Endovascular repair of isolated iliac artery aneurysms

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.

Single-Center Experience in the Endovascular Management of the Combination of Isolated Common and Internal Iliac Artery Aneurysms

Objective: The combination of isolated common and internal iliac artery aneurysms (CIIAA) are rare, life-threatening, abnormal conditions with relatively complex treatment. This study aimed to evaluate the clinical characteristics and treatment outcomes of CIIAA.

Methods: We retrospectively reviewed 26 patients with CIIAA consecutively treated between January 2010 and August 2020 at Peking Union Medical College Hospital. Demographic, clinical characteristic, treatment strategy and outcome data were collected and analyzed.

Results: Twenty-six patients (24 men and 2 women) with a mean age of 70 years were included. There was a total of 72 aneurysms, and the mean diameters of the common iliac artery aneurysms (CIAA) and internal iliac artery aneurysms (IIAA) were 36 and 38 mm, respectively. Ten patients (38%) presented with bilateral CIAA and unilateral IIAA, and eight (31%) had CIAA with ipsilateral IIAA. All patients were treated with endovascular repair, and the overall primary technical success rate was 100%. The surgical techniques mainly included combined bifurcated stent grafting and embolization (n = 11), combined straight stent grafting and embolization (n = 8), and internal iliac artery (IIA) reconstruction (n = 7). There were no patient deaths or reintervention during hospitalization. The mean follow-up time was 43 months, and the patency rate of the stent was 96.2%. The overall reintervention rate was 7.7%. During the follow-up period, there were no aneurysm-related deaths.

Conclusions: Endovascular repair involving stent graft placement, coil embolization and IIA revascularization is a safe and effective treatment for isolated CIIAA.

[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.

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.

Atypical Type 2 Endoleak from an Artery Supplying the Psoas Major Muscle Following Endovascular Repair in a Case of Isolated Common Iliac Artery Aneurysm

In this report, we present a rare case of type 2 endoleak (T2EL) from an artery supplying the psoas major muscle, following an endovascular repair of a common iliac artery aneurysm (CIAA). A 79-year-old male underwent endovascular aneurysm repair (EVAR) for the right isolated CIAA using stent graft, with embolization of the ipsilateral internal iliac artery. The aneurysm was stable for 2 years, after which a follow-up CT revealed a 5 mm increase in the CIAA diameter and an endoleak of unknown origin. Conventional and CT angiographies revealed the source to be a branch from the ipsilateral deep circumflex iliac artery supplying the psoas major muscle that had developed an anastomosis at its terminal end with the vasa vasorum at the CIAA. Transarterial embolization of T2EL using glue was performed successfully, following which the T2EL disappeared.

[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.

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.

Technical issues and clinical outcomes of endovascular repair of isolated iliac artery aneurysms: A single-center experience

Purpose

Isolated iliac artery aneurysms are the relatively uncommon condition. This study aims to evaluate the technical issues and clinical outcomes of endovascular repair in a cohort of isolated iliac artery aneurysms treated.

Methods

We retrospectively reviewed 22 consecutive patients with isolated iliac artery aneurysms between December 2006 and September 2016. Iliac artery aneurysms were treated in one of the three ways: (1) standard bifurcated aortic stent graft placement with limb extension; (2) coverage of iliac artery aneurysms with covered stent grafts; and (3) embolization of the arterial branches distal to the aneurysms with coils or vascular plugs.

Results

Twenty-two patients (20 men) with a mean age 64.7 years underwent endovascular repair during the study period. The median diameter of the isolated iliac artery aneurysms was 5.9 ± 1.7 cm (2.9–9.0 cm). Technical success was 95.5%. Conversion to open surgery was performed in one patient with bilateral internal iliac artery aneurysms. Four patients underwent placement of a bifurcated stent graft. A covered stent graft was deployed in 16 patients, with embolization of internal iliac artery in 14 patients. Simple coil embolization of isolated internal iliac artery aneurysm was performed in one patient. There was one sudden cardiac death on day 4 after the procedure due to heart failure. During the follow-up period (range: 1–50 months, mean 19.8 months), five patients died of causes not related to isolated iliac artery aneurysms, and transient buttock claudication was observed in one patient.

Conclusions

Our study documents the safety and effectiveness of endovascular repair of isolated iliac artery aneurysms with low morbidity and mortality.

Initial Experience with the E-liac® Iliac Branch Device for the Endovascular Aortic Repair of Aorto-iliac Aneurysm

PURPOSE

Occlusion of internal iliac arteries during endovascular treatment (EVAR) of abdominal aortic (AAA) and common iliac artery aneurysms might be associated with ischemic pelvic complications. This study evaluates technical and clinical success, safety and mid-term results of a novel iliac branch device (IBD) for revascularization of the internal iliac artery (IIA) during EVAR.

MATERIALS AND METHODS

Retrospectively, we identified 21 men (mean age 73.3 ± 6.2 years) treated for aorto-iliac aneurysms by use of a novel IBD (E-liac^®, Jotec Hechingen, Germany). We analyzed safety (30-day survival), technical (no type I and III endoleaks, "EL"), clinical (no ischemic complications) success, mid-term patency of this IBD, peri-procedural complications, occurrence of type II ELs, rate of re-interventions and additional treatment of the revascularized IIA for landing zone preparation.

RESULTS

Twenty-three IBDs were implanted. Aneurysms of the ipsilateral IIA were present in 6/23 IIAs (26.1%). Super-selective branch embolization was performed in these patients and the landing zone for the iliac sidebranch stent-graft was within the superior gluteal artery. Mean follow-up was 341 days (range 4-1103 days). Technical success and 30-day survival were 100%. Clinical success was 95.2%. Primary patency of the IBDs was 100% at 12 months. Peri-procedural complications occurred in 3/21 patients (14.3%), none of them related to the IBD. AAA-related type II ELs were found in 6 patients (28.6%), IBD-related ELs in 4/23 IBDs (17.4%) (two type Ib, two type II endoleaks). Overall re-intervention rate was 23.8%, IBD-related 8.7%.

CONCLUSION

Utilization of the E-liac^® IBD is safe and effective for the treatment of aorto-iliac aneurysms.

[Management of isolated iliac aneurysms: A Tunisian center experience]

Isolated aneurysms of the iliac arteries are rare. The diagnoses of these aneurysms become easier with non-invasive radiologic investigations. The development of endovascular treatment is a recent alternative to surgical treatment. We report our experience in the management of 8 cases of isolated iliac aneurysms in the department of cardiovascular and thoracic surgery of the Habib Bourguiba Hospital of Sfax.

Embolization of a Previously Excluded Symptomatic Internal Iliac Aneurysm Through the Iliac Vein

A 69-year-old man was referred urgently for a 58-mm enlarging painful right internal iliac artery (IIA) aneurysm. Since exclusion through proximal IIA coverage and distal IIA branches embolization had been previously performed, aneurysm sac puncture through the iliac vein was decided. The ipsilateral common femoral vein was antegradely punctured, and a 16.5 G Ross modified Colapinto needle from a transjugular intrahepatic access set was used to puncture the sac and fill the aneurysm with coils. Embolization of an IIA aneurysm through the iliac vein may represent an alternative when prior IIA aneurysm exclusion has been performed.

Midterm results of internal iliac artery aneurysm embolization

OBJECTIVE

We describe the immediate and midterm results of endovascular treatment of isolated internal iliac artery aneurysms (IIAA).

METHODS

This was a retrospective single center study. From 2005 to 2014, data from 20 consecutive patients who had an embolisation for an isolated atherosclerotic internal iliac artery aneurysm underwent an endovascular treatment. We retrospectively evaluated the technical aspects and outcomes.

RESULTS

The mean aneurysm diameter was 42mm (range 30-97mm). No perioperative deaths or treatment failures occurred. No endoleaks or secondary aneurysm ruptures were observed during the follow-up. Three patients experienced disabling buttock claudication, which was spontaneously remissive in two cases. No relationship was found between buttock claudication and the patency of the contralateral internal iliac artery and the deep femoral artery. Six patients (30%) died during follow-up. Among these, three patients died due to cardiovascular events. The mean follow-up interval was 24 months (range 6-96 months).

CONCLUSION

The endovascular treatment of isolated internal iliac artery aneurysm is safe in the short-term and could prevent secondary aneurysm rupture at midterm.

Fate of Enlarged Iliac Arteries After Endovascular or Open Abdominal Aortic Aneurysm Repair

Purpose: To examine the fate of untreated ectatic and aneurysmal common iliac arteries (CIAs) after open treatment and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods: Databases of scientific literature were searched between January 1980 and February 2016 to identify publications on the follow-up of ectatic and aneurysmal CIAs after open or endovascular AAA repair. The primary outcome measure was the increase of iliac artery diameter during follow-up. The secondary outcome was the subsequent reintervention rate during follow-up. Results: Only 3 open AAA and 3 EVAR studies containing 1239 patients met the inclusion criteria for analysis. In the open AAA group, ectatic iliac arteries (defined as 12–18 mm) had a diameter progression of 1.7 to 1.8 mm during a follow-up period of 51.6 to 85.2 months. The aneurysmal iliac arteries (>18 mm) in the open repair group showed a faster growth (2.3–3.0 mm) in a follow-up period of 50.4 to 85.2 months. The pooled assessment of arteries ≥18 mm had a mean growth of 2.56 mm at 60 months of follow-up. In the entire open AAA cohort, the reintervention rate for CIA transformation was <1%. In the EVAR studies, arbitrary cutoff sizes of 16 to 20 mm for ectatic arteries and >20 mm for aneurysmal arteries were used. During a follow-up of 39.2 to 60 months, the diameter progression was 1.5 mm for the 16-mm iliac arteries and 2.7 mm for the 20-mm iliac arteries. The need for endovascular reinterventions was similar in patients with previously normal or enlarged CIAs. Conclusion: After open AAA repair, the overall size of CIA aneurysms grows slowly, but enlarged CIAs >20 mm in EVAR patients show faster growth during follow-up. However, the need for secondary interventions was similar in patients with normal or enlarged CIAs post EVAR.

U Stent-Graft Technique as a Treatment for Homolateral Metachronous Common Iliac and Internal Iliac Arteries Aneurysms after Open Surgery

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

Perigraft Plug Embolization of the Internal Iliac Artery and Implantation of a Bifurcated Stentgraft: One Treatment Option for Insufficient Tubular Stentgraft Repair of a Common Iliac Artery Aneurysm

We report an endovascular technique for the treatment of type Ia endoleak after a plain tubular stentgraft had been implanted for a large common iliac artery aneurysm with an insufficient proximal landing zone and without occlusion of the hypogastric in another hospital. CT follow-up showed an endoleak with continuous sac expansion over 12 months. This was classified as type Ia by means of dynamic contrast-enhanced MRI. Before a bifurcated stentgraft was implanted to relocate the landing zone more proximally, the still perfused ipsilateral hypogastric artery was embolized to prevent a type II endoleak. A guidewire was manipulated alongside the indwelling stentgraft. The internal iliac artery could then be selectively intubated followed by successful plug embolization of the vessel's orifice despite the stentgraft being in place.

The effect of endovascular treatment on isolated iliac artery aneurysm treatment and mortality

OBJECTIVE

Isolated iliac artery aneurysms are rare, but potentially fatal. The effect of recent trends in the use of endovascular iliac aneurysm repair (EVIR) on isolated iliac artery aneurysm-associated mortality is unknown.

METHODS

We identified all patients with a primary diagnosis of iliac artery aneurysm in the National Inpatient Sample from 1988 to 2011. We examined trends in management (open vs EVIR, elective and urgent) and overall isolated iliac artery aneurysm-related deaths (with or without repair). We compared in-hospital mortality and complications for the subgroup of patients undergoing elective open and EVIR from 2000 to 2011.

RESULTS

We identified 33,161 patients undergoing isolated iliac artery aneurysm repair from 1988 to 2011, of which there were 9016 EVIR and 4933 open elective repairs from 2000 to 2011. Total repairs increased after the introduction of EVIR, from 28 to 71 per 10 million United States (U.S.) population (P < .001). EVIR surpassed open repair in 2003. Total isolated iliac artery aneurysm-related deaths, due to rupture or elective repair, decreased after the introduction of EVIR from 4.4 to 2.3 per 10 million U.S. population (P < .001). However, urgent admissions did not decrease during this time period (15 to 15 procedures per 10 million U.S. population; P = .30). Among elective repairs after 2000, EVIR patients were older (72.4 vs 69.4 years; P = .002) and were more likely to have a history of prior myocardial infarction (14.0% vs 11.3%; P < .001) and renal failure (7.2% vs 3.6%; P < .001). Open repair had significantly higher rate of in-hospital mortality (1.8% vs 0.5%; P < .001) and complications (17.9% vs 6.7%; P < .001) and a longer length of stay (6.7 vs 2.3 days; P < .001).

CONCLUSIONS

Treatment of isolated iliac artery aneurysms has increased since the introduction of EVIR and is associated with lower perioperative mortality, despite a higher burden of comorbid illness. Decreasing iliac artery aneurysm-attributable in-hospital deaths are likely related primarily to lower elective mortality with EVIR rather than rupture prevention.

Isolated common iliac artery aneurysm: a rare entity

Isolated aneurysms in iliac artery are not common. A 65-year-old male patient presented with complaints of pain abdomen, abdominal distension and history of hypertension, Clinical examination revealed pulsatile mass in the right iliac fossa extending upto paraumbilical region with palpable pulsations in all the limbs. Computed tomographic (CT) angiogram was done and it revealed large aneurysm of right common iliac artery. CT chest and abdomen did not reveal aneurysm in thoracic and abdominal aorta. As the size of aneurysm was large and there was risk of rupture, surgical intervention in the form of aneurysmorrhaphy was done. Open surgery was done as the anatomy was not favourable for endovascular intervention. Aneurysmorrhapy was done using 6mm ringed Poly Tetra Fluoro Ethylene graft. Patient recovered well and was discharged after 10 days.

A novel endovascular treatment for long-standing high-flow arteriovenous fistula

We describe a novel use of an Amplatzer III plug device (St. Jude Medical, St. Paul, Minn) in the treatment of a traumatic arteriovenous fistula between the innominate vein and the origin of the left common carotid artery causing symptomatic right heart failure. A review of the literature indicates this is the first case to describe the use of the Amplatzer III device in this way. We demonstrate immediate closure of fistula radiologically and complete symptomatic resolution at short-term follow-up.

Technical and outcome considerations of endovascular treatment for internal iliac artery aneurysms

PURPOSE

This study was designed to analyze the outcomes of endovascular treatment for internal iliac artery aneurysm (IIAA) at mid-term follow-up.

METHODS

We retrospectively analyzed 33 patients (28 males, mean age 77.4 years) who underwent endovascular treatment of 35 IIAAs (mean diameter 39.8 mm) from 2002 to 2012. We attempted to completely and selectively embolize all distal branches with permanent embolic materials, followed by proximal controls either by stent-graft placement (type 1) or coil embolization (type 2).

RESULTS

Procedural success rate was 97.1% (n = 34). Complete permanent distal branches embolization was achieved in 27 (79.4%), type 1 in 24 (70.6%), and type 2 in 10 (29.4%) cases. During mean follow-up period of 29.1 months (range, 1.2-92.8), no IIAA-related mortality and stent/stent-graft related complications occurred. Pelvic ischemia occurred and resolved in 8 (25%) patients. Among 32 cases followed by CT, the aneurysm diameter was stable in 18 (56.3%), shrank in 11 (34.4%), and enlarged in 3 (9.4%) cases. In 22 assessed by contrast-enhanced CT, secondary endoleak occurred in 3 (13.6%) cases and 2 required secondary interventions (2/32, 6.3%). Type 1 procedure tends to have better mid-term outcomes. Incomplete permanent distal branches embolization was associated with enlargement and secondary intervention (p = 0.007 and p = 0.042, respectively). The secondary intervention-free rate at 3 years in the complete and incomplete distal embolization group was 100 and 83.3%, respectively (p = 0.128).

CONCLUSIONS

Endovascular treatment for IIAA is feasible and safe. Complete permanent distal branches embolization is important to achieve satisfactory mid-term outcomes.

Endovascular treatment of isolated iliac artery aneurysms using a custom-made stent graft with proximal barb fixation: early outcome

Current endovascular treatments for isolated iliac artery aneurysms (IIAAs) include the use of aortoiliac stent grafts with coverage of the distal aorta or stent grafts confined to the iliac artery without active proximal fixation. We report our experience in the use of custom-made Cook Zenith™ iliac limb stent grafts with proximal barb fixation. Patients treated from July 2009 to February 2011 were included. All imaging and patient records were assessed for perioperative and early outcomes. Nine IIAAs (seven patients) were treated. The mean patient age was 80 years (range 58-91 years). The mean aneurysm size was 48 mm (35-80 mm), and the mean length of the proximal landing zone (PLZ) was 29 mm (10-50 mm). The distal landing zone was in the external iliac artery after coil embolization of the internal iliac artery. The Mean diameter of the PLZ was 21 mm (20-24 mm). Technical success was achieved in eight cases. Perioperative complications included reoperation in one patient for groin bleeding and ischemia. On follow-up (mean 12 months, range 1-26), all aneurysms were successfully excluded from the circulation and there was no stent graft migration or thrombosis. Use of custom-made stent grafts with proximal barb fixation in treatment of IIAAs is a feasible option which may reduce the risk of migration when compared with stent grafts with lack of proximal fixation.

Endovascular repair of an infected ruptured isolated iliac artery aneurysm combined with congenital lymphedema: report of a case

PURPOSE

A novel technique using the reversed iliac leg of a Zenith device has been reported. This study reports a complicated isolated iliac artery aneurysm (IIAA) using this novel technique and reviews the relative literature to discuss current treatment modalities.

CASE REPORT

A 46-year-old man presented with a mass in the left lower quadrant accompanied by abdominal pain for 60 days. Computer tomography angiography (CTA) revealed a complicated IIAA and a massive retroperitoneal hematoma. Percutaneous puncture and drainage at the hematoma was done. Enterococcus faecium was isolated from the hematoma. The infection was controlled after 2 weeks of drainage and anti-infection treatment. The IIAAs were successfully excluded using the novel technique. The 12-month CTA follow-up was unremarkable.

CONCLUSION

Using inverted Zenith device legs is safe and effective even in complicated IIAAs. Further studies are warranted before it can become a widely acceptable definitive treatment option.

The midterm experience of tapered stent grafts in the endovascular management of iliac artery aneurysms with unfavorable anatomy

We report our experience and the midterm results of a modern technique for endovascular management of isolated iliac artery aneurysms (IAAs) with unfavorable neck anatomy, which involves the inversion of an iliac leg of a Zenith stent graft. Patients who underwent endovascular IAA repair from 2002 to 2010 were reviewed. A total of 12 patients, with a mean age of 77.6 years, underwent endovascular repair of 13 IAAs. Mean size of the aneurysms was 54.6 mm (range 34-133 mm). Mean proximal neck diameter was 18 mm (range 15-22 mm). In 7 patients, the length of the proximal neck was <15 mm (10-14 mm). Only 1 patient developed thrombosis of the stent graft immediately after the operation. Patients were followed up for a mean of 31.5 months (range 18-72 months). Our midterm results demonstrate the durability of this technique in the management of iliac aneurysms with unfavorable anatomy.