Bilateral Internal Iliac Artery Occlusion Research Articles

Incidence and Outcomes of Visceral Ischemia in Acute Aortic Occlusion

Acute aortic occlusion (AAO) is a morbid diagnosis in which mortality correlates with severity of ischemia on presentation. Visceral ischemia (VI) is challenging to diagnose and its presentation as a consequence of AAO is not well-studied. We aim to identify characteristics associated with VI in AAO to facilitate diagnosis. Patients diagnosed with AAO who underwent revascularization were identified retrospectively from institutional records (2006-2020). The primary outcome was the development of VI (intra-abdominal ischemia). Univariate analysis was used to compare demographic, exam, imaging, and intraoperative variables between patients with and without VI in the setting of AAO. Ninety-one patients were included. The prevalence of VI was 20.9%. Preoperative comorbidities, time to revascularization, and operative approach did not differ between patients with and without VI. Patients with VI more frequently were transferred from outside institutions (100% vs. 53%, P=0.02), presented with advanced acute limb ischemia (Rutherford III 36.9% vs. 7.5%, P<0.01), and had elevated preoperative serum lactate (4.31 vs. 2.41mmol/L, P<0.01). VI patients had an increased occurrence of bilateral internal iliac artery (IIA) occlusion (47.4% vs. 18.1%, P=0.01). Unilateral IIA occlusion, level of aortic occlusion, and patency of inferior mesenteric arteries were not associated with VI. Patients with VI had worse postoperative outcomes. In particular, VI conferred significant risk of mortality (odds ratio 5.45, P<0.01). Visceral ischemia is a common consequence of AAO. Elevated lactate, bilateral IIA occlusion, and advanced acute limb ischemia (ALI) should increase clinical suspicion for concomitant VI with AAO and may facilitate earlier diagnosis to improve outcomes.

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair.

This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications. Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors. IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication. The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Association between aortic coverage and spinal cord ischemia after endovascular repair of type B aortic dissection.

To examine the association between aortic coverage and occurrence of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Thirty-eight consecutive patients (mean age 52years; 35 men) who underwent TEVAR for type B aortic dissection at our centre were included. Patients were stratified into two groups based on stent graft length (SGL): group I (≤ 200mm; n = 19) and group II (> 200mm; n = 19). All the procedures were performed under strict blood pressure monitoring. Preoperative cerebrospinal fluid (CSF) drain was instituted in two patients. Mean SGLs were 200mm in group I and 277 ± 27mm in group II. The number of segmental arteries covered was significantly different between the two groups (p < 0.001). There was no significant difference in vertebral artery dominance between groups I and II (p = 0.99). One patient in group II, who also had bilateral internal iliac artery occlusion, developed postprocedural neurological deficit referrable to SCI, which resolved completely after institution of CSF drainage. However, the incidence of SCI was not significantly different between group I and group II (p = 0.5). Based on our experience, we recommend longer aortic coverage (beyond 200mm) in type B aortic dissection (TBAD) for better aortic remodelling, provided that the mean arterial pressure of > 90mm Hg is maintained perioperatively to avoid SCI.

The clinical evaluation of internal iliac arteries balloon occlusion for placenta accreta spectrum.

To evaluate the balloon occlusion of the internal iliac arteries during a caesarean section in the group of patients with placenta accreta spectrum. We analysed 29 pregnant women with placenta accreta spectrum. The study group consisted of 15 patients, who underwent a caesarean delivery with temporary bilateral internal iliac artery occlusion. In the control group, we examined 14 women who had a standard caesarean delivery without any radiologic procedure. We compared pre- and post-operative haemoglobin level, necessity of blood transfusion, intraoperative blood loss, intensive care requirement, complications, duration of surgery, anaesthesia and hospital stay. The history and obstetric outcomes were similar in both groups. The study group required fewer blood transfusions than the control group (p = 0.0176). We administered less packed red blood cells and fresh frozen plasma. Complications were more frequent in the control group (p = 0.0014). Complications related to occlusion of the internal iliac arteries did not occur. The intensive care unit transfer was more frequent in the control group (p = 0.0329). The duration of surgery and hospital stay did not differ between groups. The anaesthesia time was longer in a study group, which related to the radiologic procedure. Caesarean delivery for placenta accreta spectrum with bilateral balloon occlusion of the internal iliac arteries requires fewer transfusions. It contributes to a decrease in the complication rate and maternal morbidity.

Internal iliac artery revascularisation versus internal iliac artery occlusion for endovascular treatment of aorto-iliac aneurysms.

Endovascular aortic aneurysm repair (EVAR) is used to treat aorto-iliac and isolated iliac aneurysms in selected patients, and prospective studies have shown advantages compared with open surgical repair, mainly in the first years of follow-up. Although this technique produces good results, anatomic issues (such as common iliac artery ectasia or an aneurysm that involves the iliac bifurcation) can make EVAR more complex and challenging and can lead to an inadequate distal seal zone for the stent-graft. Inadequate distal fixation in the common iliac arteries can lead to a type Ib endoleak. To avoid this complication, one of the most commonly used techniques is unilateral or bilateral internal iliac artery occlusion and extension of the iliac limb stent-graft to the external iliac arteries with or without embolisation of the internal iliac artery. However, this occlusion is not without harm and is associated with ischaemic complications in the pelvic territory such as buttock claudication, sexual dysfunction, ischaemic colitis, gluteal necrosis, and spinal cord injury. New endovascular devices and alternative techniques such as iliac branch devices and the sandwich technique have been described to maintain pelvic perfusion and decrease complications, achieving revascularisation of the internal iliac arteries in patients not suitable for an adequate seal zone in the common iliac arteries. These approaches may also preserve the quality of life of treated individuals and may decrease other serious complications including spinal cord ischaemia, ischaemic colitis, and gluteal necrosis, thereby decreasing the morbidity and mortality of EVAR. To assess the effects of internal iliac artery revascularisation versus internal iliac artery occlusion during endovascular repair of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation. The Cochrane Vascular Information Specialists searched the Cochrane Vascular Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 28 August 2019. The review authors searched Latin American Caribbean Health Sciences Literature (LILACS) and the Indice Bibliográfico Español de Ciencias de la Salud (IBECS) on 28 August 2019 and contacted specialists in the field and manufacturers to identify relevant studies. We planned to include all randomised controlled trials (RCTs) that compared internal iliac artery revascularisation with internal iliac artery occlusion for patients undergoing endovascular treatment of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation. Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. We identified no RCTs that met the inclusion criteria. We found no RCTs that compared internal iliac artery revascularisation versus internal iliac artery occlusion for endovascular treatment of aorto-iliac aneurysms and isolated iliac aneurysms involving the iliac bifurcation. High-quality studies that evaluate the best strategy for managing endovascular repair of aorto-iliac aneurysms with inadequate distal seal zones in the common iliac artery are needed.

Cesarean Scar Ectopic Pregnancy - Operative Management with Bilateral Temporary Iliac Artery Occlusion

Objective: The paper describes management of cesarean scar pregnancy with bilateral internal iliac artery occlusion prior to operative removal of the gestational sac.Methods: Both internal iliac arteries were temporally occluded before the operation to assure perioperative bleeding control.Results: The bleeding was well controlled during the operation and the cesarean scar pregnancy was safely removed. The anterior uterine wall healed completely within 8 weeks postoperatively. The total blood loss was approximatey 1150 ml.Conclusions: Bilateral internal iliac artery occlusion is a safe and effective method of perioperative bleeding control in patients diagnosed with cesarean scar pregnancy.

Endovascular treatment of patients with bilateral internal iliac artery disease and buttock claudication.

This study aims to investigate the therapeutic value of endovascular treatment in patients with buttock claudication caused by stenosis or occlusion of the bilateral internal iliac arteries. This single-center, retrospective study included a total of 12 patients (9 males, 3 females; mean age 63.7±6.4 years; range 54 to 74 years) with persistent buttock claudication who underwent endovascular repair of bilateral internal iliac artery stenosis or occlusion and were treated with percutaneous transluminal angioplasty in another session at our center between July 2012 and February 2016. The iliac Doppler ultrasonography and/or computed tomography angiography were performed at six and 12 months to evaluate restenosis or occlusion. Symptom relief was considered a successful outcome. The median follow-up was 16.5±3.7 (range, 12 to 24) months. Four patients underwent a bilateral intervention and eight patients underwent unilateral intervention. There was a 100% technical success rate with no complications. The primary patency rate at 12 months was 87.5%. Six patients (50%) had complete and four patients (33.3%) had partial relief of the buttock claudication symptoms. Percutaneous angioplasty of the internal iliac arteries is a technically feasible and safe method in patients with buttock claudication and bilateral internal iliac artery occlusion or stenosis. Complete or partial relief of symptoms can be achieved in the majority of patients with a high primary patency rate.

Treatment Outcomes and Risk Factors for In-Hospital Mortality in Patients with Acute Aortic Occlusion.

PurposeThe aims of the present study are to determine the outcomes after acute aortic occlusion (AAO) and analyze the risk factors for in-hospital mortality.Materials and MethodsWe retrospectively analyzed 24 patients who were diagnosed with AAO from 2002 to 2017 in our registered data. Demographic and radiologic characteristics of AAOs were retrospectively collected. Perioperative treatment outcomes including in-hospital mortality were also assessed and the risk factors of in-hospital mortality were analyzed.ResultsThe median symptom duration was 21 hours. Five patients had complete paraplegia and 10 patients (41.7%) were initially evaluated for central nervous system disorders instead of acute arterial occlusion. The etiology was determined to be aortoiliac thrombosis in 17 patients (70.8%) and embolic occlusion in 7. Surgical revascularization was performed in 23 patients, and one patient did not receive any treatment. The overall in-hospital mortality was 34.8% (8/23) and 30-day mortality was 26.1%. In the univariate analysis, age (P=0.040), preoperative renal insufficiency (serum creatinine over 1.5 mg/dL at the time of presentation) (P=0.008), postoperative acute kidney injury (need for dialysis or an increase in serum creatinine of >50.0% within 48 hours) (P=0.006), combined external iliac artery occlusion (P=0.019) and combined bilateral internal iliac artery occlusion (P=0.039) were associated with in-hospital mortality.ConclusionA substantial number of AAO patients were initially evaluated for a central nervous system lesion, which led to a delay in diagnosis. Thus, vascular examinations should always be performed in every patient presenting with lower limb neurologic deficits. Age, perioperative renal function, and combined iliac artery occlusion were associated with the prognosis of AAOs.

Risk factors for perioperative mortality after revascularization for acute aortic occlusion

ObjectiveAcute aortic occlusion (AAO) is a life-threatening event necessitating prompt revascularization to the pelvis and lower extremities. Because of its uncommon nature, outcomes after revascularization for AAO are not well characterized. Our aim was to describe the perioperative morbidity and mortality associated with revascularization and to identify the patients at highest risk. MethodsA retrospective chart review was performed of patients who presented to our institution from 2006 to 2017 with acute distal aortic occlusion. Patients with a prior aortofemoral bypass were excluded, but those with aortoiliac stents were included. Baseline demographics and comorbidities, preoperative clinical presentation and imaging, procedural details, and postoperative hospital course were reviewed. The primary outcome was 30-day mortality, and major complications were evaluated as secondary outcomes. Logistic regression models were constructed to identify factors associated with 30-day mortality. ResultsWe identified 65 patients who underwent revascularization for AAO. Median age was 63 years (range, 35-89 years), and 64.6% were male; 56.4% of patients presented within 24 hours of symptom onset, and 43.8% were treated within 6 hours of presentation. There were particularly high rates of prior coronary artery disease (62.3%) and chronic obstructive pulmonary disease (41.0%); 18.5% had prior iliac stents. Preoperative imaging in 44 patients showed occlusion of the inferior mesenteric artery in 36.0% and both internal iliac arteries in 34.7%. Treatments for revascularization included axillobifemoral bypass (55.4%), aortoiliac thromboembolectomy (15.4%), aortobifemoral bypass (13.9%), and aortoiliac stenting (15.4%). Overall 30-day mortality was 27.7% and was not affected by treatment modality. Mortality was highest in patients older than 60 years (40.5% vs 10.7%; P = .01) and those presenting with lactate elevation (45.5% vs 5.9%; P = .004) or motor deficit in at least one extremity (36.6% vs 9.5%; P = .03). Univariate predictors of 30-day mortality were age ≥60 years (odds ratio [OR], 5.68; 95% confidence interval [CI], 1.45-22.26; P = .01), presentation with motor deficit (OR, 5.48; 95% CI, 1.12-26.86; P = .04), presentation with elevated lactate level (OR, 13.33; 95% CI, 1.58-11.57; P = .02), history of prior stroke (OR, 4.80; 95% CI, 1.21-18.97; P = .03), and bilateral internal iliac artery occlusion (OR, 7.11; 95% CI, 1.54-32.91; P = .01). At least one postoperative complication was observed in 78.5% of patients, including acute kidney injury (56.9%, with 21.5% requiring hemodialysis), respiratory complications (46.2%), cardiovascular complications (33.9%), major amputation (15.4%, bilateral in 7.7%), and bowel ischemia (10.8%). ConclusionsEven with prompt revascularization and despite the chosen treatment modality, AAO carries high risk of mortality and numerous life-threatening complications. Older patients presenting with elevated lactate levels, motor deficit, and bilateral internal iliac artery occlusions are at the highest risk of perioperative mortality. These factors may aid in risk stratification and managing expectations in this critically ill population.

Internal Iliac Artery Embolization for Benign Prostatic Hyperplasia? First Read the Fine Print

The study by Deipolyi et al titled “Occlusion of the Internal Iliac Artery Is Associated with Smaller Prostate and Decreased Urinary Tract Symptoms” (1) is a retrospective review of 99 men with pelvic computed tomographic (CT) angiograms in whom the prostate size and presence of lower urinary tract symptoms (LUTS) was compared between those with and without embolization of the internal iliac artery during endovascular repair of aortic aneurysms. The authors concluded that the presence of unilateral or bilateral internal iliac artery occlusion (IIAO) was associated with decreased prostatic volume and significantly fewer LUTS. The manuscript underwent a rigorous review, its statistical analysis was held to a high standard, and it involved a large cohort of patients. However, a number of questions immediately arise from reading the study. Is this association nevertheless real? Is it relevant to the study of prostate artery embolization (PAE)? What does the signal contained in the positive results of the study mean in the context of actual PAE? Although the authors demonstrated a statistically significant difference in prostate size of 29%–32% (smaller) in patients with unilateral or bilateral IIAO, and significantly fewer LUTS in these patients, it is important to point out that they were not implying that iatrogenic IIAO is a viable treatment for LUTS caused by benign prostatic hyperplasia (BPH). Although it may in fact be real, the observed association is not

Occlusion of the Internal Iliac Artery Is Associated with Smaller Prostate and Decreased Urinary Tract Symptoms

PurposeTo characterize the relationship of proximal internal iliac artery (IIA) occlusion or embolization on prostate volume (PV) and the presence of lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH). Materials and MethodsThe study included 2 parts: Part 1 comprised 99 men ≥ 50 years old who underwent abdominopelvic computed tomography angiography for lower extremity claudication assessed in a retrospective cohort design; Part 2 comprised 18 patients who underwent iatrogenic IIA embolization during endovascular aneurysm repair assessed by a within-subjects approach. Prostate volume and IIA origin diameter were measured; IIA occlusion was noted. Chart review documented body mass index, LUTS, impotence, and buttock claudication. ResultsOf 99 men in Part 1, 60 had no IIA occlusion, and 39 had IIA occlusion (17 unilateral, 22 bilateral). Prostate volume differed significantly between groups (no IIA occlusion, 27.3 mL; unilateral IIA occlusion, 20.7 mL; bilateral IIA occlusion, 17.1 mL; P = .001). Men without IIA occlusion had more LUTS (27%) than men with IIA occlusion (10%; P = .04). The number of men with complaints of impotence or buttock claudication was similar in both groups (40% vs 46%; P > .05). Multiple regression showed that age and IIA occlusion were independent predictors of PV (P < 0.05), whereas body mass index was not (P > .05), and that IIA occlusion was the only independent predictor of LUTS/BPH (P < .05). Among the 18 men in Part 2, PV declined by 29% after embolization (P = .00001); 6 men had improvement or resolution of LUTS. ConclusionProximal IIA occlusion is associated with nearly one-third reduction in PV and decreased findings of LUTS/BPH.

Kissing Iliac Artery Stent Technique for Salvage of Hypogastric Artery Occlusion Secondary to Iliac Artery Dissection During Endovascular Aneurysm Repair

While undergoing endovascular aneurysm repair (EVAR), dissection occurred in bilateral common and external iliac arteries resulting in acute bilateral hypogastric artery occlusion. Attempts were made to reestablish flow to the left internal iliac artery via retrograde ipsilateral approach without success. A left brachial approach was used to gain access to the left internal iliac artery and kissing angioplasty and subsequent stent placement with 2 self-expanding stents was performed raising the iliac bifurcation to the level of the stent graft to salvage the internal iliac artery.

Heterotopic cervical pregnancy treated with transvaginal ultrasound-guided aspiration resulting in cervical site varices within the myometrium

To report a case of successful treatment of a heterotopic cervical pregnancy from IVF-embryo transfer and intracytoplasmic sperm injection (ICSI) that resulted in uterine varices at the cervical site. Case report. Tertiary university clinical center. A 34-year-old with a history of infertility associated with oligospermia who developed a heterotopic cervical pregnancy diagnosed at 7 weeks gestation. Transvaginal ultrasound (TVS)-guided aspiration of the cervical pregnancy; preoperative placement of bilateral hypogastric artery occlusion balloons; cesarean section. Successful delivery of intrauterine pregnancy; conservation of the uterus. Successful termination of the cervical site pregnancy was achieved with TVS-guided aspiration. However, the pregnancy was then complicated by development of uterine varices at the cervical site noted on serial obstetric ultrasounds and magnetic resonance imaging (MRI). Successful management of the pregnancy required a multidisciplinary approach and preoperative placement of bilateral hypogastric artery occlusion balloons. A scheduled high fundal classic cesarean section at 37 weeks allowed for safe delivery of a healthy infant. Complete spontaneous resolution of the uterine varices was noted after the delivery. It is unclear whether residual ectopic tissue contributed to this later complication; however, it cannot be ignored that the locations of the aborted site and the prominence of dilated venous vasculature in this same location suggests a correlation. The interventions applied are reasonable conservative treatments of a cervical heterotopic pregnancy and a management strategy for uterine varices.

Staged Endovascular Repair of Bilateral Internal Iliac Artery Aneurysms

Internal iliac artery (IIA) aneurysms present several challenges to the vascular surgeon: They are uncommon, and the often difficult repair is associated with relatively high morbidity/mortality. Bilateral internal iliac disease adds technical complications secondary to ischemic complications. In this case, a 76-year-old male with bilateral IIA aneurysms underwent staged endovascular coil embolization, resulting in exclusion of flow to the aneurysms and avoidance of ischemic postoperative complications. Angiography during the procedure verified complete bilateral IIA occlusion, which remained intact at 6-week and 1 year follow-up (computed tomography). This case illustrates successful repair of bilateral IIA using endovascular techniques.

Bilateral Hypogastric Artery Occlusion in Endovascular Repair of Abdominal Aortic Aneurysms and Its Clinical Significance

Endovascular treatment of aortoiliac aneurysms near or involving the hypogastric artery (HGA) requires HGA occlusion before endografting to avoid retrograde filling of the aneurysm. The purpose of this study is to evaluate clinical outcomes of bilateral HGA occlusion and determine if benefits gained by endovascular aneurysm repair (EVAR) outweigh the morbidity associated with the procedure. Between 1999 and 2004, 128 patients with abdominal aortic aneurysm (AAA) were treated with bifurcated endograft placement. Bilateral coverage or embolization of HGAs was performed in 14 patients (10.9%). Embolization was achieved by deployment of coils and coverage was accomplished by extending the endoprosthesis into the external iliac artery. Clinical follow-up and computed tomographic angiography were performed at 1, 3, 6, 9, and 12 months and annually thereafter to detect potential aneurysm growth and endoleaks. During follow-up (range, 1-72 months), buttock claudication was noted in four patients (28.6%), including unilateral claudication in two and bilateral claudication in two. One patient experienced claudication longer than 12 months, which resolved within 18 months. De novo erectile dysfunction was seen in one patient, and pelvic ischemia was not found in any patient. There was no evidence of endoleak, aneurysm enlargement, or death associated with HGA occlusion. In our series, complications of bilateral HGA occlusion before EVAR were moderate and resolved over time. The benefits gained from EVAR outweigh the clinical problems caused by bilateral HGA occlusion, as there are no technical complications added to the EVAR procedure.

Perioperative Endovascular Internal Iliac Artery Occlusion Balloon Placement in Management of Placenta Accreta

The purpose of our study was to evaluate the efficacy of the perioperative placement of occlusion balloons within the internal iliac arteries in reducing intraoperative blood loss and transfusion requirements during cesarean delivery for women with placenta accreta or its variants. Over a 30-month period, 11 patients with placenta accreta or its variants underwent cesarean delivery after bilateral internal iliac artery occlusion balloon placement (study group). The intraoperative blood loss and transfusion volumes, immediate postoperative change in hemoglobin levels, duration of surgery, and length of ICU stay and hospitalization of this study group were compared with 14 similar patients who underwent cesarean delivery without occlusion balloon placement over a 36-month period (control group). The mean intraoperative blood loss in the study group (2,011 mL; range, 400-5,000 mL) was 39.4% less than in the control group (3,316 mL; range, 1,000-4,000 mL) (p = 0.042). The mean volume of blood transfused was 52.1% less in the study group (1,058 mL; range, 0-3,600 mL) than in the control group (2,211 mL; range, 1,190-3,980 mL) (p = 0.005). There was no significant difference in the immediate postoperative change in hemoglobin levels (p = 0.44), length of hospitalization (p = 0.203), or ICU admission (p = 0.614). The duration of the surgery was significantly less in the study group (p = 0.046). Perioperative internal iliac artery occlusion balloon placement is a safe and minimally invasive technique that reduces intraoperative blood loss and transfusion requirements in patients with placenta accreta and its variants undergoing cesarean delivery.

Regional blood flow occlusion during extensive pelvic procedures for ovarian cancer: a randomized trial

The objective of this study was to determine the effects of intraoperative aortic occlusion on blood loss and operative time when used duringen blocresection of internal reproductive organs, pelvic peritoneum, and rectosigmoid colon [modified posterior exenteration (MPE)] for primary cytoreduction of ovarian cancer. Patients undergoing MPE, without palpable distal aortic plaque or calcification, were randomized to: (a) complete distal aortic occlusion (≤60 min, with heparin and protamine reversal) with a vascular clamp immediately before MPE, (b) bilateral hypogastric artery occlusion, or (c) no regional blood flow occlusion. Outcomes were compared with respect to blood loss, operative time, and the transfusion rate (ANOVA analysis of variance). Fifty-six patients were accrued. Groups were equivalent with respect to age, disease severity, extent of upper abdominal surgery done, and cytoreductive outcomes. Aortic occlusion significantly reduced the total operative time (P= 0.02), estimated blood loss (P= 0.01), transfusion rate (P= 0.02), hospital stay (P= 0.05), and both operative time (P≤ 0.001) and blood loss (P≤ 0.001) specifically associated with MPE. There were no immediate or delayed complications due to aortic clamping. Aortic occlusion significantly reduces the blood loss and operative time for patients requiring MPE in the context of primary cytoreductive operations.

Internal Iliac Artery Embolization with Bilateral Occlusion before Endovascular Aortoiliac Aneurysm Repair—Clinical Outcome of Simultaneous and Sequential Intervention

To retrospectively evaluate the clinical outcome of patients after simultaneous or sequential internal iliac artery (IIA) embolization for bilateral IIA occlusion. Sixteen patients (65-88 y; mean, 75.6 y; two women), 11 with aortobiiliac aneurysms, three with bilateral common iliac artery (CIA)/IIA aneurysms, and two with unilateral CIA/IIA aneurysms, underwent IIA occlusion before endovascular aortoiliac repair. Eight patients underwent simultaneous bilateral IIA embolization before endovascular aortic repair (EVAR). Eight patients had sequential bilateral IIA occlusion. The outcome was assessed by clinical follow-up. There were no severe ischemic complications such as buttock necrosis or acute bowel, bladder, or spinal cord ischemia. Early ischemic complications occurred in 25% (buttock/thigh claudication, n = 3, 18.8%; and sexual dysfunction, n = 1, 6.2%) and had an onset not later than 6 months after intervention: buttock claudication resolved (n = 2) or persisted after aggravation by inferior mesenteric artery embolization for type II endoleak (n = 1). Impotence in a fourth patient persisted. The ischemic complication rate after 6 months was 30% (three of 10) because of a fifth patient who developed ischemic colitis with aggravation of ischemic heart disease after 15 months. The mean follow-up duration was 19.7 months. Patients with simultaneous embolization had a lower complication rate than those with sequential embolization (one of eight [12.5%] vs four of eight [50%], respectively). IIA embolization for bilateral IIA occlusion can be performed with a complication rate comparable with results of previous studies of unilateral IIA embolization. Chronic buttock claudication may be aggravated by embolization of aortic side branches. Late complications can have an insidious course and be initiated by low-output cardiac failure. Bilateral IIA occlusion is recommended only in patients who are considered unfit for aortic surgery.

Overt colon ischemia after endovascular aneurysm repair: The importance of microembolization as an etiology

Objective: The purpose of this study was to analyze the incidence, severity, and etiologic factors of the development of colon ischemia after endovascular aortoiliac aneurysm repair (EVAR). Methods: During the last 9 years we performed 278 elective EVARs using a variety of grafts. To facilitate these repairs, one hypogastric artery (HA) was coil embolized in 109 patients and both HAs were coil embolized in 13 patients. The preprocedural status of the inferior mesenteric, hypogastric, and iliac arteries as well as anatomical characteristics of the abdominal aortic aneurysm were determined arteriographically and by computerized tomographic scans. Postoperative colon ischemia was documented by colonoscopy or operative findings. Results: Colon ischemia occurred in eight patients (2.9%). Three patients with colon ischemia died and had evidence of widespread (cutaneous, renal, small bowel, and/or lower extremity) microembolization. One of these three had a colectomy and microscopic emboli were present. One other patient who required a colectomy also had pathologic evidence of colonic microembolization but survived. Four other patients with colon ischemia were treated conservatively and survived. In one patient, previous colectomy with interruption of mesenteric collaterals may have been a contributory cause of colon ischemia. Of the eight patients with colon ischemia, only one had unilateral HA occlusion, and none had bilateral HA occlusion. The other 121 patients with unilateral and bilateral HA occlusion had no evidence of colon ischemia. Conclusions: Colon ischemia occurs after EVAR with an incidence approximating that of open repair. Colon ischemia was unrelated to HA interruption. Embolization appears to be a major cause of colon ischemia, although inadequate mesenteric collateral circulation may also play an etiologic role. Mortality with colon ischemia accompanied by widespread embolization was high, whereas colon ischemia without it was often mild and amenable to nonoperative management. (J Vasc Surg 2001;34:986-96.)

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms

Purpose: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. Methods: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 ± 0.7 cm; ipsilateral common iliac, 3.7 ± 1.0 cm; contralateral common iliac, 3.9 ± 0.8 cm. Results: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). Conclusions: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion. (J Vasc Surg 2001;34:892-9.)