Preliminary Embolization of the Hypogastric Artery to Expand the Applicability of Endovascular Aneurysm Repair

Abstract

To evaluate the efficacy and safety of preliminary hypogastric artery (HA) embolization prior to endovascular aneurysm repair (EVAR). A retrospective review was conducted of all 101 consecutive patients (91 men; mean age 73.4 ± 8.7 years) who underwent preliminary embolization of 133 HAs ∼4 to 6 weeks prior to EVAR from January 2005 to August 2009. Fourteen patients with 19 HAs were treated using coils, while 87 patients were treated with Amplatzer Vascular Plugs (AVP) in 114 HAs. All the patients were evaluated before discharge; at 1, 3, and 6 months; and annually thereafter to evaluate the clinical symptoms, potential endoleaks, and the aneurysm size. In the coil group, complete occlusion was achieved in 16 (84.2%) of 19 procedures. There were no acute pelvic ischemic symptoms after HA embolization or EVAR. Five (35.7%) patients had buttock claudication and 2 (16.7%) of 12 men experienced new erectile dysfunction after embolization. At a mean 42.2-month follow-up (range 14-58), 3 (21.4%) patients had a type II leak via retrograde flow in the HA without aneurysm growth and were under observation. In the AVP group, all 114 HAs in 87 patients were successfully occluded; there was no device dislodgment or acute pelvic or limb ischemia observed. Buttock claudication and new sexual dysfunction developed in 12 (13.8%) patients and 4 (5.1%) of 79 men after the procedure, respectively. During a mean 26.4-month follow-up (range 4-54), 2 (2.3%) patients developed distal type I endoleaks after EVAR, but angiography confirmed that neither of the endoleaks was related to the vessel embolized with the AVP. Comparing the outcomes of the treatment groups, the AVP was placed with fewer intraoperative complications (p = 0.013) and more complete occlusion (p = 0.01) than coil embolization. The rate of buttock claudication was lower in the AVP group (p = 0.042). Hypogastric artery embolization prior to EVAR is safe and effective. In our experience, the AVP affords easier and more precise placement and provides more complete occlusion, with fewer intraoperative and postoperative ischemic complications than coil embolization.