Management of Internal Iliac Artery during Aorto-Iliac Reconstruction

Mohan AdiseshiahEndovascular Unit

University College Hospital

The Challenge of the iliac landing site

Aneurysmal common iliac artery:-

Unilateralbilateral

Iliac Artery Challenge

The internal iliac artery;-

UnilateralBilateral

Internal Iliac Aneurysm

Rare 7/440 (1.6 %) with concommittant AAA

3/440 (0.7%) not associated with AAA

(ZimmerAnn.Vasc.Surg. 1999;13:515-9)

Common Iliac Aneurysm

Of 154 AAAs:-No iliac involvement - 60 (42.9%)Aorto-iliac aneurysm – 60 (39.0%)Iliac Artery aneurysm without obvious AAA -

28 (18.2%)Mehta J Vasc Surg.2001; 33:S27-32

Problems associated with internal iliac artery during and after EVAR

Consequences of covering the Internal Iliac Artery

The internal iliac after EVAR when left uncovered

Consequences of covering the Internal Iliac Artery

Buttock claudicationColonic ischaemia?Impotence?Sacral soreLumbosacral plexus ischaemiaSpinal cord ischaemia

Buttock Claudication

Common (28%) and disabling

Can subside after a period

(Usually untreated)

Colonic Ischaemia

Coverage of inferior mesenteric artery by endograftSuperior mesenteric

artery insufficiencyInternal iliac artery

coverageHypotensive episodes

Impotence

No firm figures for incidenceSubstantial erectile dysfuction before surgery

(Prinssen M, et al J Endovasc Ther. 2004 Dec;11(6):613-20.)

Sacral Sore

Usually in bed ridden patients

No data on the incidence of internal iliac cover.

Spinal and plexus ischaemia

Extremely rare:-<0.5% of all EVARNumber of Internal Iliacs covered unknown

Late problems associated with the Internal Iliac Artery: (Case

Report)

White, male, 70 years

6 cm infrarenal AAA - with normal iliacs

Case Report

1996 AAA repaired-

UCH homemade device - pre-expanded PTFE fixed with Palmaz stents. Contralateral

proximal common iliac coiled.

Case Report

2002 -6 years post-op :-

Right internal and common iliac distal to coils become aneurysmal

Case Report

Common iliac and internal aneurysms coiled + ligature external iliac :-

open + endovascular surgery

Conclusion

The internal iliac rarely causes serious problems during or after EVARButtock claudication is the commonest

problemColon ischaemia, spinal cord and nerve

plexus ischaemia occurs in < 1% of casesLate aneurysm formation is also rare