Need for hypogastric artery preservation in endovascular repair for aorto – Iliac Aneurysms

Abstract

Objective: Effective distal sealing in endovascular aorto-iliac aneurysm repair often requires landing in the external iliac artery, thus questioning the fate of the hypogastric artery circulation. Besides simple embolization to prevent a type 2 endo-leak, several solutions exist for hypogastric flow preservation, each laden with increasing complexity and/or financial burden. The present study evaluated the rationale of hypogastric artery preservation in this clinical setting. Methods: From January 1999 to June 2016, 749 patients underwent endovascular repair of abdominal aortic aneurysm. Among these, 112 with aneurysm involving the iliac vessels required consideration for closing one (95) or both (17) hypogastric arteries. One-hundred and three patients were male and 9 were female. The mean age was 75 (52-88). When only one hypogastric artery (with patency of the contralateral) needed sacrifice, the usual practice has been simple embolization with plugs or coils before the endografting. Nevertheless, 4 patients with unilateral iliac involvement, who had an active lifestyle, received a branched endograft for hypogastric preservation. When landing in the external iliac artery was needed bilaterally, in 16 cases one hypogastric artery was embolized and the other one was preserved with branched endografts (N=11), “double barrel” technique (N=3) or hybrid repair using an open bypass from external to internal iliac artery (N=2); in only one patient a bilateral branched endograft was used to preserve both hypogastrics. Results: Preservation of the hypogastric artery was achieved in 21 out of the 22 target vessels: one patient, who received a bran-ched endograft, experienced immediate occlusion of the hypogastric stent, without any clinical sequalae. In the early postoperative period none of the 112 patients had symptoms of critical gluteal and/or pelvic visceral ischemia. At a mean follow-up of 48 months (1-152), no further procedures were necessary for proximal and/or distal type I endoleak. All the hypogastric arteries but one, in the 20 patients in whom they were preserved, remained patent. Even though 33% of the patients (37 out of 112) reported mild to moderate gluteal claudication during the first 6 months after the procedure, the symptoms improved progressively, and residual complaints were presented at the 1 year visit or later only in 8% of cases. Moreover, no substantial changes in sexual activity were reported in any case. Conclusion: From a cost-effectiveness perspective, adjunctive procedures for monolateral hypogastric artery preservation with contralateral patency are not warranted. These techniques should be reserved for the selected few cases when both hypogastric arteries need to be sacrificed, or when there is a peculiar need for their preservation. Keywords: Aortoiliac aneurysm, Hypogastric artery, Iliac branched device, Endovascular aneurysm repairn