Iliac Aneurysms Current Treatment Strategies

Patrick Chong Department of Vascular Surgery, Frimley Park Hospital NHS Foundation Trust Surrey Vascular Group Network

South East Coast Vascular Network Inaugural Meeting Kent & Canterbury Hospital 26th September 2012

The Solitary Iliac artery aneurysm

> 50% increase c.f. native iliac artery diameter Prevalence of 2%-6% in autopsy series Asymptomatic Clinically difficult to detect Consider repair > 3.5cm in good risk patients Rupture is common Elective open repair (11%) Emergency open repair (40-60%)

Iliac artery aneurysms - Aetiology

Degenerative Atherosclerosis Infection Dissection Trauma Fibromuscular Dysplasia Marfans

Iliac artery aneurysms natural history

Average rate of expansion: 0.118 +/- 0.017 cm/year
No expansion in 37.5% <3cm: 0.05-0.15cm/year >3cm: 0.25-0.28cm/year All IAA between 4 and 4.9cm expanded
Santilli et al. 2000

Internal iliac artery aneurysms -Aetiology

Progressive atherosclerosis 80%
Childbirth Trauma Mycotic
Staphylococcus Aureus Klebsiella spp. Pseudomonas spp.

11%

Salmonella spp.

Previous IR-AAA repair CTDs

Iliac artery aneurysms - complications

Rupture
Extrinsic compression
Urological Neuropathy Deep venous

Distal Embolisation Thrombotic occlusion Fistula formation

Ureteric Enteric

Internal iliac artery aneurysms

Rare incidence Male : Female ratio Mean age at presentation Ruptured at initial presentation Mortality from rupture Risk of rupture >3cm 0.4% 6: 1 67.2 years 33-40% 31-58% 14-31%

There is no significant correlation between size of internal iliac aneurysm and risk of rupture
r=+0.161 Spearman p=0.279 De Donato 2005

The classification of isolated iliac artery aneurysms

Uberoi et al. 2011

Endovascular options
Balloon expandable
Jostent by JOMED,

Self-expanding
Fluency stent by BARD Haemobahn by GORE

Cheshire, UK Advanta by ATRIUM Medical International

TECHNICAL TIPS Antibiotics Heparin Percutaneous or open cut down access Bilateral groin approach LA or Regional or GA 10F sheath or larger if using EVAR limbs 180mm or 260mm carriage wire

Viabahn by GORE

Treatment options
Open repair
Bypass

Endovascular repair
Stent Embolisation Hybrid approaches

Ligation

EVAR limb stent graft options

COOK spiral Z iliac limbs > 10mm landing vessel 7.5-20mm (outer to outer wall) length 39-12mm 10-15% oversize

VASCUTEK Anaconda iliac limbs

10-23mm stent diameter 60-140mm stent length >25mm proximal >20mm distal 10-15% oversize

Technical and Clinical Outcomes

Technical Success Primary Patency Rates Re-intervention 100% 85-95% at 2 years 86-97% at 3 years 0-26%
for stent occlusion For stent endoleaks

Data is not robust after 2 years Is your patient fit for open repair?

Complications of endovascular therapy

Left IIAA found on diagnostic trans-femoral angiography Beware of using TFA findings alone ! CT Aortogram showed no proximal neck coil embolization

Treatment strategy for Type A anatomy

Treatment strategy for Type B anatomy

Large Right CIAA with no distal landing zone proximal to the Right IIA origin. Proximal coiling of Right IIA origin Right iliac stent with distal landing zone in the external iliac artery

Endovascular management Type B anatomy

Large Right CIAA with no proximal landing zone Aorto-uni-iliac stent to Left CIA Fem-Fem crossover bypass

Treatment strategy for Type C anatomy

Treatment strategy for Type D anatomy

Treatment strategy for Type E anatomy

Embolisation tips
Contralateral approach / Ansel crossover sheath (COOK) / Terumo hydrophilic wire Amplatzer vascular plugs Coils Glue Thrombin Onyx

Endovascular embolisation of IIA when is it not required?

Landing zone in distal CIA available Occluded IIA High grade stenosis of IIA origin

Buttock claudication reported in up to 23% Persistent symptoms in 1 in 6 up to 2 years

Summary
Rupture risk Surveillance Consider repair when < 3cm low >5cm significant <3cm 3.5-4.0 cm yearly 6 months

>4cm or symptomatic

Open repair may be better in patients with compressive symptoms Endovascular therapy may be safer in co-morbid patients

Further need for long term durability comparison of open vs. endovascular repair