Common iliac artery aneurysm: Expansion rate and results of open surgical and endovascular repair

Short-Term Outcomes of Management of Endovascular Aneurysm Repair in Patients With Dilated Iliacs

OBJECTIVES

This study aims to evaluate outcomes following endovascular aneurysm repair (EVAR) in patients with dilated but not aneurysmal common iliac arteries.

METHODS

Data prospectively collected from 342 elective EVARs were analyzed retrospectively. Dilated common iliac anatomy was defined as 21 to 24 mm. Patients with iliac aneurysms or external iliac artery (EIA) extension were excluded. Patients were followed up using clinical review, plain radiographs, duplex imaging, and selective computed tomography scanning.

RESULTS

Median age was 75 years with a mean follow-up of 3.6 years. In all, 33 patients had dilated common iliac arteries (DCIAs) and 309 had non-dilated common iliac arteries (NDCIA). There was no difference in aneurysm diameter or neck characteristics (length, diameter, angulation, thrombus, and flare) between the subgroups. There was no significant difference in technical success, 30-day mortality, late mortality, aneurysm-related mortality, 30-day reinterventions, stent graft migration, limb occlusion, sac expansion, graft rupture, type 1 endoleaks, type 3 endoleaks, and total reinterventions (all Ps > .05). There was a significant decrease in type II endoleaks in patients with DCIA compared to NDCIA (NDCIA 12.9% and DCIA 0.0%; P = .02).

CONCLUSION

Patients presenting with abdominal aortic aneurysms with DCIA can be successfully treated with EVAR with no increase in complications without extension into the EIA.

Covered stent in the superior gluteal artery in a hybrid approach to treat internal iliac artery aneurysm: a technical note

This brief report describes a hybrid endovascular and open procedure to treat internal iliac artery (IIA) aneurysms and preserve pelvic blood flow. A covered stent was deployed before surgery in the superior gluteal artery, extending across the IIA aneurysm, with the proximal end in the common iliac artery lumen. During open aortoiliac aneurysm repair, the stent graft was anastomosed in an end-to-side manner to the surgical graft. Four aneurysms were treated in 3 patients. Technical success was achieved in all cases. There were no complications or repeat interventions. Stents were all patent at imaging follow-up (range, 6-25 mo). Patients were free from buttock claudication.

Successful surgical repair of an ilio-iliac arteriovenous fistula associated with a ruptured common iliac artery aneurysm

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We report the successful surgical treatment of an ilio-iliac arteriovenous fistula.

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Although rare, this disease can be life-threatening.

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Use of multiple imaging modalities facilitates correct preoperative diagnosis.

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Balloon occlusion technique is used to minimize blood loss during open repair.

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There was no sign of high-output heart failure because of venous flow failure.

Introduction

We describe the case of an 86-year-old man with an ilio-iliac arteriovenous fistula (AVF) resulting from a ruptured aneurysm. This condition rarely occurs, has a high mortality rate, and was successfully treated via surgery.

Presentation of case

The patient presented with a temporary loss of consciousness and left leg edema. A pulsatile abdominal mass with vascular murmur and thrill was detected. Enhanced computed tomography showed abdominal aortic and iliac aneurysms with left common iliac vein occlusion, and the left external iliac vein was easily seen through the AVF. We directly sutured the AVF and performed aneurysmectomy and prosthetic graft replacement. During surgery, placement of occlusive balloon catheters through the AVF minimized intraoperative bleeding. The patient recovered uneventfully, and swelling of the left leg was immediately reduced after surgery.

Discussion

Although rare, AVFs can be life-threatening, and urgent treatment and intensive care are occasionally needed. Surgical management of AVF requires a definitive preoperative diagnosis and control of venous bleeding during surgery. Fulfilling these major requirements can potentially reduce morbidity and mortality in patients with AVFs. Interestingly, there was no sign of high-output heart failure throughout the treatment course due to compression of the aneurysm and consequent blood flow failure to the left iliac vein.

Conclusion

Using the balloon occlusion technique, we were able to minimize blood loss during open repair. Use of multiple imaging modalities facilitates correct preoperative diagnosis and consequently improves surgical outcome.

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.

Rapid aneurysm growth after transarterial chemoembolization

Chemotherapy has been anecdotally related to aneurysm growth, but no correlation has been noted to date for localized transarterial chemoembolization. We present the case of a 64-year-old man with clearly documented accelerated aortic and iliac artery aneurysm dilation after two rounds of transarterial chemoembolization for hepatocellular carcinoma. Given the large size with rapid growth of his aneurysms and inability to be listed for transplant consideration before repair, he was offered endovascular repair and was successfully treated.

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.

Endovascular interventions for human immunodeficiency virus-associated iliac artery aneurysms

OBJECTIVE

Aneurysms associated with human immunodeficiency virus (HIV) are pseudo-aneurysms and the pathology is unique to HIV vasculopathy. We report outcomes of endovascular therapy for HIV iliac artery aneurysms in a series of patients to augment the sparse literature on these aneurysms.

METHODS

The records from January 2010 to December 2013 of all patients treated for HIV-related iliac artery aneurysms were extracted from a prospectively maintained database at our institution.

RESULTS

Preprocedural, periprocedural, and postprocedural data were retrieved for five black patients (three males and two females), who were treated for HIV-associated iliac artery aneurysms. All patients underwent endovascular therapy. There were seven aneurysms (three common iliac arteries, three internal, and one external). Pain was a common presenting feature, and two patients presented with rupture. One patient was receiving antiretroviral therapy, and one patient was receiving treatment for pulmonary tuberculosis. Three patients had significant weight loss. The average hemoglobin value was 8 g/dl. Six aneurysms were managed with covered stents and one (internal iliac artery) with coil embolization. There were no procedure-related complications, and only one patient required a blood transfusion. Symptoms resolved in all patients. One re-intervention was required for stent thrombosis after 30 days.

CONCLUSION

Endovascular therapy for the HIV-associated iliac artery aneurysm has good short-term results and avoids pelvic dissection with its associated morbidity and mortality.

Isolated iliac artery aneurysms: a single-centre experience

PURPOSE

This paper reviews our experience in endovascular treatment of isolated iliac artery aneurysms (IIAAs) with a large number of patients.

MATERIALS AND METHODS

From May 2005 to September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs underwent endovascular treatment at our institute. We evaluated technical success, long-term patency, early and late complications and overall mortality. Patients were divided into two groups: emergency-treatment group and elective-treatment group.

RESULTS

At a median follow-up of 34.3 months, we achieved a technical success of 97.8 %, a primary patency of 95.5 % and a secondary patency of 100 %, with complete exclusion of the aneurysm in 84.5 % of cases. The incidence of endoleaks was of 15.5 %: eight were type II and one was type III; perioperative mortality was 4.7 %.

CONCLUSIONS

Our study documents the effectiveness, in both emergency and elective settings, of the endovascular treatment of iliac aneurysms (EVIAR), which has become the first-choice treatment at our institute. In particular cases, it is also possible to avoid embolisation of the internal iliac artery.

Complex common and internal iliac or aortoiliac aneurysms and current approach: individualised open-endovascular or combined procedures

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates.

Survey of management of common iliac artery aneurysms by members of the Vascular Society of Great Britain and Ireland

INTRODUCTION

The aim of this study was to determine whether the current management of common iliac artery aneurysms (CIAAs) by vascular surgeons is in tune with existing guidelines for referral.

METHODS

This was a postal survey of members of the Vascular Society of Great Britain and Ireland. The main outcome measures were relative frequency of ruptured CIAA, respondents' size threshold for surveillance versus intervention, and their management strategies for isolated unilateral CIAAs, bilateral CIAAs and aortoiliac aneurysms.

RESULTS

Two hundred and eighty-four (anonymous) replies were received (48% response rate). Respondents estimated that a ruptured abdominal aortic aneurysm (AAA) was 25 times more common than a ruptured CIAA. Most surgeons (64%) would wait until a CIAA reached 4 cm in diameter before considering intervention. This threshold was not affected by other scenarios such as the presence of a bilateral CIAA or a small (4 cm) AAA. Eighty per cent of surgeons would treat a non-ruptured CIAA by stenting, where possible. The majority of surgeons felt that ultrasonography surveillance should be commenced when a CIAA exceeds 1.5 cm, with a surveillance interval of 1 year but with more frequent surveillance for CIAAs wider than 3 cm.

CONCLUSIONS

Existing guidelines that recommend referral for possible intervention for non-ruptured CIAAs at a diameter of 3 cm are out of tune with current practice. Most surgeons in this survey would wait until the diameter was 4 cm.

[Reconstruction of the aortic bifurcation: endovascular aortic repair (EVAR) and alternatives]

CLINICAL ISSUE

Diseases of the aortic bifurcation, whether stenotic or dilating, are mostly a manifestation of arteriosclerosis. If only stenosis is present aortic bifurcation disease is equivalent to a certain form of peripheral arterial occlusive disease (PAOD) characterized by the specific anatomical location. Aneurysmal disease and PAOD of the aortic bifurcation may occur together and men older than 60 years are particularly affected. The main symptom of aortic bifurcation PAOD is bilateral claudication whereas aneurysmal disease of the aortic bifurcation is frequently asymptomatic.

STANDARD TREATMENT

Therapy of stenotic and aneurysmal disease of the aortic bifurcation depends on the degree of the disease. Simple lesions, such as isolated stenoses of the aortic bifurcation or unilateral occlusions of the common iliac artery extending to the aortic bifurcation have been treated endoluminally for many years. Current standard treatment of complex aortic bifurcation disease is open surgery with implantation of an aortobifemoral bypass graft. However, recent developments in less invasive endoluminal methods have shifted the indications more towards endoluminal therapy. This development is mirrored by the international TransAtlantic Inter-Society Consensus (TASC) II recommendations from 2007 and even more clearly by the current national S3 guidelines on PAOD (http://www.degir.de/site/leitlinien). It is stated that in complex aortic bifurcation disease, such as bilateral occlusions of the common iliac arteries (TASC C lesions) or diffuse aortobiiliac stenoses and occlusions (TASC D lesions), endoluminal therapy may be considered as an alternative to open surgery. Therapy of aneurysmal disease of the aortic bifurcation depends on the pathoanatomical conditions. Prerequisite for endoluminal therapy is a sufficient landing zone for the prostheses. If this prerequisite is fulfilled endoluminal therapy is very likely comparable to open surgery with regard to technical and clinical success. Long-term results are still lacking.

DIAGNOSTIC WORK-UP

For the decision on the type of therapy and the sizing of the prostheses, thin-slice (≤ 3 mm slice thickness) computed tomography angiography (CTA) of the abdominal aorta and the iliac arteries including multiplanar reconstruction in the sagittal and coronal plane are sufficient. The inguinal arteries have to be included in the CTA volume.

PERFORMANCE

Compared to open surgery, endoluminal therapy of stenotic and aneurysmal disease of the aortic bifurcation has the advantage of reduced invasiveness. Hence patient recovery and hospital stay may be shorter.

ACHIEVEMENTS

Therapy of stenotic and aneurysmal disease of the aortic bifurcation is changing. Standard treatment of complex aortic bifurcation disease, which is open surgery is extended by the possibilities of endoluminal methods. Due to improvements in current endoluminal systems and development of new techniques, the importance of endoluminal therapy will further increase.

PRACTICAL RECOMMENDATIONS

Good quality of the preinterventional CTA is important for planning the intervention. In order for a radiologist to offer endoluminal therapy, besides knowledge of interventional skills a close cooperation with clinical colleagues, in particular vascular surgeons is mandatory.

Prognostic value of tissue factor in patients with abdominal aortic and iliac arterial aneurysms - preliminary study

INTRODUCTION

The decision on the time and choice of strategy of treatment of abdominal aortic aneurysm must be especially carefully balanced. The aim of the study was to evaluate the tissue factor (TF) plasma level as a potential factor useful in anticipation of abdominal aortic aneurysm and/or iliac arterial aneurysm via comparison of plasma TF level in patients with ruptured and non-ruptured aneurysms.

MATERIAL AND METHODS

The study included 33 patients with aneurysm (17 operated on electively because of non-ruptured aneurysm and 16 operated on emergently due to ruptured aneurysm), 33 claudicant patients with atherosclerosis of the abdominal aorta and iliac arteries with normal diameter of arteries, and 30 healthy controls. Plasma TF level was assessed by ELISA method using the IMUBIND Tissue Factor ELISA Kit (American Diagnostica Inc.).

RESULTS

The study showed an increased TF level in patients with aneurysm (134 ±54 pg/ml) and in patients with atherosclerosis without concomitant aneurysm (91 ±30 pg/ml) in comparison with the control group (62 ±20 pg/ml), respectively p < 0.001 and p = 0.008. A significantly higher TF plasma level was observed in patients with ruptured abdominal aortic aneurysms (160 ±57 pg/ml) as compared to patients with non-ruptured aortic aneurysms (109 ±39 pg/ml) or peripheral arterial occlusive disease (91 ±30 pg/ml), respectively p < 0.001 and p < 0.001. The difference in TF level between the group with non-ruptured aortic aneurysms (109 ±39 pg/ml) and the patients with atherosclerosis without aneurysm (91 ±30 pg/ml) was not statistically significant.

CONCLUSIONS

No difference in TF level between patients with non-ruptured AAA/IAA and patients with aortic and iliac atherosclerosis without aneurysm indicates that an increased TF plasma level is not specific for any of the above-mentioned vascular pathologies.

Endovascular management of ruptured common iliac mycotic aneurysm in an HIV-positive patient

Isolated iliac artery aneurysms are a rare entity. The majority of cases are asymptomatic and often escape detection. Mortality rates after sudden rupture and emergent surgery for iliac artery aneurysm are very high. We report a case of a 56-year-old man who presented with right hip pain masquerading as septic arthritis or psoas abscess. CT showed ruptured right common iliac artery aneurysm with extensive active extravasation into psoas with a retroperitoneal haematoma. Aneurysm was repaired using an endovascular technique. Postoperative recovery was eventful with the patient experiencing severe back pain radiating down the leg accompanied with fever. CT showed persistent, right iliopsoas haematoma and pelvic haematoma with secondary hydronephrosis. Viral screen for hepatitis B, C and HIV returned positive. The patient was started on intravenous meropenem. Fever and pain settled. Repeated CT scan showed decrease in retroperitoneal pelvic haematoma.

Internal iliac aneurysm presenting with lower back pain, sciatica and foot drop

Internal iliac aneurysms are usually silent and are identified as an incidental finding on a radiological investigation for an unrelated condition, unless catastrophic bleeding occurs. We present the first case of a middle-aged man with a large internal iliac aneurysm presenting with a foot drop and sciatic nerve pain. The endovascular management is discussed.

Aneurysm-osteoarthritis syndrome with visceral and iliac artery aneurysms

OBJECTIVE

Aneurysms-osteoarthritis syndrome (AOS), caused by SMAD3 mutations, is a recently described autosomal-dominant syndrome characterized by arterial aneurysms, tortuosity, and aortic dissections in combination with osteoarthritis. Our objective was to evaluate the AOS-related vascular consequences in the visceral and iliac arteries and raise awareness for this aggressive syndrome among vascular specialists.

METHODS

All AOS patients were monitored regularly according to our clinical AOS protocol. The study included those with one or more visceral aneurysms or tortuosity, or both. Clinical and surgical data were obtained from record abstraction.

RESULTS

The study included 17 AOS patients (47% men) aged 47±13 years. A total of 73 aneurysms were encountered, of which 46 were located in the abdomen. The common iliac artery was most commonly affected (37%), followed by the superior mesenteric artery (15%), celiac trunk (11%), and splenic artery (9%). Rapid aneurysm growth≤1 year was found in three arteries (gastric, hepatic, and vertebral artery). Furthermore, arterial tortuosity was noted in 94% of patients. Four patients underwent six elective (endo) vascular interventions for aneurysms in the iliac, hepatic, gastric, or splenic artery, without major perioperative or postoperative complications.

CONCLUSIONS

AOS predisposes patients to widespread visceral and iliac artery aneurysms and extreme arterial tortuosity. Early elective aneurysm repair should be considered because the risk of aneurysm rupture is estimated to be very high and elective (endo) vascular interventions were not complicated by fragility of arterial tissue. Given the aggressive behavior of AOS, it is of utmost importance that vascular specialists are aware of this new syndrome.

Using the Multilayer Stent as a Supplement to EVAR in Combined Abdominal Aortic Aneurysm and Iliac Artery Aneurysm With Inadequate Distal Landing Zone—A Case Report

Combined abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA) is a common condition. The recently approved Cardiatis Multilayer stent (Cardiatis, Isnes, Belgium) is an innovative stent system for peripheral aneurysm management that has been applied in several clinical cases. After deployment, the unique stent design reduces mean velocity and vorticity within the aneurysm sac, causing thrombus formation and thus exclusion of the aneurysm while the vessels branching from the aneurysm remain patent. We describe a case of combined AAA and IAA with successful endovascular aneurysm repair of the AAA and treatment of the internal iliac artery with the Cardiatis Multilayer stent at 12 months of follow-up.

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).

Surgical repair for abdominal aortic aneurysm concomitant with iliac arterial disease using InterGard™ Quadrifurcated

InterGard™ Quadrifurcated [InterVascular S.A. (MAQUET Cardiovascular), La Ciotat, France], a knitted quadrifurcated prosthetic graft, is useful to simplify the procedures for patients with abdominal aortic aneurysm concomitant with iliac arterial disease. From March 2008 to April 2010, 59 patients underwent abdominal aortic aneurysm repair in our department. InterGard™ Quadrifurcated was used in 22 patients (37.3%). All patients were male with a mean age of 72.1 ± 12.1 years (range from 45 to 90 years). Four were emergency cases. Nineteen patients had common iliac arterial lesions, and 19 patients had internal iliac arterial lesions. In addition to abdominal aortic aneurysm repair, reconstruction of bilateral internal iliac arteries was performed in 4 patients, reconstruction of unilateral internal iliac artery in 15 (right 6, left 9), and internal mesenteric artery in 13. There was one hospital death due to nonocclusive mesenteric infarction. There were two complications, which were intestinal perforation and intestinal obstruction. All of these three cases were emergency cases. Computed tomography scan 1 week after operation showed that all reconstructed grafts were patent. Although patients with abdominal aortic aneurysm concomitant with iliac arterial disease had many preoperative comorbidities, surgical results with InterGard™ Quadrifurcated were satisfactory. It is useful to simplify the procedures for these patients.

Surgical Repair of Arteriovenous Fistula Associated with Iinfrarenal Aorto-iliac Aneurysm: Report of Two Contrasting Cases

We present two cases of arteriovenous fistulas associated with aneurysms of the infrarenal aorta or common iliac artery. A definitive diagnosis is sometimes difficult given the varied and unclear presentation. However, with the correct preoperative diagnosis, mortality can be reduced. Both cases, being reported here, were diagnosed preoperatively and underwent alternate surgical repairs. One case was treated by aortic exclusion, whereas the second case was treated by primary closure of the fistula. Repair techniques were chosen based on acuity of presentation. Given our experience with these two cases, we conclude that direct closure is possible but dependent on the chronicity of the lesion.

Bilateral retroperitoneal approach to repairing a ruptured right iliac artery aneurysm in a patient who has undergone transperitoneal abdominal surgery

An 84-year-old woman with a history of surgery for cholangiocarcinoma presented to Akita University Hospital with severe right lower abdominal pain, respiratory distress, and hypotension. Computed tomography scanning revealed a ruptured right common iliac artery aneurysm with a massive right retroperitoneal hematoma and a right internal iliac artery aneurysm. Under the bilateral retroperitoneal approach, we preformed an in-situ repair of an aneurysm rupture from the aorta to the left common and right external iliac arteries using a bifurcated knitted Dacron graft, and then we ligated the right internal iliac artery. The postoperative course of the patient was uneventful. The patient was discharged from hospital 52 days after surgery. In conclusion, a bilateral retroperitoneal approach may be a safe and useful strategy for in-situ repair of a right iliac artery aneurysm rupture in patients with peritoneal adhesions after transperitoneal abdominal surgery.

Isolated iliac artery aneurysm rupture presenting as left iliac fossa pain and diarrhoea: A case report

Isolated iliac aneurysm rupture is rare and difficult to diagnose, but needs to be actively considered and excluded. We document the case of a 71 year old female who presented with left iliac fossa pain and diarrhoea and was subsequently found to have a ruptured isolated iliac artery aneurysm. This case demonstrates the importance of urgent diagnostic CT in surgical patients, who present with features of abdominal pain and shock. The key to survival is early diagnosis, appropriate resuscitation and prompt definitive open or endovascular repair.

Right retroperitoneal approach for repair of an abdominal aortic aneurysm involving bilateral iliac arteries in a patient with a left-side stoma after abdominoperineal resection

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Giant iliac artery aneurysm

Isolated iliac artery aneuryms are very rare vascular malformations. They can remain unnoticed for long periods of time because of their deep location in the pelvic region. Most of the patients present to the clinic with rupture of the aneurysm, and thus the condition has a very high mortality rate. We report here the case of an 84-year-old man with giant iliac artery aneuryms who was treated successfully by aneurysmectomy and aortoiliac bypass.

Ruptured aneurysm of the common iliac artery as a cause of unilateral hip pain

Rupture of an aneurysm of the common iliac artery is a rare cause of pain in the hip. We describe an elderly hypertensive patient with an aneurysmal rupture of the left common iliac artery who presented with unilateral hip pain masquerading as septic arthritis.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.

Percutaneous access with closure devices and iliac extension limbs allows safe repair of common iliac artery aneurysm repair as an outpatient procedure

The true benefits of endovascular therapy will be realized when treatment for common vascular conditions can be performed effectively and safely, with minimal morbidity and in a cost-effective manner. We describe three cases of common iliac artery aneurysm repair performed as an outpatient procedure without problems. This was done in a cost-effective manner and with a high degree of patient satisfaction.

Endovascular treatment of a ruptured iliac aneurysm previously excluded

We report a case of an isolated ruptured iliac artery aneurysm that had previously been treated, 25 months before, with iliac endovascular exclusion. Urgent computed tomographic (CT) scan showed the retroperitoneal hematoma and a type IA endoleak. On an emergency basis, at the operating room, an aortouni-iliac graft and femorofemoral crossover bypass were performed, successfully. This is a very rare but serious complication and requires careful indication and close follow-up with CT. In isolated common iliac artery aneurysms, the common iliac artery and distal aorta may tend to enlarge with failure of the endograft proximal attachment site and migration, thus leading to a late aneurysm rupture. A safe length and width, especially of the proximal sealing zone, should be accurately defined and closely followed up, or otherwise complete exclusion of the aortoiliac arteries should be considered.

Durability of endovascular infrarenal aneurysm repair: when does late failure occur and why?

The first commercially available stent grafts were unable to withstand the hemodynamic forces of the vascular environment. The past 15 years have seen a gradual improvement in long-term stent graft performance as designs evolved through the elimination of features associated with late failure and the replication of features associated with durable success. Clinical experience provides the following principles on which to base device design and implantation techniques. Few patients have an adequate length of non-dilated aorta distal to the aneurysm to allow implantation of an aorto-aortic stent graft; bifurcated stent grafts are usually required for AAA repair. Friction, column strength and tissue ingrowth do not prevent migration of the stent graft from its attachment within the neck into the aneurysm; some form of active fixation is required, usually in the form of barbs. Any movement between the apex of a stent and the overlying graft material will erode the fabric; stents and grafts need to move as a single unit. Nitinol is versatile, but fragile; Nitinol components must be polished to eliminate all surface irregularities and they cannot be subjected to compression loading, or excessive pulsatile movement. The neck of an aneurysm is unstable; it will dilate unless protected by a securely fixed, non-compliant stent graft. The aneurysm does not heal; freedom from risk of rupture depends on durable depressurization of the sac. The sole objective of image-based follow-up is the early detection, and catheter-based correction, of device failure. Once any given design has been in use long enough to identify its failure modes, the frequency of follow-up studies can be adjusted accordingly. However, it takes a long time to identify all the potential forms of late failure, and pre-clinical testing remains an imprecise science. New, or recently modified, devices cannot necessarily be assumed to be as durable as their predecessors.

Endovascular approach for isolated common iliac aneurysm and severe kyphoscoliosis

We report the case of a 72-year-old patient presenting with an isolated common iliac aneurysm with occlusion of contralateral common iliac artery and severe kyphoscoliosis. Because of high risk for open surgery due to chronic obstructive pulmonary disease, this patient was treated with an endovascular approach using an aortomonoiliac stent graft, followed by a femoro-femoral crossover bypass. This report illustrates the usefulness of a minimally invasive approach, and feasibility even for patients with difficult anatomy.

Endovascular treatment of iliac aneurysm: Concurrent comparison of side branch endograft versus hypogastric exclusion

OBJECTIVE

To analyze early and mid-term outcome of endovascular treatment in patients with iliac aneurysms, comparing the results of hypogastric revascularization by branch endografting with those of hypogastric occlusion.

METHODS

Consecutive patients with iliac aneurysms receiving side branch endograft (Group I) were compared with those receiving endograft with hypogastric exclusion (Group II) during the interval from January 2000 to May 2008. Procedural details and outcomes were prospectively collected and were analyzed at one year to avoid mismatch in follow-up length.

RESULTS

A total of 74 patients (mean age, 75.8 years, 95% males) were treated: 32 in Group I and 42 in Group II. No differences in baseline risk factors and aneurysm diameter (40.2 +/- 7.9 mm in Group I vs. 38.4 +/- 10.8 in Group II) were found. Concurrent treatment of aortic aneurysm was performed in 25/32 (78%) of Group I and 36/42 (86%) of Group II. Fluoro time was 48 minutes (interquartile range [IQR] 31-57) in Group I vs. 31 minutes (IQR 23-38) in Group II (P = .04). The amount of contrast was similar in both Groups: 184 ml (IQR 155-210) in Group I vs. 183 ml (IQR 155-200) in Group II. No intestinal ischemia or deaths occurred. There were no significant differences in failures of hypogastric side branch deployment (2/32) compared with hypogastric coiling (3/42). Limb occlusions all occurring in the external iliac artery side were 2/32 in Group I vs. 3/42 in Group II. Reintervention rates were similar (5/32 vs. 4/42) at one year. Shrinkage of 5 mm or more was detected in 7/23 (30%) of Group I and in 13/37 (34%) of Group II. Iliac endoleak was present in eight patients (19%) in Group II and in one patient in Group I (4%) (P = .1). Similarly, buttock claudication or impotence were more frequent after hypogastric exclusion, recorded in eight patients in Group II and in one patient in Group I (P = .1).

CONCLUSIONS

Endovascular treatment of iliac aneurysm with hypogastric revascularization through side branched endografts is feasible and safe in the mid-term. When compared with hypogastric embolization, this option leads to similar technical success and reintervention rates. Endoleak and buttock claudication occur frequently in patients with iliac aneurysm treated with hypogastric exclusion, while are uncommon in those with hypogastric revascularization. Side branch endografting for iliac aneurysm may be considered a primary choice in younger, active patients with suitable anatomy, but larger studies and longer postoperative observation periods are needed.

Percutaneous common iliac artery aneurysm repair - a case report

Endovascular repair of common iliac artery aneurysms has become the preferred form of treatment, provided the appropriate anatomy for endovascular repair exists. The Zenith abdominal aortic aneurysm graft converter (Cook Medical Inc, USA), by virtue of its design, appears to be the ideal device for such a repair. A case to illustrate the same is presented.

Common iliac artery aneurysms in patients with abdominal aortic aneurysms

OBJECTIVES

To determine the incidence of common iliac artery (CIA) aneurysms in patients with abdominal aortic aneurysms (AAA) and to evaluate the relationship between AAA and CIA diameter.

METHODS

Spiral CT angiography was used to measure the maximum diameters of the abdominal aorta and the common iliac arteries of 215 patients with AAA.

RESULTS

The median CIA diameter was 1.7 cm--significantly greater than the published mean of 1.25 (2 S.D. = 0.85-1.65) cm of an age-matched, non-vascular population. Thirty-four patients (16%) had unilateral and 26 patients (12%) bilateral CIA aneurysms > or = 2.4 cm diameter. Eight-six vessels (20%) were affected. Right CIA diameters were wider than left CIA diameters (p < 0.0001, Wilcoxon matched-pairs signed rank test). The correlation between AAA size and CIA diameter was weak.

CONCLUSIONS

The AAA population has abnormally dilated common iliac arteries. In this population, common iliac artery aneurysms should be defined as those greater than 2.4 cm diameter. 20% of CIAs in patients with AAA are aneurysmal according to this definition.