Bilateral Common Iliac Aneurysms Research Articles

Internal iliac debranching in combination with abdominal aortic stent graft to treat bilateral common iliac aneurysms

Introduction
 Common iliac artery aneurysms are often diagnosed during routine screening for infrarenal abdominal aortic aneurysms. Preserving the internal iliac artery helps avoid colonic ischemia and buttocks claudication. Hybrid surgery combining internal iliac artery transposition and endovascular treatment is a method with good early and long-term results.
 Methods
 We report of a case of bilateral common iliac artery aneurysm treated by hybrid surgery and endovascular intervention at Dong Nai General Hospital
 Results
 A 69 year-old male, diagnosed with bilateral common iliac artery aneurysm and left internal iliac artery occlusion. Surgical transposition was performed to repimplant the right internal iliac artery into the right external iliac artery, folowed by endovascular treatment, the right branch of the graft was placed at the external iliac artery, the left branch of the graft was placed at the common iliac artery. Postoperative condition was stable, no early complications recorded
 Conclusion
 Hybrid surgery to treat iliac aortic aneurysms and common iliac artery aneurysms has quite good mid- and long-term results. The initial successful implementation of this technique at Dong Nai General Hospital contributes to team development, reduces the load on central hospitals and brings practical benefits to patients.

Hypogastric Preservation Using a Retrograde Endovascular Bypass in a Patient with Ruptured AAA and Concomitant Bilateral Common Iliac Aneurysms: A Feasible Option in the Acute Setting

Preservation of the hypogastric circulation is of major clinical importance in cases of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Pelvic ischemia can be detrimental and significantly increase post-operative morbidity and mortality. However, the application of a side branch device or a bell-bottom graft is not possible in ruptured aortoiliac aneurysms (due to off-the-shelf unavailability and/or prolonged operative time) and in most cases pelvic circulation may have to be sacrificed. We report a case of a rAAA with bilateral common iliac artery (CIA) aneurysms that was successfully repaired with an aorto-uni-iliac (AUI) endograft, a cross-femoral bypass, and an inverted-U shaped contralateral EIA to IIA endovascular bypass. The procedure is described in detail and certain technical points are further discussed. The steps in cases where the aneurysm has ruptured are different compared to elective repairs and vascular surgeons need to be aware of certain pitfalls. This strategy may be feasible in the acute setting and permits preservation of the hypogastric circulation with the combination of standard techniques and grafts that are readily available in most institutions.

A Case of Bilateral Common Iliac Aneurysms Treated by EVAR Using Excluder with the Repositioning Function to Preserve the Inferior Mesenteric Artery

A Case of Bilateral Common Iliac Aneurysms Treated by EVAR Using Excluder with the Repositioning Function to Preserve the Inferior Mesenteric Artery

Hypogastric Preservation Using Retrograde Endovascular Bypass

Maintenance of pelvic circulation has been connected to reduced risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluate the mid-to-late follow-up of a cohort of patients treated using 1 preservation technique, the endovascular external iliac artery (EIA) to internal iliac artery (IIA) bypass. All patients undergoing elective retrograde EIA-IIA endovascular bypass at a single institution were retrospectively reviewed over a 10-year period from 2006 to 2016. Anatomic inclusion criteria were single or bilateral common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle greater than 45°. Procedures were performed using aortouni-iliac (AUI) endografts extended to 1 EIA (with endovascular occlusion of the ipsilateral hypogastric artery), cross-femoral artery bypass, and retrograde placement of 1 of 3 types of covered stent grafts into the contralateral IIA. In the case of patients with prior open repair, AUI placement was not required. Follow-up surveillance included duplex ultrasound 1 and 6months postoperatively and annually thereafter, with computed tomography scan (with selective contrast usage) 1month postoperatively and annually thereafter. Seventeen patients (mean age 70years, 93% male) were treated over the period studied. Most were treated for primary disease (N=11) while the remainder was secondary interventions following open repair (N=4) or endovascular aneurysm repair (N=2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac N=8, left iliac N=9). Retrograde bypasses were performed using Fluency stent graft (N=1), Viabahn stent graft (N=13), or Gore Excluder limbs (N=3). Additional hypogastric embolization with AUI extension to the EIA (for bilateral common iliac aneurysms) was required in 6 patients. Proximal extension requiring snorkel/fenestration was present in 5 patients. Technical success was 100% with mean operative time was 168min (range 50-300min), and 71cc contrast usage (range 30-115cc). Mean preoperative iliac artery aneurysm size was 4.0cm with iliac bifurcation angle 71° (range 51-102°). Median length of stay was 3days (range 1-13). Over mean follow-up of 29.8months, there were no aorta-related mortalities, 1 EIA-IIA bypass occlusion (asymptomatic), and 1 reintervention (for type II endoleak not attributed to the EIA-IIA bypass). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series. Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.

IP089. Options for Preservation of Pelvic Circulation During Endovascular Aortic Aneurysm Repair

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of aortoiliac aneurysmal disease. We evaluated the use of four techniques for preservation of flow to hypogastric arteries. All patients undergoing endovascular aneurysm repair requiring extension into the external iliac artery (and therefore management of the hypogastric artery) at a single institution were reviewed from 2006 to 2016. Choice of preservation vs embolization and preservation technique was at surgeon discretion. Four techniques were used in the series: external-to-internal iliac artery endovascular bypass (EIA-IIA), iliac branch endograft (IBD), kissing iliac stents extended from the gate of a bifurcated endograft (parallel grafts), and double bifurcated main-body graft use. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively and annually thereafter for patients who required cross-femoral bypass (with the EIA-IIA bypass). For the remainder of patients, surveillance computed tomography scan (with selective contrast usage) was done 1 month postoperatively and annually thereafter. Thirty-two patients (mean age, 70 years; 97% male) were treated, preserving 36 hypogastric arteries. Most were treated for primary disease (n = 20), and the remainder was secondary interventions following open repair (n = 4) or endovascular repair (n = 8). Thirty patients had bilateral common iliac aneurysms, one had bilateral hypogastric aneurysms, and the remaining 18 had unilateral common iliac aneurysms. There was no preference for laterality (right, n = 20; left, n = 16). Proximal extension requiring snorkel/fenestration was present in seven patients. Seventeen aneurysms were treated with EIA-IIA bypass, 2 by IBD, 4 with double-bifurcated endografts, and 13 with parallel grafts. Technical success was 100%, with mean operative time 182 minutes and 71 mL contrast usage (range, 30-275 mL). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 22 months, there were no aortic-related mortalities, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, buttock claudication, and paralysis was zero in the series. While it is not yet clear which patients warrant preservation vs embolization, multiple techniques exist for preservation of pelvic circulation during endovascular repair. All four techniques presented appear to offer acceptable success and patency rates, and the optimal technique for each patient is largely a factor of preoperative selection based on anatomy and surgeon experience.

IP043. Hypogastric Preservation Using Retrograde Endovascular Bypass

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass. All patients undergoing retrograde EIA-IIA endovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle >45°. Procedures were performed using aortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, and annually thereafter with computed tomography CT scan (with selective contrast usage) 1 month postoperatively and annually thereafter. Seventeen patients (mean age, 70 years; 93% male) were treated over the period. Most were treated for primary disease (n = 11), while the remainder underwent secondary interventions following open repair (n = 4) or endovascular repair (n = 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac, n = 8; left iliac, n = 9). Retrograde bypasses were performed using Fluency (n = 1), Viabahn (n = 13), or Gore Excluder (n = 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71° (range, 51°-102°). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series. Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.

Preservation of hypogastric flow and control of iliac aneurysm size in the treatment of aortoiliac aneurysms using the Nellix EndoVascular Aneurysm Sealing endograft

The purpose of this study was to determine the long-term effectiveness of endovascular aneurysm sealing (EVAS) in the treatment of complex aortoiliac aneurysms with preservation of hypogastric artery flow. We reviewed all patients with abdominal aortic aneurysms (AAAs) and common iliac aneurysms (CIAs) enrolled and treated in prospective studies of EVAS using the Nellix endograft (Endologix, Irvine, Calif) at two centers from 2008 to 2014. Patients with 1year or more of computed tomography follow-up underwent quantitative morphometric assessment by two independent vascular radiologists blinded to clinical outcome results. Hypogastric patency and CIA diameter changes over time were assessed and compared in three treatment groups: totally excluded CIA, partially excluded CIA, and untreated CIA. Among 125 patients with EVAS, 68 patients (mean age, 75± 8years; 79% men) had both AAA (mean diameter, 55.8± 2.0mm) and CIA (median diameter, 23.4; interquartile range, 21.3-27.0mm), with bilateral CIAs in 33 patients. Treatment of 101 CIAs included complete CIA exclusion in 40 (39.6%), partial CIA exclusion in 33 (32.7%), and no CIA treatment in 28 (27.7%), with successful AAA exclusion in all patients. Internal iliac flow was preserved in all 122 hypogastric arteries that were patent before treatment (14 hypogastric arteries were occluded at baseline). During the 5-year follow-up period (median follow-up, 24.7months; range, 11.5-61.7months), three patients required secondary treatment with hypogastric occlusion and graft extension to the external iliac. Thus, internal iliac flow was maintained in 98% of at-risk hypogastric arteries. There were no aneurysm-related clinical events, except for the three secondary treatments. Totally excluded iliac aneurysms did not change in diameter over time (P= .85), whereas untreated CIAs enlarged at a rate of0.16mm/y (95% confidence interval, 0.09-0.23; P< .0001). Partially excluded CIAs enlarged at a higher rate of 0.59mm/y (95% confidence interval, 0.47-0.71; P< .0001). Enlargement ≥3mm occurred only in partially treated CIAs larger than 3cm. EVAS was effective in treating aortoiliac aneurysms with preservation of internal iliac patency in most cases. Complete CIA exclusion prevented aneurysm enlargement over time, whereas partial exclusion did not prevent continued CIA enlargement, particularly in larger aneurysms.

Alternative Solution for Bilateral Common Iliac Aneurysm in a Patient With Left External Iliac Artery Occlusion

8 Joynt KE, Blumenthal DM, Orav E, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among medicare beneficiaries with acute myocardial infarction. JAMA 2012;308:1460e8. 9 Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, et al. Carotid endarterectomydan evidence-based review: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2005;65:794e801. 10 Kresowik TF, Bratzler DW, Kresowik RA, Hendel ME, Grund SL, Brown KR, et al. Multistate improvement in process and outCan Patients Select the Best Hospital

Endovascular Repair of a Symptomatic Aneurysm 5 Years After AneuRx Exclusion: Off-Label Use of Reversed Talent Aortomonoiliac Stent-Grafts

To describe the off-label use of 2 Talent aortomonoiliac devices to repair a symptomatic 72-mm abdominal aortic aneurysm (AAA) 5 years after AneuRx repair in a patient who had no follow-up. A 68-year-old man was referred to our hospital with a history of severe abdominal and back pain for 3 days. Five years earlier, he received an AneuRx stent-graft for an asymptomatic 51-mm infrarenal AAA, but he had not appeared for scheduled follow-up examinations. Computed tomographic angiography (CTA) showed a 72-mm AAA with bilateral common iliac aneurysms of 25 and 24 mm, respectively. The aortic segment of the AneuRx stent-graft appeared to be migrated distally by at least 20 mm; however, no type I endoleak was visible. Both distal iliac ends of the AneuRx stent-graft were migrated proximally and appeared to be floating free in the aneurysm sac, causing a bilateral type I endoleak distally. At operation, a 28-mm Talent aortic extension was inserted and dilated to cover the proximal migration zone. A Talent 28x16x126-mm aortomonoiliac stent-graft was reversed, re-installed into the deployment device, and deployed into the right AneuRx limb. The same procedure was followed on the left side, with deployment of a reversed 26x16x126-mm aortomonoiliac device. Angiography showed a fully excluded aneurysm with good anchoring of both stent-grafts. The patient was discharged on the third postoperative day in good general condition, without evidence of endoleak. At 3 and 6 months, CTA demonstrated no change in the position of the stent-graft and no signs of endoleak. The off-label use of a reversed aortomonoiliac stent-graft is an easy alternative to the well-known technique of a distally placed aortic extension cuff and also eliminates the risk of a type III endoleak.

Abdominal Aortic Aneurysm Repair in Patients with End Stage Renal Disease

Objective : Abdominal aortic aneurysm (AAA) in patients with end stage renal disease (ESRD) represents a challenging therapeutic problem. This study was undertaken to analyze the surgical outcome of AAA repair in patients with ESRD and discuss the optimal peri-operative management of problems that resulted.Methods : Between January 1995 and January 2005, 11 patients with ESRD underwent abdominal aortic aneurysm repair. All patients were under chronic haemodialysis. Risk factors related to surgical morbidity were evaluated. Results : The average age was 68 years (57–84 years). Nine patients were men: 8 were hypertensive, 6 had diabetes, 4 had coronary artery disease, 3 had suffered a previous stroke, 3 had prior myocardial infarct and 8 were smokers. The duration of haemodialysis was 19 months (range 2 to 46 months). Five of the 11 patients had bilateral common iliac aneurysms in addition to the abdominal aortic aneurysm. The average diameter of infrarenal AAA was 6 cm (4.8–7.5). The mean duration of operation was 191 min. All patients underwent haemodialysis on the day before operation with an average period of 8.5 hours (6–12) and 2 to 20 hours postoperatively.The mean follow-up was 11.5 months (range 1 to 93 months). None of the patients died during the 30-day postoperative period. Two patients died from heart failure 3 and 7 months later.Conclusion : Abdominal aortic aneurysm can be repaired in patients with end stage renal disease with good results, despite the increased morbidity and mortality of this population.

A modular multi-branched system for endovascular repair of bilateral common iliac artery aneurysms.

To describe a modular stent-graft for cases of bilateral common iliac aneurysm. The aortic aneurysm is repaired using a standard bifurcated modular system (Zenith). A modified bifurcated component is deployed with its trunk in one limb of the original aortic stent-graft, its long limb in the external iliac artery, and its short limb in the iliac aneurysm just above the internal iliac orifice. A flexible extension is introduced from the right brachial artery and used to bridge the gap between the short limb of the modified bifurcated component and the left internal iliac artery. Endovascular repair of bilateral iliac aneurysm is feasible using a modular stent-graft with separate branches to the internal and external iliac arteries.

A CASE OF EARLY COLORECTAL CANCER PRESENTING WITH MASSIVE MELENA

An 88-year-old man was urgently admitted to the hospital because of massive melena on September 27 1991. Emergency colonoscopy revealed a polyp of Yamada's type III in the sigmoid colon, but no definite bleeding site was determined. Ultrasonography and CT showed bilateral common iliac aneurysms which were not thought the bleeding source. Hemorrhagic scintigraphy for exploration of bleeding site led to a diagnosis that it was located in a portion of the sigmoid colon. On October 1 sigmoidectomy and colostomy were performed. A 10×8mm Yamada's type III polyp was found in the sigmoid colon and clots adhered to its surface. So it was determined that the bleeding stemmed from the polyp. Histopathologically the polyp was carcinoma in adenoma with invasion depth of m, with an artery locating in shallow layer of sm which appeared the bleeding vessel. It is very rare that massive hemorrhage breaks out from a small carcinoma in adenoma with a diameter of less than one cm, and is also interesting that hemorrhagic scintigraphy greatly contrubutes to determine the bleeding site. This paper describes such a rare and interesting case with a review of the literature.

A CASE OF ISOLATED ILIAC ANEURYSM RUPTUR ED INTO THE COMMON ILIAC VEIN

A succesfully treated case of an isolated iliac aneurysm that ruptured into the left common iliac vein was experienced.A 61-year-old man was admitted with the chief complaint of swelling of the left lower extremity. A pulsatile mass and thrill were palpable in the left lower abdomen, and heart failure was noticed additionally. Abdominal ultrasonography, abdominal computed tomography and angiography revealed a left isolated iliac aneurysm together with an arteriovenous fistula.Before surgery, medical treatment for heart failure was given to improve his general condition. A bilateral common iliac aneurysm, together with the arteriovenous fistula, was confirmed preoperatively. A radical operation comprising resection of the aneurysm, closure of the fistula and circulatory reconstruction resulted in healing.Histological examination of the aneurysmal wall should the aneurysm to be artherosclerotic in origin. Sixty-three cases of ruptured and non ruptured aneurysms reported in Japan, including the present case were analyzed.