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Thursday, January 10, 2019

Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable—Results of 72 Consecutive Patients


Summary


Research from the University Hospital of Zurich (Switzerland) recently evaluated the outcome of elective/emergent endovascular repair of isolated iliac artery aneurysms (IIAAs) as the first treatment option. A retrospective study was conducted including 72 patients with 85 IIAAs. Treatment strategy included coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. The following arterial segments were involved: common iliac (63 patients; 74.1%), internal iliac (21 patients; 24.7%), and external iliac (1 patient; 1.2%). Mean diameter was 5 cm (range, 2.5–11 cm). Emergent repair was performed in 19 patients due to rupture (26.4%). Mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0–14.2 y). Primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group). In-hospital mortality rate was 1.4%. Total of 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall re-intervention rate was 16.7%. Primary patency rate was 98.6%. 22 deaths occurred (30.6%), but only 2 aneurysm-related deaths (2.8%). The authors concluded that primary endovascular repair of IIAAs shows excellent results and should be considered the first-line therapy for IIAAs. Surgical backup should be available in emergent cases. 



Fig: Anatomic classification of IIAA.

Commentary


This paper reinforces the important role of endovascular approach for arterial aneurysms, specifically for rare cases of isolated iliac artery aneurysms. The low incidence of this entity should not undermine its significance since it can lead to major complications such as rupture, which is associated with high morbidity and mortality. Therefore, it is recommended to treat aneurysms > 3cm. However, even for elective cases, surgical repair can have up to a 10% mortality rate, given the deep location of the iliac arteries within the pelvis. The present retrospective study demonstrated that endovascular repair was safe and effective for both elective and emergent cases even after long term follow-up (median of 4.3 years). There was a low conversion rate (4.6%) to open repair and they all occurred in emergent cases. This is not surprising given the severe clinical presentation of this patient population. Therefore, surgical back up is definitely recommended in these cases as mentioned by the authors. The initial critical presentation also explains the higher incidence of in-hospital major complications and increased length of admission for those emergent cases presenting with rupture. The standardized endovascular way to treat those aneurysms according to the location as performed by the research definitely helps replication of the results and solidification of the endovascular approach as the first line treatment for this condition.

Click here for abstract

Post Author:
Ricardo Yamada, MD
Assistant Professor
Department of Radiology
Division of Vascular and Interventional Radiology
Medical University of South Carolina

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