Reply to “A Word of Caution Before Killing Hypogastric Arteries”

Abstract

In response to the letter by Dalainas [1], we broadly agree with the importance of preservation of the collateral circulation in patients undergoing bilateral internal iliac embolization prior to endovascular aneurysm repair (EVAR). Yano et al. [2] identified two main factors in patients developing buttock claudication: stenosis of the contralateral internal iliac artery (IIA) with nonopacification of at least three of the six branches of the IIA and stenosis or occlusion of the circumflex femoral arteries. We [3] found that proximal embolization confined to the main trunk of both IIAs resulted in a significant reduction in buttock claudication. However, bowel ischemia appears to be an uncommon complication following IIA embolization and EVAR, with 1 case in Yano’s series of 103 patients [2]. A review of the two largest series of bilateral IIA embolizations [3, 4] shows that there was 1 case of delayed self-limiting colonic ischemia associated with cardiac failure in a total of 71 patients. Similarly, current data suggest that spinal cord ischemia remains an uncommon complication [3, 4]. IIA embolization allows extension of EVAR to patients with complex aorto-iliac aneurysms, and we believe that EVAR has distinct advantages over current alternative treatment options.