysms in different vascular beds and analysed putative risk factors for multiple aneurysms.

METHODS

Medline, Embase, and Cochrane libraries were searched up to February 2020 for studies reporting co-prevalence of aneurysms in different vascular beds using the keywords: "aneurysm", "co-prevalence", or synonyms. All studies were reviewed by two authors independently. Studies were excluded if they described concomitant treatment of multi-aneurysms, or if the aneurysm was reported solely bilateral, post-dissection, mycotic, traumatic, iatrogenic, or caused by a connective tissue disease. Radar plots were used to indicate studies that found an association between the investigated features and aneurysm co-prevalence against those that did not.

RESULTS

Thirty-two studies met the inclusion criteria, describing in total 16 353 patients of whom 2 015 had at least one additional aneurysm. The weighted co-prevalence was 16.9% (95% confidence interval [CI] 11.8-22.6), I² > 90%. At least 19 combinations of aneurysms were described, mostly derived from retrospective studies. Seventeen of 32 (53%) studies described concurrent aneurysms in patients with an abdominal aortic aneurysm. Predominantly positive associations were found for higher age, hypertension, stenotic disease, presence of multiple (at least three) aneurysms, and primary aneurysm size.

CONCLUSION

Approximately one in six patients with a primary aneurysm harbours an additional aneurysm, increasing to one in four if the patient has a popliteal artery aneurysm. Higher age, hypertension, stenotic disease, presence of multiple (at least three) aneurysms, and primary aneurysm size were predictive of aneurysm co-prevalence. These clinical predictors may assist when deciding whether a patient with a primary aneurysm needs to be screened for additional aneurysms.

Successful repair of an arteriovesical fistula as a complication after coil embolization for right hypogastric artery aneurysm

An 84-year-old man has a history of a right hypogastric artery aneurysm that was excluded with endograft several years ago. His course was complicated by a type II endoleak with an enlarging aneurysm that required multiple attempts of coil embolization. Several years later, he presented with gross hematuria and was found to have embolization coils extruding into his bladder and an arteriovesical fistula. As seen in this case, endovascular intervention for a type II endoleak is not benign. We describe a novel complication of an arteriovesical fistula that necessitated a difficult repair and ultimate revascularization.

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy-related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large-scale data over longer periods of time, the importance of centralization of care to high-volume centres was shown, particularly for open repair. Additionally, large-scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.

Big data in vascular surgery: registries, international collaboration and future directions

Given the increasing availability of large data set, small single-institutional series raise decreasing attention. Rapid expansion of technology from electronic medical records to easily accessible internet access, and widespread use and acceptance of registries in the medical world has allowed for research and quality improvement efforts using 'big data'. Big data, although technically not defined, typically refers to large databases that can be used to investigate common or rare disease processes or outcomes, describe variation in clinical practices across and between different specialties at various practice location, whilst allowing important information about trends over time. Big data have allowed investigators to quickly assimilate cohorts of patients and/or procedures to answer current questions, with more complete population representation and improved generalizability whilst decreasing the likelihood of power problems and type II errors. On the other hand, pitfalls still exist with the growing problem of hypothesis fishing, lack of granularity and the fear by many clinicians that registry transparency may have already gone too far, where surgery groups or individual surgeon outcomes are readily available to patients and referring providers. Within vascular surgery specifically, big data have expanded over the last decade and now includes regional, national and global registries that have major benefits of gathering specific clinical and procedural information within vascular surgery. In this review, we highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement and ultimately patient care. Additionally, we outline future directions that will be imperative for continued expansion, acceptance and adoption of 'big data' utilization inpatients with vascular disease.

Therapeutic management of isolated internal iliac artery aneurysms

OBJECTIVE

Isolated internal iliac artery aneurysms (IIIAAs) are rare, life-threatening entities for which the optimal treatment strategy has not been established. This study aimed to evaluate the outcomes of open and endovascular treatment of IIIAAs.

METHODS

IIIAA cases between January 2009 and March 2019 at two hospitals were retrospectively reviewed. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed.

RESULTS

Forty-two patients (37 men and 5 women) with a mean age of 71 years were included. Twenty-five patients (60%) had a history of hypertension. Twenty-two patients (52%) were asymptomatic, and 16 (38%) presented with abdominal pain (12 with ruptured aneurysms). The 42 included patients had 43 treated IIIAAs. The following surgical techniques were used: surgical resection (n = 6), endovascular coil embolization (n = 12), endovascular stent graft placement across the internal iliac artery origin (n = 8 with 9 aneurysms), and combined coil embolization and stent graft placement (n = 16). The immediate technical success rate was 67%, 67%, and 88% for embolization, stent graft placement, and combined method, respectively. Open surgery was associated with the longest operative time and hospital stay. Overall 30-day mortality was 5% for all patients and 17% for patients with ruptured IIIAAs. Buttock claudication occurred in 7 of 40 patients who survived (18%). The median follow-up time was 56 months. The combined approach was associated with the lowest rates of endoleak (6% vs 25% and 29%) and reintervention (6% vs 17% and 29%) of the three endovascular methods.

CONCLUSIONS

Endovascular coil embolization with stent graft placement is a feasible, safe, and effective treatment approach for large IIIAAs without adequate aneurysm necks.

Outcomes after Standalone Use of Gore Excluder Iliac Branch Endoprosthesis for Endovascular Repair of Isolated Iliac Artery Aneurysms

BACKGROUND

The aim of our study was to describe outcomes of stand-alone use (i.e., without concomitant implantation of an aortic stent graft) of the Gore Excluder iliac branch endoprosthesis (IBE) for elective endovascular repair of isolated iliac artery aneurysms.

METHODS

We evaluated all consecutive patients electively treated for isolated iliac artery aneurysms using standalone Gore Excluder IBE (January 2014-December 2018). Early (i.e., 30-day) endpoints were technical success, mortality, major adverse events (MAEs), and major access-site complications. Late endpoints were survival, freedom from aortic-related mortality (ARM), internal iliac artery (IIA) primary patency, IIA branch instability, graft-related adverse events (GRAEs), secondary interventions, endoleaks (ELs), aneurysm sac behavior, and new-onset buttock claudication (BC).

RESULTS

A total of 11 consecutive patients (10 men; median age 75 years) were included. The technical success rate was 100%. At 30 days, mortality, MAEs, and major access-site complications were all 0%. Survival and freedom from ARM were 91% and 100%, respectively; only one nonaortic related death was recorded during follow-up. At a median follow-up of 14 months, IIA primary patency, IIA branch instability, and GRAEs were 100%, 0%, and 0%, respectively. No instances of graft migration ≥10 mm were detected. No graft-related secondary interventions were recorded, and 2 patients required a procedure-related secondary intervention 3 months after the index procedure (1 common femoral artery endarterectomy and 1 external iliac artery stenting). Although new-onset type 1 or type 3 ELs were never noted, one patient developed a new-onset type 2 EL. Aneurysm sac regression ≥5 mm was noted in 6 patients (55%), whereas in the remaining ones, the sac size was stable. No instances of new-onset BC were noted.

CONCLUSIONS

Use of standalone Gore Excluder IBE for elective endovascular repair of isolated iliac artery aneurysms is a safe, feasible, and effective treatment option. These results may support use of the technique as an effective means of endovascular reconstruction in patients with suitable anatomy.

Morphology and Computational Fluid Dynamics Support a Novel Classification of Common Iliac Aneurysms

OBJECTIVE

Isolated common iliac artery aneurysms (CIAAs) are uncommon, and evidence concerning their development, progression, and management is weak. The objective was to describe the morphology and haemodynamics of isolated CIAAs in a retrospective study.

METHODS

Initially, a series of 25 isolated CIAAs (15 intact, 10 ruptured) in 23 patients were gathered from multiple centres, reconstructed from computed tomography, and then morphologically classified and analysed with computational fluid dynamics. The morphological classification was applied in a separate, consecutive cohort of 162 patients assessed for elective aorto-iliac intervention, in which 55 patients had intact CIAAs.

RESULTS

In the isolated CIAA cohort, three distinct morphologies were identified: complex (involving a bifurcation); fusiform; and kinked (distal to a sharp bend in the CIA), with mean diameters of 90.3, 48.3, and 31.7 mm, and mean time averaged wall shear stresses of 0.16, 0.31, and 0.71 Pa, respectively (both analysis of variance p values < .001). Kinked cases vs. fusiform cases had less thrombus and favourable haemodynamics similar to the non-aneurysmal contralateral common iliac artery (CIA). Ruptured isolated CIAAs were large (mean diameter 87.5 mm, range 55.5-138.0 mm) and predominantly complex. The mean CIA length for aneurysmal arteries was greatest in kinked cases followed by complex and fusiform (100.8 mm, 91.1 mm, and 80.6 mm, respectively). The morphological classification was readily applicable to a separate elective patient cohort.

CONCLUSION

A new morphological categorisation of CIAAs is proposed. Potentially this is associated with both haemodynamics and clinical course. Further research is required to determine whether the kinked CIAA is protected haemodynamically from aneurysm progression and to establish the wider applicability of the categorisation presented.

Ultrasound Assisted On-Table Management of Type III Endoleak at Endovascular Repair of Isolated Giant Common Iliac Aneurysm

Objectives

This report presents the endovascular treatment of a large isolated common iliac artery aneurysm, focusing on the use of on table ultrasonography to characterise and treat an early endoleak that could not be defined by angiography alone.

Report

A 58 year old man presented with an asymptomatic, large (13cm) left common iliac artery aneurysm (LCIAA) whilst being investigated for change in bowel habit. This was treated successfully via a percutaneous approach using left internal iliac embolisation followed by endovascular aneurysm repair (EVAR) with deployment of an aorto-uni-iliac converter system from the LCIA origin to the external iliac artery. A non-characterised endoleak at the end of the procedure was shown to be a type IIIb endoleak by application of immediate on table ultrasonography, allowing immediate supplementary targeted stent graft deployment to cover the leaking segment.

Discussion

The patient was discharged uneventfully and will remain on follow up. On table ultrasonography allowed both localisation and characterisation of an immediate intra-procedural endoleak and confirmed cessation of the endoleak with supplementary stent grafting and thrombosis within the sac.

Conclusions

Isolated CIAA is rare, and endovascular therapy is appropriate for them, given that open surgery, whilst feasible, carries a high morbidity and mortality risk. Application of on-table ultrasound allows definition and targeted treatment of endoleaks, reducing the need for further intervention at a later stage, and thus also reducing the risk of continued pressurisation of the large sac post-EVAR till the next surveillance episode.

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Isolated common iliac artery aneurysms (CIAAs) are very rare.

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They can be asymptomatic but have a high risk of rupture.

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Open repair is high risk and associated with high morbidity/mortality.

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This paper highlights successful endovascular repair of a giant isolated CIAA.

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On table ultrasound helps immediately to characterise and treat endoleaks at EVAR.

Endovascular Treatment of an Internal Iliac Artery Aneurysm in a Patient with Previous Aortic Surgery Using a Novel Covered Stent Graft

BACKGROUND

We report endovascular treatment of a patient with an isolated Internal Iliac Artery (IIA) aneurysm who was treated by positioning a novel covered stent that could adapt to different proximal and distal diameters.

CASE REPORT

A 68-year-old man who had already had several previous aortic surgeries underwent endovascular treatment for a 41 mm isolated right IIA aneurysm. Two Viabahn VBX (W. L. Gore & Associates, Flagstaff, AZ) covered stents (7 × 79 mm and 8Lx59 mm) were placed from a 6 mm gluteal artery to an 11 mm Dacron hypogastric artery via contralateral femoral surgical access. No complications occurred. One-month follow-up computed tomography angiography (CTA) scan showed the complete exclusion of the aneurysmal sac with spontaneous endoleak resolution and patency of the covered stents. Geometric analysis of the postoperative CTA highlighted VBX conformability to the native vessel. Maximum stented vessel diameter ranged between 9 and 13 mm, and circularity was maintained along the whole stent length, even in zones of higher centerline curvature.

CONCLUSIONS

The Viabahn VBX covered stent could be used to treat aneurysms of the IIA.

Giant Hypogastric Aneurysm Induced by Type-II Endoleak Presenting 4 Years after Endovascular Repair: A Case Report

Bilateral isolated hypogastric aneurysm (HA) is a rare type of abdominal aneurysm. Endovascular repair has become predominant compared with surgical repair because of its minimal invasiveness. However, type-II endoleak after procedure may lead to continuous enlargement of HA and rupture. Herein, we report a rare case involving a very large HA induced by type-II endoleak after endovascular repair. A 68-year-old male patient underwent endovascular repair of bilateral isolated HAs 4 years ago. Stent grafts were used to block the orifices of bilateral HAs, and main distal outflows were embolized with coils. In the absence of a 4-year follow-up, he returned to the clinic with symptoms of lower abdominal pain and frequent urination. Computer tomography angiography revealed a giant left HA with a maximum diameter of 18 cm combined with the enlargement of the left common iliac artery (CIA) induced by type-II endoleak. The right isolated HA decreased from 5.5 cm to 3 cm. Angiography was performed, and multiple arteries from the middle sacral and external iliac arteries were detected as the sources of type-II endoleak. Considering the compression effect, surgical repair of the left giant HA was performed. Thrombus was removed from the giant aneurysm, and the distal outflows of HA were sutured. As the left CIA was enlarged, a prosthetic graft was interposed through the inner side of the previous cover stent to revascularize the external iliac artery. The patient had an uneventful postoperative clinical course and was discharged from the hospital 7 days after operation. Treatments of HA induced by type-II endoleak require regular patient follow-ups to monitor specific conditions, particularly the embolization of distal outflows. Surgical repair remains the first choice for HA with compression symptoms.

Isolated internal iliac artery aneurysm causing rectal necrosis due to compression early after endovascular repair: A case report

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Many advantages of endovascular repair for aneurysms have been reported.

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The compression by aneurysms was not resolved early after endovascular repair.

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Rectal necrosis caused by residual aneurysms early after endovascular repair is rare.

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Aneurysm reduction and intestinal resection after embolization was a useful method.

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Embolization performed earlier assisted surgical decompression of aneurysms.

Introduction

Recently, endovascular repair has become the first-line treatment for internal iliac artery aneurysm (IIAA). However, rectal necrosis due to the compression of the residual IIAA early after endovascular repair is rare.

Presentation of case

We present a rare case of a huge, isolated left IIAA that severely compressed the rectum and ureter. The patient underwent emergency endovascular repair; however, rectal necrosis occurred 10 days later because the repair failed to shrink the size of the aneurismal sac.

Discussion

We hypothesize that the compression of the residual IIAA caused rectal necrosis. During open surgery, endovascular repair disrupted blood flow within the IIAA, which probably allowed for aneurysm dissection and residual hematoma removal.

Conclusion

Endovascular repair alone could not immediately release compression on the surrounding organs; however, open surgical removal of aneurysms after successful endovascular repair may be a useful option for IIAAs with compression of surrounding organs.

[Isolated iliac artery aneurysms : Interventional treatment]

CLINICAL ISSUE

Isolated iliac artery aneurysms occur considerably less often than abdominal aortic aneurysms. Mainly older men are affected by this disease. Most of these aneurysms are asymptomatic and are incidentally detected during cross-sectional imaging. Iliac aneurysms with a diameter larger than 3 cm are at risk for rupture, which is associated with high morbidity and mortality.

STANDARD TREATMENT

To prevent their rupture as well as for symptomatic or ruptured aneurysms, endovascular treatment has recently been established as the primary approach due to the decreased morbidity and mortality compared to open repair. Endovascular aneurysm exclusion is performed with stent grafts, and depending on the anatomy, by adjunctive internal iliac artery embolization.

TREATMENT INNOVATIONS

Up to a quarter of treated patients will require additional endovascular revisions during the long term. Reliable imaging follow-up likely increases the safety of elective or emergent endovascular iliac artery aneurysm repair.

Endovascular treatment of hypogastric artery aneurysms

OBJECTIVE

Internal iliac artery aneurysm (IIAA) is a rare entity. Its treatment can be technically challenging. The aim of this study was to evaluate the treatment possibilities in an era of advanced endovascular techniques and their potential to preserve iliac blood flow while reliably excluding the aneurysm.

METHODS

A retrospective analysis of 46 consecutive patients with endovascularly treated IIAA was performed. Data were collected from a single-institution aortoiliac database. The following end points were recorded: technique of aneurysm exclusion, technical success rates, perioperative morbidity and mortality, primary patency, and midterm follow-up.

RESULTS

Between September 2009 and May 2016, a total of 46 patients with 55 IIAAs were identified. The majority of patients (n = 39 [84.8%]) had aortoiliac aneurysms and seven had isolated IIAAs (15.2%). The following surgical techniques were used: implantation of iliac branch devices (IBDs; n = 29), occlusion of the internal iliac artery (IIA) by ostium coverage with or without prior coil embolization (n = 23), and other endovascular techniques (n = 3). Primary assisted technical success was achieved in 93.1% of IBD implantations and in 100% of occlusions by ostium coverage and other techniques. Overall 30-day mortality was 4.3% (n = 2) and 0% in electively treated patients. Assisted midterm patency after IBD implantation was 93.1%. Gluteal claudication occurred in seven patients (15.2%) who had undergone intentional or accidental occlusion of the IIA or the superior gluteal artery. Reintervention rates within the midterm follow-up were 13.8% (n = 4) after IBD implantation and 4.3% (n = 1) after coverage of the IIA ostium. No ruptures were observed during follow-up, and no complications occurred during reinterventions.

CONCLUSIONS

Implantation of IBD devices for the treatment of hypogastric artery aneurysms shows good technical results with a high primary patency and a low rate of perioperative complications. Although successful aneurysm exclusion while preserving pelvic blood flow is associated with a higher rate of reinterventions during midterm follow-up, it should be taken into consideration, especially in complex endovascular aortoiliac aneurysm repair.

Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable-Results of 72 Consecutive Patients

PURPOSE

To evaluate outcome of endovascular elective repair and repair of ruptured isolated iliac artery aneurysms (IIAAs) as a primary treatment strategy.

MATERIALS AND METHODS

All patients with an IIAA undergoing endovascular treatment were included. Aneurysms were classified according to an anatomic classification and treated with coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. Between November 1996 and November 2015, 72 patients with 85 IIAAs underwent endovascular repair. Mean age was 73.9 years ± 9.2. Common iliac artery was involved in 63 patients (74.1%), internal iliac artery was involved in 21 patients (24.7%), and external iliac artery was involved in 1 patient (1.2%). Mean diameter was 5 cm (range, 2.5-11 cm). Emergency repair was performed in 19 patients owing to rupture (26.4%).

RESULTS

Overall primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group) and in-hospital mortality rate of 1.4%. During mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0-14.2 y), 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall reintervention rate was 16.7%. Primary patency rate was 98.6%. During the follow-up period, 22 deaths occurred (30.6%), including 2 aneurysm-related deaths (2.8%).

CONCLUSIONS

Primary endovascular repair of IIAAs shows excellent results and should be considered as first-line therapy. Surgical backup should be available in emergency cases.

Giant internal iliac artery aneurysm successfully treated with endovascular stent-graft placement

An 88-year-old male patient of high surgical risk was presented with left sciatic pain symptoms and a palpable pulsatile left lower abdominal mass. He was operated 8 years ago for a large infrarenal aortic aneurysm. Computed tomography angiography (CTA) revealed a giant 161 mm left internal iliac aneurysm with multilocular appearance and left sacral bone erosion causing the symptoms. Endovascular repair was successfully performed using a monotubular iliac stent-graft. Follow-up CTA showed absence of contrast enhancement and a fully thrombosed sac. Patient recovered completely and was discharged 1 month after the procedure in a relatively good condition, nevertheless sciatic symptoms remained.

Percutaneous Access of an Expanding Internal Iliac Artery Aneurysm via a Direct Posterior Transgluteal Approach

BACKGROUND

Internal iliac artery aneurysms (IIAAs) are rare, comprising 0.3% of all aortoiliac aneurysms. Endovascular management is associated with lower morbidity and mortality than open repair. We present a 91-year-old female with a rapidly expanding 8.2-cm IIAA who previously underwent incomplete endovascular treatment, using endovascular aneurysm repair, to exclude the right internal iliac artery (IIA). Transarterial access to the IIAA was not possible secondary to the iliac limb of the endograft over the origin of the IIA. We recommended that the patient undergo embolization and coiling of the IIAA via a direct percutaneous transgluteal approach.

METHODS

With the patient in a prone position, under fluoroscopic guidance, a 10-cm long, 18-gauge needle was placed through the gluteus muscle into the right IIAA. Needle location was confirmed by angiography and a 6-French sheath was advanced into the aneurysm. Selective catheterization of the native aorta was accomplished around the occluded limb of the previously placed endograft. Aortography confirmed robust filling of 2 large lumbar arteries with brisk runoff through branches of the IIA. Coil embolization was used to treat both the lumbar arteries causing aortic endoleak, as well as the outflow branches of the IIAA.

RESULTS

Completion angiography revealed static flow in the aorta and aneurysm, with minimal flow through the inflow and outflow tracts. At a 1-month follow-up appointment, repeat computed tomography angiography revealed resolution of the endoleak and no blood flow within the aneurysm. There have only been a few case reports utilizing alternative access to an IIAA. Although computed tomography and ultrasound-guided techniques have been described in the literature, a percutaneous, fluoroscopy-guided, transgluteal approach to access the IIAA is a new and unique approach.

CONCLUSIONS

In patients who are not candidates for open or standard endovascular repair with a large, inaccessible IIAA, a transgluteal approach to directly access the aneurysm sac may offer a less invasive and successful management strategy.

Ruptured popliteal artery aneurysm

BACKGROUND

Popliteal artery aneurysms (PAAs) are generally complicated by thrombosis and distal embolization, whereas rupture is rare. The aim of this study was to describe the clinical characteristics and outcome in a cohort of patients who had surgery for ruptured PAA (rPAA).

METHODS

Operations for rPAA were identified from the Swedish Vascular Registry, Swedvasc, 1987-2012. Medical records and imaging were reviewed. Comparison was made with patients treated for PAA without rupture.

RESULTS

Forty-five patients with rPAA were identified. The proportion with rupture among those operated on for PAA was 2·5 per cent. Patients with rPAA were 8 years older (77·7 versus 69·7 years; P < 0·001), had more lung and heart disease (P = 0·003 and P = 0·019 respectively), and a larger mean popliteal aneurysm diameter (63·7 versus 30·9 mm; P < 0·001) than patients with PAA treated for other indications. At time of surgery, 22 of 45 patients were already receiving anticoagulants, seven for concomitant deep venous thrombosis (DVT) in the affected leg. There was extensive swelling of the whole leg in 20 patients. In 27 patients, the initial diagnosis was DVT or a Baker's cyst. All patients underwent surgery, all but three by the open method. There were four amputations, all performed within 1 week of surgery. One year after surgery, 26 of the 45 patients were alive. Among these, the reconstructions were patent in 20 of 22 patients.

CONCLUSION

The diagnosis of rPAA is difficult, and often delayed. The condition affects old patients, who often are on anticoagulation treatment and have large aneurysms. The immediate surgical results are acceptable, but the condition is associated with a high risk of death within the first year after surgery.

MicroRNA‑29a contributes to intracranial aneurysm by regulating the mitochondrial apoptotic pathway

Intracranial aneurysm (IA) is an abnormal expansion in the intracranial arteries that weakens the arterial wall by consistently pushing the vascular wall outwards, which leads to a higher risk of aneurysm rupture. A number of reports have demonstrated that apoptosis is associated with the growth and rupture of IA. MicroRNAs (miRNAs/miRs) perform vital roles in the regulation of the mitochondrial apoptotic pathway and signaling proteins. Increasing evidence has already revealed the role of miR‑29a in injury, including liver injury, cardiovascular injury and ischaemia‑reperfusion injury. However, the role of miR‑29a in IA remains unclear at present. The present study investigated the role of miR‑29a in IA pathogenesis and the underlying mechanisms. By using reverse transcription‑quantitative polymerase chain reaction and western blot analysis, the present study demonstrated that genes, including caspase‑3, ‑8 and ‑9, and proteins, including cytochrome c and myeloid cell leukemia 1 (Mcl‑1), involved in mitochondrial apoptosis pathways were upregulated in IA groups compared with controls. In addition, microarray analysis demonstrated that miR‑29a, one of the most altered miRs in IA mice, was overexpressed in IA mice compared with controls. In vitro experiments revealed that miR‑29a downregulation attenuated human brain vascular smooth muscle cell (HBVSMC) apoptosis, while miR‑29a overexpression increased the apoptosis of HBVSMCs. Furthermore, luciferase reporter analysis revealed that Mcl‑1 is a direct target gene of miR‑29a. An in vivo IA model confirmed that miR‑29a overexpression may promote apoptosis through mitochondrial pathways. It was therefore concluded that miR‑29a may contribute to the progression of IA by regulating mitochondrial apoptotic pathways. Thus, miR‑29a is a potential therapeutic target for IA.