Iliac Aneurysms – Current Treatment StrategiesPatrick Chong

Department of Vascular Surgery,

Frimley Park Hospital NHS Foundation Trust

Surrey Vascular Group Network

South East Coast Vascular Network Inaugural MeetingKent & Canterbury Hospital26th September 2012

The Solitary Iliac artery aneurysm> 50% increase c.f. native iliac artery diameterPrevalence of 2%-6% in autopsy seriesAsymptomaticClinically difficult to detectConsider repair > 3.5cm in good risk patientsRupture is commonElective open repair (11%)Emergency open repair (40-60%)

Iliac artery aneurysms - Aetiology

Degenerative AtherosclerosisInfectionDissectionTraumaFibromuscular DysplasiaMarfans

Iliac artery aneurysms – natural historyAverage rate of expansion: 0.118 +/- 0.017 cm/year

No expansion in 37.5%<3cm: 0.05-0.15cm/year>3cm: 0.25-0.28cm/yearAll IAA between 4 and 4.9cm expanded

Santilli et al. 2000

Internal iliac artery aneurysms -AetiologyProgressive atherosclerosis 80%

Childbirth Trauma 11%Mycotic

Staphylococcus Aureus

Klebsiella spp.Pseudomonas spp.

Salmonella spp.

Previous IR-AAA repairCTDs

Iliac artery aneurysms - complicationsRuptureExtrinsic compression

UrologicalNeuropathyDeep venous

Distal EmbolisationThrombotic occlusionFistula formation

UretericEnteric

Internal iliac artery aneurysmsRare – incidence 0.4% Male : Female ratio 6: 1Mean age at presentation 67.2 years

Ruptured at initial presentation 33-40%Mortality from rupture 31-58%Risk of rupture >3cm 14-31%

“There is no significant correlation between size of internal iliac aneurysm and risk of rupture” r=+0.161 Spearman p=0.279De Donato 2005

The classification of isolated iliac artery aneurysmsUberoi et al. 2011

Endovascular options

Balloon expandable Jostent by JOMED,

Cheshire, UK Advanta by ATRIUM

Medical International

Self-expanding Fluency stent by

BARD Haemobahn by

GORE Viabahn by GORE

TECHNICAL TIPSAntibioticsHeparinPercutaneous or open cut down accessBilateral groin approachLA or Regional or GA10F sheath or larger if using EVAR limbs180mm or 260mm carriage wire

Treatment options

Open repair Bypass Ligation

Endovascular repair

Stent Embolisation Hybrid approaches

EVAR limb stent graft optionsCOOK spiral Z iliac limbs > 10mm landing

vessel 7.5-20mm(outer to outer wall)length 39-12mm10-15% oversize

VASCUTEK Anaconda iliac limbs

10-23mm stent diameter 60-140mm stent length

>25mm proximal>20mm distal10-15% oversize

Technical and Clinical OutcomesTechnical Success 100%Primary Patency Rates 85-95% at 2 years

86-97% at 3 yearsRe-intervention 0-26%

for stent occlusion

For stent endoleaks

Data is not robust after 2 yearsIs your patient fit for open repair?

Complications of endovascular therapy

Left IIAA found on diagnostic trans-femoral angiography Beware of using TFA findings alone !CT Aortogram showed no proximal neck – coil embolization

Treatment strategy for Type A anatomy

Treatment strategy for Type B anatomy

Large Right CIAA with no distal landing zone proximal to theRight IIA origin.Proximal coiling of Right IIA originRight iliac stent with distal landing zone in the external iliac artery

Endovascular management Type B anatomy

Large Right CIAA with no proximal landing zone Aorto-uni-iliac stent to Left CIAFem-Fem crossover bypass

Treatment strategy for Type C anatomy

Treatment strategy for Type D anatomy

Treatment strategy for Type E anatomy

Embolisation tipsContralateral approach / Ansel crossover sheath (COOK) / Terumo hydrophilic wireAmplatzer vascular plugsCoilsGlueThrombinOnyx

Endovascular embolisation of IIA – when is it not required?

Landing zone in distal CIA availableOccluded IIAHigh grade stenosis of IIA origin

Buttock claudication reported in up to 23%Persistent symptoms in 1 in 6 up to 2 years

SummaryRupture risk < 3cm low >5cm

significant

Surveillance <3cm yearly 3.5-4.0 cm 6 months

Consider repair when >4cm or symptomatic

Open repair may be better in patients with compressive symptoms

Endovascular therapy may be safer in co-morbid patients

Further need for long term durability comparison of open vs. endovascular repair