management of internal iliac artery during aorto-iliac
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Management of Internal Iliac Artery during Aorto-Iliac Reconstruction
Mohan AdiseshiahEndovascular Unit
University College Hospital
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The Challenge of the iliac landing site
Aneurysmal common iliac artery:-
Unilateralbilateral
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Iliac Artery Challenge
The internal iliac artery;-
UnilateralBilateral
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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)
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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
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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
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Consequences of covering the Internal Iliac Artery
Buttock claudicationColonic ischaemia?Impotence?Sacral soreLumbosacral plexus ischaemiaSpinal cord ischaemia
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Buttock Claudication
Common (28%) and disabling
Can subside after a period
(Usually untreated)
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Colonic Ischaemia
Coverage of inferior mesenteric artery by endograftSuperior mesenteric
artery insufficiencyInternal iliac artery
coverageHypotensive episodes
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Impotence
No firm figures for incidenceSubstantial erectile dysfuction before surgery
(Prinssen M, et al J Endovasc Ther. 2004 Dec;11(6):613-20.)
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Sacral Sore
Usually in bed ridden patients
No data on the incidence of internal iliac cover.
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Spinal and plexus ischaemia
Extremely rare:-<0.5% of all EVARNumber of Internal Iliacs covered unknown
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Late problems associated with the Internal Iliac Artery: (Case
Report)
White, male, 70 years
6 cm infrarenal AAA - with normal iliacs
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Case Report
1996 AAA repaired-
UCH homemade device - pre-expanded PTFE fixed with Palmaz stents. Contralateral
proximal common iliac coiled.
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Case Report
2002 -6 years post-op :-
Right internal and common iliac distal to coils become aneurysmal
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Case Report
Common iliac and internal aneurysms coiled + ligature external iliac :-
open + endovascular surgery
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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