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

Ruptured Complex Aortoiliac Aneurysm in an Elderly Patient With a Kidney Transplant Presenting With Sciatica

Background: Common iliac artery aneurysms are uncommon, with an estimated incidence of less than 0.01% in adults and accounting for only 1% of all intra-abdominal aneurysms. While the risk of rupture is approximately 5%, it increases significantly to 29% once the aneurysm reaches 4 cm. Similarly to abdominal aortic aneurysms, common iliac artery aneurysms often develop silently, remaining asymptomatic in about 70% of cases. This report describes the treatment of a patient with a kidney transplant who underwent endovascular repair of a ruptured left common iliac artery aneurysm with a concomitant abdominal aortic aneurysm and a focal aneurysm of the right renal artery origin. Case Description: A 78-year-old male patient with a kidney transplant presented with left sciatica symptoms and was found to have a contained rupture of a 10 x 7 cm left common iliac artery aneurysm with a concomitant 8 cm abdominal aortic aneurysm and a focal 1.8 cm aneurysm of the right renal artery origin. He underwent an endovascular aneurysm repair with an Aorto-Uni-iliac stent graft and a concomitant right-to-left femoral-femoral bypass using 8 mm ringed PTFE graft and ligation of left external iliac artery to prevent retrograde flow into the left common iliac artery aneurysm. At 3-year follow-up, patient remains stable with a functioning kidney transplant and excluded aneurysms with no evidence of endoleak. Conclusion: This report describes the endovascular repair of a ruptured left common iliac artery aneurysm conducted under local anesthesia in a patient with a renal transplant and complex aneurysm anatomy. The calcification pattern observed on a non-contrast CT scan was effectively used for surgical planning, leading to a successful aneurysm repair while preserving kidney transplant function.

Factors influencing stent graft occlusion in endovascular repair of internal iliac artery aneurysms

OBJECTIVE

This study aimed to evaluate technical factors influencing stent graft occlusion following endovascular repair of internal iliac artery aneurysms (IIAAs), with a specific focus on the longitudinal length of unsupported stent graft segments and connecting stent grafts.

METHODS

A retrospective single-center analysis was performed on 61 IIAAs treated with endovascular techniques between 2010 and 2022. Anatomical and technical factors, including the unsupported stent graft length within the aneurysm sac (Distance A) and the length of the distal sealing zone (Distance B), were assessed. Statistical analyses were conducted to identify factors associated with stent graft occlusion, type Ib endoleaks, and clinical outcomes.

RESULTS

The primary technical success rate was 90.2%, with a stent graft occlusion rate of 23% documented over a mean follow-up period of 25.7 months. A longer unsupported stent graft length (Distance A) was significantly associated with increased risk of occlusion (53.7 vs 37.0 mm in nonoccluded cases; P = .017). Occlusion rates were also higher in cases with a greater number of connecting stent grafts used to extend the iliac branched device to healthy vessel segments (P = .015). Type Ib endoleaks occurred in 6.6% of cases and were significantly associated with shorter distal sealing zones (≤15 mm; odds ratio, 18.0). Despite these technical challenges, clinical success was achieved in 83.3% over the follow-up period, with low rates of ischemic complications. Buttock claudication occurred in 12.9% of cases, and erectile dysfunction was reported in one patient.

CONCLUSIONS

Endovascular repair of IIAAs is effective and provides a viable option for patients unfit for open surgery. However, it carries risks of stent graft occlusion and endoleaks, particularly when the unsupported stent graft length is extended or when multiple connecting stents are used. Optimizing graft configurations and minimizing unsupported segments may reduce occlusion risks. Furthermore, ensuring an adequate distal sealing zone length is critical to minimizing the occurrence of type Ib endoleaks. These findings highlight the importance of careful procedural planning and technical considerations to improve long-term outcomes and enhance durability in endovascular management of IIAAs.

Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone

BACKGROUND

Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting.

METHODS

This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1 cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon.

RESULTS

Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28 min; the median fluoroscopy time was 9 min and a median 70 mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1 year.

DISCUSSION

Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10 mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Endovascular Treatment versus Open Surgical Repair for Isolated Iliac Artery Aneurysms

Purpose

Endovascular treatment (EVT) has been shown to be effective and safe for isolated iliac artery aneurysms (IAAs). However, concerns remain regarding the lack of consideration to recent advances in perioperative care and surgical techniques, as well as a significant number of re-interventions with EVT. This study compares the outcomes of open surgical repair (OSR) and EVT using recent clinical data.

Materials and Methods

This retrospective, single-center study included patients who underwent OSR or EVT for isolated degenerative IAAs between January 2007 and December 2018. Primary outcomes were procedure time, number of transfusions during admission, length of hospital stay, complications, and number of preserved internal iliac arteries. Secondary outcomes included all-cause and aneurysm-related mortality, and re-intervention rates.

Results

Fifty-eight consecutive patients underwent treatment for isolated IAAs (25 underwent OSR and 33 underwent EVT), with a median follow-up of 75 months (range: 39-133 months). Baseline characteristics were similar between the groups, except for a lower mean age in the OSR group than in the EVT group (66.0±8.2 vs. 73.1±8.6, P=0.003). Both groups had a mild risk of comorbidity severity score. Early complications (within 30 days of the procedure) occurred more frequently in the OSR group, though not statistically significant (24.0% vs. 6.1%, P=0.07). Late complications, including sac expansion and thrombotic occlusion, were significantly more common in the EVT group (15.2% vs. 0%, P=0.04). Re-intervention rate was higher in the EVT group but not statistically significant (9.1% vs. 4.0%, P=0.44). No significant differences were observed in major adverse cardiovascular events and mortality between the groups (P=0.66 and P=0.27), and there were no aneurysm-related deaths.

Conclusion

For patients with mild risk factors, EVT does not offer a survival or re-intervention advantages over OSR in the treatment of isolated IAAs. However, EVT is associated with an increased risk of late complications. Although larger randomized studies are necessary, OSR may be considered the first-line treatment for isolated IAAs in younger and mild-risk patients.

Incidental diagnosis of bilateral common iliac artery aneurysms: a case report and comprehensive literature review

Introduction and importance

Aneurysms are dilatations of arteries, with abdominal aortic ectasias (AAE) considered precursors to abdominal aortic aneurysms (AAA). Iliac artery aneurysms (IAAs), often accompanying AAA, present a serious risk, particularly due to rupture. Here, the authors present a case highlighting the importance of recognizing and managing isolated bilateral common iliac artery aneurysms (CIAAs).

Case presentation

A 66-year-old male presented following a road traffic accident (RTA) with ankle and leg pain. Examination revealed tenderness in the leg, mild right flank tenderness, and a history of mild pelvic pain. Biochemical studies showed deranged glucose and lipid levels. Imaging revealed large CIAAs, prompting surgical intervention. The patient's fracture was also managed accordingly.

Clinical discussion

CIAAs are rare but serious, typically occurring in elderly males with risk factors including advanced age, male sex, smoking, and hypertension, while diabetes and hyperlipidemia may exert protective effects. While often asymptomatic, they can lead to complications such as thrombosis or rupture. Diagnosis relies on imaging, and intervention is recommended for larger or symptomatic aneurysms.

Conclusion

It's crucial to consider CIAAs in high-risk individuals and recognize the significance of early detection and intervention to prevent potentially life-threatening complications. Prompt management, either through open surgical repair or endovascular options, is crucial for improving patient outcomes.

A hybrid approach to complex bilateral common iliac artery and internal iliac artery aneurysm repair

A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, with bilateral stent grafts deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. One week later, an open infrarenal aorto-bi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion.

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.

[Step-by-step endovascular repair for thoracoabdominal aortic aneurysm]

OBJECTIVE

To demonstrate successful treatment of a patient with aneurysmal lesions of several aortic segments.

MATERIAL AND METHODS

A patient with myelodysplastic syndrome and pancytopenia underwent endovascular repair for abdominal aortic aneurysm. Aneurysm of common iliac artery and borderline thoracic aortic aneurysm occurred 2 years after surgery. For this reason, the patient underwent repeated surgery with implantation of a modified iliac bifurcation component with favorable immediate result. The patient was discharged with recommendations for further follow-up. However, repeated CT aortography after a year revealed type 1A endoleak and enlargement of thoracic aortic aneurysm. Considering aortic anatomy and comorbidities, the aortic team preferred endovascular multilevel aortic reconstruction.

RESULTS

Stenting for exclusion of type 1A endoleak was impossible. Thus, the patient underwent endovascular thoracoabdominal aortic repair with T-branch device while maintaining blood flow through visceral arteries. The stent graft previously implanted in abdominal position was connected to the T-branch using a physician-modified PTFE stent graft. To seal the system, additional iliac components were simultaneously implanted into the modified stent graft. The last ones were distally landed in iliac stent grafts installed after primary surgery. Stenting of descending aorta was additionally performed.

CONCLUSIONS

Complex intervention allowed reconstruction of the entire aorta in a patient with hematopoietic abnormalities. Currently, such treatment tactics can be used as an alternative to total open surgical approach in comorbid patients.

Spontaneous Iliac Arteriovenous Fistula Leading to High-Output Heart Failure and Cardiac Arrest

We report a case of a 70-year-old male who complained to family members of the sudden onset of groin pain. He then collapsed, and emergency medical services were called. The patient arrived at the ED with a return of spontaneous circulation after cardiac arrest. The patient was diagnosed with a spontaneous iliac arteriovenous (AV) fistula secondary to aneurysmal rupture. This is a rare but potentially life-threatening condition that can result in high-output heart failure and, as described here, cardiac arrest. The differential diagnosis of groin pain is vast, but in the setting of cardiac arrest, vascular causes must be considered. Treatment is most often operative intervention, as was the case with the patient presented. It is predictable that as the population ages and invasive vascular surgeries become more common, the incidence of iliac AV fistulas will increase, resulting in more presentations of high-output heart failure or cardiac arrest in the emergency department.

A hybrid approach to previously excluded, expanding internal iliac artery aneurysms

Previously excluded internal iliac artery (IIA) aneurysms can continue to expand and pose a risk of rupture. In this case series, we present three patients with previously excluded, expanding IIA aneurysms after endovascular stent coverage or open surgical ligation of the proximal IIA. We describe a hybrid approach to treat these patients safely and effectively.

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.

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 repair for iliac artery aneurysms

Introduction

This study aimed to retrospectively determine the association between aortic dilatation and common iliac artery neck size.

Methods

Consecutive patients who had undergone elective endovascular aneurysm repair for iliac artery aneurysms (IAAs) from January 2009 to December 2017 were evaluated.

Results

Aneurysm dilatations >3 mm were observed in five cases; two cases were LAND+ and three cases were LAND-. Radiological analysis revealed that type 1 and type 2 endoleaks caused dilatations in all cases. In LAND+ cases, endoleaks occurred due to blood inflow from the distal side of the aneurysm due to coil embolization failure, whereas in LAND- cases, endoleaks occurred due to retrograde inflow from the distal side of the internal iliac artery (IIA) and antegrade inflow from the lumbar artery. Decreased IAA diameters were significantly more common in the LAND+ group than in the LAND- group.

Discussion

Endoleaks are the major cause of postoperative dilatation in IAA. The neck size of the common iliac artery was determined to be a crucial factor contributing to postoperative dilation of IAA. Radiological analysis revealed that the endoleaks in the IIA and lumbar artery were responsible for dilatation in all cases.

Conclusion

When the portion of the common iliac artery from the terminal aorta to the IAA was <16 mm in diameter, postoperative aneurysms decreased.

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.

Differential Diagnosis of Multiple Systemic Aneurysms

Atherosclerosis and systemic hypertension are the most common pathogeneses of solitary acquired arterial aneurysms. The rare occurrence of multiple synchronous or metachronous arterial aneurysms requires considering alternative underlying causes. We present the unusual case of a male patient who sequentially developed multiple co-existing arterial aneurysms between the ages of 51 and 59. The sites of involvement included high-pressure systemic arteries and low-pressure pulmonary arteries. We discuss the broad differential diagnosis that includes heritable and non-inheritable etiologies. A keen clinical awareness of this broader array of arterial aneurysms is essential for accurate early diagnosis and proper management.

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.

A distinguished case of a spontaneously dissecting Left Common Iliac Artery Aneurysm, associated with an Elastinopathy, in a healthy 36-year-old male, successfully treated with open surgical repair - A Case Report

INTRODUCTION AND IMPORTANCE

Elastin is a major protein of the Extracellular Matrix (ECM), essential in providing elasticity to the vascular wall, which enables blood vessels to reversibly expand and contract. Several inherited or acquired etiologies, such as elastinopathies and fibrillinopathies negatively impact the objective of the Extracellular Matrix via compromising the Elastin fibers in the Cardiovascular System (CVS) and the skin. Such compromises will have devastating ramifications through the increase in vascular wall stiffness and the inability to properly dissipate energy. This impact on the vascular wall will contribute to the development of arterial aneurysms and dissections.

CASE PRESENTATION

Our case is of a 36-year-old previously healthy male patient who presented with an acute onset of left lower limb pain associated with cold sensation two days prior to admission. Radiology demonstrated a dissecting aneurysm in the left Common Iliac Artery.

CLINICAL DISCUSSION

The patient was surgically treated with an Aorto-bi-Femoral Bypass (ABFB). Histopathological analysis of the excised aortic and iliac specimens revealed no Elastin fibers in the vessel walls.

CONCLUSION

Isolated Iliac aneurysms are a rare entity and are challenging to diagnose preoperatively. In our case, there were no risk factors whatsoever and the patient's history - including family history - was negative. It is vital to establish preoperative diagnostic approaches in such cases and keep them in mind so that we can diminish the morbidity and mortality resultants from the complications.

Bilateral Implantation of Double-Branched Iliac Branch Devices for Endovascular Repair of Aorto-Bi-Iliac Aneurysm With Concomitant Hypogastric Aneurysms: The Quadruple Branch

PURPOSE

The purpose of this report is to describe the use of a double-branched custom-made iliac branch device (IBD) for the endovascular repair of an aorto-bi-iliac aneurysm with concomitant bilateral hypogastric aneurysms.

TECHNIQUE

A 61-year-old man on peritoneal dialysis underwent a computed tomography (CT) of the infrarenal aorta before planned kidney transplantation. The CT showed an asymptomatic aorto-bi-iliac aneurysm of 54 mm involving the hypogastric artery (HA) bilaterally (right HA 31 mm; left HA 40 mm). The treatment consisted of an endovascular aortic repair (EVAR) and the bilateral implantation of custom-manufactured IBDs with double inner branches to preserve both superior and inferior gluteal arteries. At 1 year follow-up, the patient remains free of symptoms and the postoperative CT showed a successfully excluded aneurysm with patent bridging stent grafts to all HA branches.

CONCLUSION

The bilateral implantation of double-branched IBDs is a feasible technique. Preservation of both hypogastric arteries and its branches can be achieved with this technique and therefore decrease the risk of buttock claudication and other ischemic complications.

[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.

Bilateral Deep Vein Thrombosis and Pulmonary Embolism Due to Right Common Iliac Artery Aneurysm with a Contained Rupture

Venous thromboembolism (comprising deep venous thrombosis and/or pulmonary embolism) is a common disease, often of multifactorial cause. Focal iliac artery aneurysms are relatively rare, and only a few reports exist in the literature describing patients with venous thromboembolism resulting from venous floe disruption due to iliac artery aneurysm. Thus, we report a case of a 65-year-old male presenting with pulmonary embolism and bilateral deep vein thrombosis associated with a contained rupture of the right common iliac artery aneurysm.

Endovascular repair of an ilio-iliac arteriovenous fistula following rupture of common iliac artery aneurysm with an aortic extension cuff in common iliac vein: A case report

RATIONALE

Common iliac artery aneurysm (CIAA) is complicated by ilio-iliac arteriovenous fistulas (IIAVF), which is rare but fatal and require prompt diagnosis and appropriate treatment. As open repair is associated with high morbidity and mortality, endovascular therapy is considered appropriate for treating an IIAVF.

PATIENT CONCERNS

A 76-year-old male patient who developed an IIAVF as a complication of ruptured CIAA, requiring immediate surgical repair presented to the hospital with hemodynamic instability.

DIAGNOSIS

Computed tomography angiography and conventional angiography revealed an IIAVF.

INTERVENTION

Endovascular therapy was selected to reduce the risk of morbidity and mortality. As the angiogram after the first endovascular aneurysm repair with stent-grafting showed contrast medium filling in the aneurysm sac, right common iliac vein, and the inferior vena cava, an aortic extension cuff was inserted into the right common iliac vein to close the orifice on the venous side.

OUTCOMES

The right lower leg edema and discomfort were resolved immediately after the procedure, with the vital signs remaining stable. Computed tomography performed 6 months postoperatively showed patent stent-grafts of the artery and vein, with no evidence of IIAVF and endoleak.

LESSONS

IIAVF following CIAA rupture can be repaired successfully by stenting of the common iliac vein with an aortic extension cuff. For successful endovascular repair, the vein side of the fistula tract should be excluded with a stent-graft to block the backflow into the aneurysm sac.

Iliac Artery Aneurysms Expand in Quadratically Proportion to the Diameter

BACKGROUND

Iliac artery aneurysms (IAAs) are life-threatening once ruptured. Although some studies have revealed the pathology of IAAs, clinical information on IAAs is still limited. Moreover, previous studies were conducted in Western countries; thus, we aimed to identify the natural history of iliac artery aneurysms in a Japanese cohort. The purpose of this study was to investigate the IAA expansion rate in a Japanese cohort to consider the management of small IAAs and to identify indications for surgical intervention.

METHODS

Patients with iliac artery aneurysms were retrospectively reviewed. The primary outcome was the expansion rate of IAAs. We also investigated the correlation between expansion rate and patients' characteristics. Natural histories, including surgical interventions and rupture, were also assessed.

RESULTS

The mean expansion rate in our study was 1.59 ± 1.16 mm/year. There was a positive correlation between expansion rate and aneurysm diameter, which was estimated by y = 0.0052 × (X - 23.270)² + 0.0632 × X - 0.0517, where y is the expansion rate, and X is aneurysm diameter. The freedom from surgical intervention rate of IAAs was 85.5% at 1 year, 54.0% at 3 years, and 41.5% at 5 years. No factors, except initial aneurysm diameter, were revealed as independent predictors of surgical intervention. We experienced one ruptured IAA, which showed unexpected rapid growth from 30.1 mm to 56.3 mm over 15 months during conservative management. This case demonstrated that IAAs ≥30 mm should be carefully followed up and considered for surgical intervention.

CONCLUSIONS

We conclude that larger aneurysms have greater expansion rates. Because IAAs ≥30 mm carry a risk of rapid expansion resulting in rupture, careful follow-up, and surgical intervention should be performed if iliac artery aneurysms are ≥30 mm in diameter.

Late Open Repair of a Massive Common Iliac Artery Aneurysm after Endovascular Failure

Giant Common Iliac Artery Aneurysms (CIAA) are an uncommon pathology that may present as a late complication after endovascular aortic repair secondary to aneurysmal degeneration with endoleak. We present an unusual case of a patient presenting 9 years after index endovascular CIAA exclusion with a painless abdominal mass found to be a 20+ cm CIAA secondary to type II endoleak from a recanalized coil embolized hypogastric artery. The patient underwent open aneurysmorrhaphy with ligation of the hypogastric artery.

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.

Endovascular treatment of arteriovenous fistula caused by ruptured iliac aneurysm and type II endoleak

Arteriovenous fistulas (AVFs) caused by an isolated iliac aneurysm rupture and postoperative type II endoleak are rare and life threatening. We report here a case of AVF caused by a ruptured iliac aneurysm and postoperative type II endoleak. The patient was successfully treated by implanting a covered stent to treat the ruptured iliac aneurysm. However, type II endoleak with AVF persisted after the operation and was treated with transiliac vein embolization. The patient recovered uneventfully during the 2-month follow-up period.

Iliac side branch technique for repair of bilateral iliac artery aneurysms associated with a congenital pelvic kidney

Pelvic kidney is a congenital anomaly with few literature reports of concomitant aortoiliac aneurysmal disease. When aneurysm repair is indicated, either open or endovascular, it poses a technical challenge, since kidney preservation is paramount. This paper reports a successful endovascular repair of bilateral common iliac artery aneurysms in a patient with a right congenital pelvic kidney, using iliac side branch technique.

[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.

Concurrent Ilio-Enteric and Ilio-Vesical Fistula From Large Aorto-Iliac Aneurysm

Iliac artery aneurysms (IAA) are associated frequently with abdominal aortic (AAA) and other degenerative large-vessel aneurysms. Concurrent fistulization of the aortoiliac tree into the gastrointestinal tract (GIT) and bladder is exceptionally rare. We herewith report a unique case of concurrent ilio-enteric and ilio-vesical fistula arising from a large aorto-iliac aneurysm.

Statistical techniques for predicting rupture risk in abdominal aortic aneurysms: A contribution based on bootstrap

The morphometry of abdominal aortic aneurysms (AAA) has been recognized as one of the main factors that may predispose them to rupture. The need to quantify the morphometry of AAA on a patient-specific basis constitutes a valuable tool for assisting in rupture risk prediction. Previous results of this research group have determined the correlations between hemodynamic stresses and aneurysm morphometry by means of the Pearson coefficient. The present work aims to find how the AAA morphology correlates with the hemodynamic stresses acting on the arterial wall. To do so, the potential of the bootstrap technique has been explored. Bootstrap works appropriately in applications where few data are available (13 patient-specific AAA models were simulated). The methodology developed can be considered a contribution to predicting the hemodynamic stresses from the size and shape indices. The present work explores the use of a specific statistical technique (the bootstrap technique) to predict, based on morphological correlations, the patient-specific aneurysm rupture risk, provide greater understanding of this complex phenomenon that can bring about improvements in the clinical management of aneurysmatic patients. The results obtained using the bootstrap technique have greater reliability and robustness than those obtained by regression analysis using the Pearson coefficient, thus allowing to obtain more reliable results from the characteristics of the samples used, such as their small size and high variability. Additionally, it could be an indicator that other indices, such as AAA length, deformation rate, saccular index, and asymmetry, are important.

Type A Thoracic Aortic Dissection Following Endovascular Repair of a Common Iliac Artery Aneurysm

We discuss a rare case of acute Type A thoracic aortic dissection (TAAD) following endovascular aneurysm repair (EVAR) of a common iliac artery aneurysm, which likely resulted from complications due to aberrant anatomy. Valve replacement, ascending aortic arch graft, and entry tear suture repair were necessary to contain the TAAD. Postoperative computed tomography with angiography (CTA) demonstrated stable disease, and the patient remained asymptomatic. Open and endovascular repair of the descending abdominal aorta was avoided. Few cases in the literature report TAAD following EVAR. Detection and repair of the entry site was crucial for containing the TAAD.

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.

Long-term fate of aortic branches in patients with aortic dissection

OBJECTIVE

Late morbidity and mortality related to aortic branches in patients with aortic dissection (AD) have not been well described. We investigated the fate of aortic branches in a population cohort of patients with newly diagnosed AD.

METHODS

We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents with a diagnosis of AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging studies were included in the present analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). The secondary outcome was the diameter change in the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify the predictors of branch-related events. Univariate and multivariate linear regression models were used to assess the aortic branch growth rate.

RESULTS

Of 77 total incident AD cases, 58 patients who had survived and had imaging follow-up studies available were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 patients (67%), 6 (10%) of whom had had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) had arisen from the true lumen, 33 (19%) from the false lumen, and 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95% confidence interval [CI], 32%-70%). A total of 31 branch-related events had occurred in 19 patients within 15 years, including 12 interventions (76% freedom; 95% CI, 63%-92%), 10 aneurysms (67% freedom; 95% CI, 50%-90%), 8 cases of malperfusion (76% freedom; 95% CI, 61%-94%), and 1 rupture (94% freedom; 95% CI, 84%-100%). No branch-related deaths had occurred. Type B AD (hazard ratio [HR], 3.5; 95% CI, 1.1-10.8; P = .033), patency of the aortic false lumen (HR, 6.8; 95% CI, 1.1-42.2; P = .038), and malperfusion syndrome at presentation (HR, 6.0; 95% CI, 1.3-28.6; P = .023) were predictors of late aortic branch-related events. The overall growth rate of aortic branches was 1.3 ± 3.0 mm annually. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase.

CONCLUSIONS

In patients with AD, aortic branch involvement was responsible for significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, and malperfusion syndrome at presentation resulted in a greater risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, especially in the case of a patent aortic false lumen or the presence of Marfan syndrome.

[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.

Transvenous endovascular repair of symptomatic type II endoleak following endovascular repair of a ruptured common iliac aneurysm with arteriovenous fistula

Arteriovenous fistula (AVF) is an uncommon presentation of ruptured aortoiliac aneurysm (rAIA). Symptomatic persistence of an AVF fed by a type II endoleak after endovascular aneurysm repair (EVAR) for rAIA is rare, with little in the literature to guide practice. We present a novel transvenous approach to treatment of symptomatic type II endoleak after EVAR for rAIA with AVF. A transvenous approach avoids complex arterial access and the need for stenting in the venous system. This technique should be considered in patients with persistent AVF after EVAR with ongoing symptomatic type II endoleak.

Internal iliac artery revascularisation versus internal iliac artery occlusion for endovascular treatment of aorto-iliac aneurysms

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) is used to treat aorto-iliac and isolated iliac aneurysms in selected patients, and prospective studies have shown advantages compared with open surgical repair, mainly in the first years of follow-up. Although this technique produces good results, anatomic issues (such as common iliac artery ectasia or an aneurysm that involves the iliac bifurcation) can make EVAR more complex and challenging and can lead to an inadequate distal seal zone for the stent-graft. Inadequate distal fixation in the common iliac arteries can lead to a type Ib endoleak. To avoid this complication, one of the most commonly used techniques is unilateral or bilateral internal iliac artery occlusion and extension of the iliac limb stent-graft to the external iliac arteries with or without embolisation of the internal iliac artery. However, this occlusion is not without harm and is associated with ischaemic complications in the pelvic territory such as buttock claudication, sexual dysfunction, ischaemic colitis, gluteal necrosis, and spinal cord injury. New endovascular devices and alternative techniques such as iliac branch devices and the sandwich technique have been described to maintain pelvic perfusion and decrease complications, achieving revascularisation of the internal iliac arteries in patients not suitable for an adequate seal zone in the common iliac arteries. These approaches may also preserve the quality of life of treated individuals and may decrease other serious complications including spinal cord ischaemia, ischaemic colitis, and gluteal necrosis, thereby decreasing the morbidity and mortality of EVAR.

OBJECTIVES

To assess the effects of internal iliac artery revascularisation versus internal iliac artery occlusion during endovascular repair of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation.

SEARCH METHODS

The Cochrane Vascular Information Specialists searched the Cochrane Vascular Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 28 August 2019. The review authors searched Latin American Caribbean Health Sciences Literature (LILACS) and the Indice Bibliográfico Español de Ciencias de la Salud (IBECS) on 28 August 2019 and contacted specialists in the field and manufacturers to identify relevant studies.

SELECTION CRITERIA

We planned to include all randomised controlled trials (RCTs) that compared internal iliac artery revascularisation with internal iliac artery occlusion for patients undergoing endovascular treatment of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions.

MAIN RESULTS

We identified no RCTs that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs that compared internal iliac artery revascularisation versus internal iliac artery occlusion for endovascular treatment of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation. High-quality studies that evaluate the best strategy for managing endovascular repair of aorto-iliac aneurysms with inadequate distal seal zones in the common iliac artery are needed.

Endovascular Therapy for Spontaneous Ilio-Iliac Arteriovenous Fistula Due To Iliac Artery Aneurysm Rupture With Multi-Organ Dysfunction

Iliac artery aneurysms can rarely present with rupture into adjacent iliac vein resulting in arteriovenous fistula leading to acute cardiac failure or multi-organ failure. End-organ damage can be reversed with timely diagnosis and intervention. Endovascular therapy is an attractive option to treat this pathology besides allowing for a quick recovery and mitigating the risk of mortality associated with open surgical treatment options. We report treatment of this pathology with Endovascular repair with preservation of ipsilateral hypogastric artery flow using an iliac branch graft device. The postoperative course was complicated by type 3 endoleak due to the separation of components between iliac branch graft and aortic stent graft with resultant recurrence of the fistula. Additional endovascular techniques, including placement of a venous stent and stent grafts to bridge the components, was used to treat the endoleak. We present this report due to the unique nature of the recurrent arteriovenous fistula, technical complexity, and resultant multi-organ dysfunction.

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

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.

Incidence and management of iliac artery aneurysms associated with endovascular treatment of juxtarenal and thoracoabdominal aortic aneurysms

BACKGROUND

This study reports the clinical impact of iliac artery aneurysms (IAAs) in a population of patients with juxtarenal and thoracoabdominal aortic aneurysms being treated with fenestrated or branched aortic endografts.

METHODS

Data from 364 patients with IAA (33%) were extracted from the 1118 patients treated for juxtarenal or thoracoabdominal aortic aneurysms with a fenestrated or branched aortic endograft in a physician-sponsored investigational device exemption trial (2001-2016). IAAs were defined as ≥21 mm in diameter, as measured by an imaging core laboratory. Outcomes were assessed by univariate and multivariable analysis.

RESULTS

IAAs were unilateral in 219 (60%) and bilateral in 145 (40%) of the 364 patients. Treatment was iliac leg endoprosthesis without coverage of the hypogastric artery (seal distal to the IAA in the common iliac artery), placement of a hypogastric branched endograft in 105 (21%), and hypogastric artery coverage with extension into the external iliac artery in 103 (20%); 67 (13%) were untreated. Procedure duration was longer for those with IAA (5.3 ± 1.79 hours vs 4.6 ± 1.74 hours; P < .001), although hospital stay was not. There was no difference in aneurysm-related mortality and all-cause mortality for patients with unilateral and bilateral IAAs compared with those without an IAA. Treatment of patients with a hypogastric branched endograft had similar all-cause mortality compared with treatment of patients without a hypogastric branched endograft but also with an IAA. Reintervention rates were significantly higher in those with bilateral IAAs compared with no IAA (hazard ratio, 1.886; P < .001). Spinal cord ischemia trended higher in patients with bilateral IAA.

CONCLUSIONS

IAA management at the time of fenestrated or branched endovascular aneurysm repair increases procedure time without increasing hospitalization. The reintervention rate and spinal cord ischemia rate are higher in patients with bilateral IAA compared with those with no IAA.

Growth of common iliac artery aneurysms coexisting with abdominal aortic aneurysms: associated factors and potential role of intraluminal thrombus

BACKGROUND

The factors influencing common iliac artery aneurysm (CIA) growth are not fully known. Intraluminal thrombus (ILT) has been studied as a marker of growth in abdominal aortic aneurysms (AAA), but its role in CIAs is unknown. This study aims to examine the factors associated with growth of CIAs coexistent with AAA using serial cross-sectional imaging (CT and MRI) with multiplanar reconstruction (MPR).

METHODS

Patients with synchronous AAA and CIA observed at contrast-enhanced CT or MRI were included. The maximal diameters of both CIA and AAA were measured using MPR. Correlation of the baseline aneurysm diameter and growth rate between CIA and AAA was evaluated. Multivariate regression analysis was used to investigate the factors associated with CIA growth.

RESULTS

Seventy-five AAA patients (age 74±9 years; all male) with 100 CIAs were followed for an average of 2.2±1.2 years. CIA and AAA growth were positively correlated (r=0.39, P<0.001). Multivariate analysis showed that CIA baseline diameter, AAA baseline diameter, and smoking were positively related to CIA growth. In 2-3 cm CIAs (n=59), ILT tends to be an independent predictor of AAA growth (P=0.076), and CIAs with ILT grow at more than twice the rate of CIAs without ILT (1.7 vs. 0.8 mm/year, P=0.036), despite similar baseline diameters.

CONCLUSIONS

CIA baseline diameter, coexisting AAA baseline diameter, and smoking are associated with CIA growth. In CIAs measuring 2-3 cm, the presence of ILT is associated with faster growth, and should be taken into account when determining surveillance intervals and timing of intervention for patients being considered for AAA repair.

Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone

BACKGROUND

Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure.

METHODS

We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA.

RESULTS

Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P = 0.02).

CONCLUSIONS

Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.

[The Treatment of Aneurysms of the Extremities Arteries - a Systematic Overview - New Therapies for Isolated Iliac Artery Aneurysm Employing a New Classification]

Aneurysms of arteries in the extremities have a low incidence and are often manifest through complications. The most serious complications are rupture and extremity-threatening ischemia. Both usually lead to the diagnosis. Absolute indications for therapy are symptomatic aneurysms and asymptomatic aneurysms of 2 cm diameter or more. The extrailiacal gold standard is interponat or bypass with venous graft material. Endovascular methods are reserved for inoperable patients and clinical decisions on special cases. In contrast, complex endovascular techniques have been established in isolated iliac aneurysms and have significantly improved treatment options. Their implementation is bound to the existence of a suitable landing zone. This is the basis for a new classification of isolated iliac artery aneurysm. With the help of morphological subtypes, this classification permits standardised procedure planning for perfusion preservation of the internal iliac artery. The present article gives an overview of the current treatment strategy for aneurysms of extremities arteries. Similarities and regional differences in therapy are discussed.

Common iliac artery aneurysm as a cause of massive hematuria post TURBT. Case report

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Bleeding after transurethral resection of bladder tumor is usually minimal and resolve spontaneously within days or weeks.

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Common iliac artery aneurysm is a rare but can cause severe hematuria after cystoscopy with minimal manipulation.

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Endovascular graft repair is minimally invasive procedure that showed excellent results in treatment of common iliac artery aneurysm.

Introduction

Transurethral resection of bladder tumor (TURBT) is an outpatient simple procedure that aims to remove bladder masses. Bleeding post TURBT is usually minimal and resolve completely within days or weeks. Massive bleeding after TURBT for small bladder masses is unusual. In this article we will report a case of unexpected massive hematuria that occurred after simple TURBT.

Presentation of case

A 69 patient who presented to our clinic complaining of intermittent painless gross hematuria. Ultrasound showed 1 cm bladder mass for which TURBT was done. On the 3rd post operative day the patient presented to ER complaining of massive hematuria and drop in hemoglobin. CT scan showed large left common iliac artery aneurysm which was managed using Endovascular graft repair (EVAR).

Discussion

Common iliac artery aneurysm is rare entity. Usually it is asymptomatic. However if it is large it can compress the perivesical vessels causing engorgement of these vessels that can manifest as massive hematuria after minimal endoscopic manipulation of the bladder.

Conclusion

Massive hematuria after simple TURBT is unusual for urologists. If it happens it may indicates iliac aneurysm or vascular malformation.