A hybrid approach to complex bilateral common iliac artery and internal iliac artery aneurysm repair

A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, where bilateral stent grafts were deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. A week later, an open infrarenal aortobi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion. A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, where bilateral stent grafts were deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. A week later, an open infrarenal aortobi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion. A healthy 64-year-old male was admitted with incidental asymptomatic bilateral common iliac artery aneurysms (CIAA) and bilateral internal iliac artery aneurysms (IIAA). His family history was significant for infrarenal abdominal aortic aneurysm (AAA). He provided written consent for the report. A computed tomography angiogram (CTA) revealed a 3.1cm AAA, as well as a 7.6 cm right CIAA and a 2.7 cm left CIAA (Figure 1A). There were bilateral contiguous IIAA measuring 5.6 cm on the right, and 5.4 cm on the left, which extended to the anterior and posterior division with no distal normal IIA. The patient elected to undergo repair of his complex aortoiliac aneurysms. A hybrid endovascular and open repair was carried out in a staged manner (Figure 1B). The technically difficult open access to the branches of the IIAs and the need for IMA reimplantation, instructed the decision to perform a hybrid repair over an exclusively open or endovascular approach. The left IIAA was accessed; a high flow microcatheter was advanced into the superior gluteal artery (SGA) outflow of the posterior division and embolized. The anterior division was then selected, and a 9mm by 50mm Gore Viabahn stent was deployed at the common origin of the inferior gluteal and internal pudendal artery. This was followed by placement of an overlapping 11mm by 59mm Gore Viabahn VBX stent graft, which was landed proud into the left CIAA sac and post-angioplastied to 16mm at the origin of the IIA. Completion angiography confirmed exclusion of the IIAA with preserved flow into the anterior division and occlusion of the posterior division. The procedure was repeated for the right IIAA, in which the internal pudendal and obturator arteries of the anterior division were coil embolized. This was followed by placement of a 9mm by 50mm Gore Viabahn stent graft into the proximal SGA, and subsequent placement of two overlapping 11mm by 39mm Gore Viabahn VBX stent grafts proud into the right IIAA. These were post-angioplastied to 16mm, however a type III endoleak was identified and an additional 11mm by 79mm Gore Viabahn VBX stent graft was placed. Completion angiography demonstrated exclusion of the right IIAA, with preserved flow into the SGA and occlusion of the anterior division. Six days following the initial endovascular procedure, the patient underwent open aortoiliac reconstruction. A standard transperitoneal exposure was performed via a midline laparotomy (Figure 2A). Bilateral external iliac arteries (EIA) and infrarenal aortic neck were clamped, the aneurysm sac was entered, and direct cannulation of the IIA stents was performed with a 9F balloon. A 22mm by 11mm bifurcated graft was sutured to the aortic neck in an end-to-end fashion. The right and left limbs of the aortobiiliac graft were sewn to the bilateral IIA Gore Viabahn VBX stents (Figure 2B-C). This was followed by translocation of the bilateral EIA in an end-to-side fashion onto the distal limbs of the bifurcated graft. A ring of dacron was sutured circumferentially around the distal anastomoses to address needle hole bleeding from the stent PTFE (Figure 2D). The IMA was reimplanted on the aortic graft as a Carrel patch (Figure 2E). The retroperitoneum was closed over the repair with the aid of a rotational omental flap, the patient’s abdomen was closed, and the patient was extubated and transferred to the post-anesthesia care unit in stable condition. The patient did not develop bowel ischemia, pelvic ischemia, or buttocks claudication post-operatively. A final completion CTA performed on post-operative day 8 demonstrated no endoleaks (Figure 3), following which the patient was discharged in stable condition. Isolated iliac artery aneurysms are rare, with an incidence of 0.03%, and account for 0.4 to 1.9% of all aneurysmal disease1Sandhu R.S. Pipinos II. Isolated Iliac Artery Aneurysms.Seminars in Vascular Surgery. 2005/12/01/ 2005; 18: 209-215Crossref PubMed Scopus (0) Google Scholar. Bilateral isolated IIAA are even less common, seen in only 25 to 50% of iliac aneurysm cases2Machado R.M. Rego D.N. de Oliveira P. de Almeida R. Endovascular Treatment of Internal Iliac Artery Aneurysms: Single Center Experience.Braz J Cardiovasc Surg. Apr 2016; 31: 127-131PubMed Google Scholar,3Krupski W.C. Selzman C.H. Floridia R. Strecker P.K. Nehler M.R. Whitehill T.A. Contemporary management of isolated iliac aneurysms.J Vasc Surg. Jul 1998; 28 (; discussion 11-3): 1-11Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar. While limited literature exists comparing outcomes of open and complex endovascular repairs of isolated iliac aneurysms, endovascular repair is considered first line due to reduced perioperative complications and decreased length of stay4Antoniou G.A. Antoniou S.A. Torella F. Editor's Choice 2013; Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials.European Journal of Vascular and Endovascular Surgery. 2020; 59: 385-397Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 5Lederle F.A. Freischlag J.A. Kyriakides T.C. Padberg Jr., F.T. Matsumura J.S. Kohler T.R. et al.Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.Jama. Oct 14 2009; 302: 1535-1542Crossref PubMed Scopus (916) Google Scholar, 6Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.Eur J Vasc Endovasc Surg. Jan 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (1556) Google Scholar. However, endovascular repair of isolated CIAA and IIAA are associated with higher rates of secondary intervention, and the operative approach to bilateral complex CIAA and IIAA is influenced by patient factors7Kobe A. Andreotti C. Puippe G. Rancic Z. Kopp R. Lachat M. et al.Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable—Results of 72 Consecutive Patients.Journal of Vascular and Interventional Radiology. 2018/12/01/ 2018; 29: 1725-1732Abstract Full Text Full Text PDF Google Scholar. The goal was to minimize risk of pelvic and bowel ischemia through maintaining antegrade flow in at least one IIA as well as preserving the IMA8Huang Y. Gloviczki P. Duncan A.A. Kalra M. Hoskin T.L. Oderich G.S. et al.Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair.J Vasc Surg. Jun 2008; 47 (; discussion 1210-1): 1203-1210Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar. Due to the patient’s young age and health, an open repair was preferred for long-term patency. Long-term outcomes and preservation of pelvic perfusion is considered superior in open repair as compared to endovascular intervention for IIAA9Rana M.A. Kalra M. Oderich G.S. de Grandis E. Gloviczki P. Duncan A.A. et al.Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms.Journal of Vascular Surgery. 2014/03/01/ 2014; 59: 634-644Abstract Full Text Full Text PDF PubMed Google Scholar. Due to the limitations of achieving distal control of the IIAA outflow in a narrow, deep male pelvis, isolated open repair was not considered. The experience of the senior author is to measure the inter-ischial tuberosity distance at the level of the internal iliac bifurcation. In this case, it was 10 cm of working distance, and based on the senior author’s experience, it was felt that distal control and exposure would be challenging. A purely endovascular approach was complicated by the patient’s bilateral IIAA. Endovascular repair of unilateral IIAA via embolization and stent graft implantation is an effective approach in patients with adequate collateralization10Pitoulias G.A. Donas K.P. Schulte S. Horsch S. Papadimitriou D.K. Isolated iliac artery aneurysms: Endovascular versus open elective repair.Journal of Vascular Surgery. 2007/10/01/ 2007; 46: 648-654Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 11Fontana F. Coppola A. Ferrario L. De Marchi G. Macchi E. Zorzetto G. et al.Internal Iliac Artery Embolization within EVAR Procedure: Safety, Feasibility, and Outcome.J Clin Med. Dec 14 2022; : 11Google Scholar, 12Rochus I. Salemans P.B. Bouwman L.H. Wong C. Yazar O. Symptomatic bilateral iliac artery aneurysms: Four cases with four different management strategies and outcomes.Annals of Vascular Surgery - Brief Reports and Innovations. 2023/03/01/ 2023; 3100180Crossref Scopus (0) Google Scholar. However, this approach applied to bilateral IIAA disease in the setting of bilateral CIAA disease requires concurrent IMA coverage and places the patient at increased risk of pelvic and colonic ischemia13Chitragari G. Schlosser F.J. Ochoa Chaar C.I. Sumpio B.E. Consequences of hypogastric artery ligation, embolization, or coverage.Journal of Vascular Surgery. 2015/11/01/ 2015; 62: 1340-1347Abstract Full Text Full Text PDF PubMed Google Scholar. Bilateral IIAA embolization is associated with rates of buttock claudication up to 30% and erectile dysfunction up to 17%. Pelvic and colonic ischemia were rare complications in a recent meta-analysis, but twice as likely to occur in patients with bilateral IIA occlusion14Bosanquet D.C. Wilcox C. Whitehurst L. Cox A. Williams I.M. Twine C.P. Systematic Review and Meta-analysis of the Effect of Internal Iliac Artery Exclusion for Patients Undergoing EVAR.Eur J Vasc Endovasc Surg. Apr 2017; 53: 534-548Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar. While branched graft technology is increasingly available for CIAA, the treatment of IIAA is not within IFU15Mansukhani N.A. Havelka G.E. Helenowski I.B. Rodriguez H.E. Hoel A.W. Eskandari M.K. Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.Ann Vasc Surg. Jul 2017; 42: 162-168Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar. However, branched grafts have been applied off-IFU in the treatment of isolated IIAAs with a distal landing zone in the posterior division16Austermann M. Bisdas T. Torsello G. Bosiers M.J. Lazaridis K. Donas K.P. Outcomes of a novel technique of endovascular repair of aneurysmal internal iliac arteries using iliac branch devices.J Vasc Surg. Nov 2013; 58: 1186-1191Abstract Full Text Full Text PDF PubMed Google Scholar. Good technical success is reported but long-term patency is unknown. Hybrid interventions for aortoiliac aneurysms have been described in the setting of concurrent occlusive disease. Krzyzaniak et al. discussed a successful hybrid approach to AAA repair in the setting of severe CIA calcification, where intraoperative CIA stents were placed, and distal graft-to-stent anastomoses were performed17Krzyzaniak H. Misati G. Rockley M. Rommens K. Hybrid surgical technique for open abdominal aortic aneurysm repair in the setting of severe iliac artery calcification.Journal of Vascular Surgery Cases, Innovations and Techniques. 2023; 9Abstract Full Text Full Text PDF Scopus (0) Google Scholar. Graft-to-stent anastomoses in the setting of isolated CIAA and IIAA repair were also discussed in a recent case series, where a unilateral self-expanding stent was placed in the SGA followed by an end-to-side stent-graft anastomosis to the aortobiiliac graft during the open repair stage18Noël-Lamy M. Teng Tan K. Lindsay T. Covered stent in the superior gluteal artery in a hybrid approach to treat internal iliac artery aneurysm: a technical note.J Vasc Interv Radiol. Jul 2015; 26: 1040-1045Abstract Full Text Full Text PDF Google Scholar. The novel approach in this case involved preservation of one anterior division of the ipsilateral IIA and the contralateral posterior division via the dominant SGA of the IIA in a staged endovascular manner. It involved deployment of bilateral stent grafts without proximal fixation initially, followed by a direct anastomosis between the aortobiiliac graft and the iliac stents. The staged open approach allowed for IMA reimplantation to further reduce the risk of postoperative bowel ischemia. While there is no robust evidence to guide duration of staging, the urgency of repair was balanced with the risk of pelvic ischemia post-endovascular stage. The delay was loosely based on the practice of delaying bilateral internal iliac artery embolization to ensure no pelvic ischemia and allow some pelvic collateralization to occur. After 72 hours without complication, the patient was booked into the next available OR time. While balloon-expandable stents were chosen for the endovascular stage to achieve a large post-dilation diameter within the proximal IIAA, this necessitated the use of iliac occluding balloons for distal control over primary clamping, and the single-layer PTFE was subject to significant needle-hole bleeding that required reinforcement with an additional dacron ring. Therefore, depending on the clinical situation, the use of self-expanding covered stents alone or a stent with dual layer PTFE to avoid could be advantageous. This report demonstrates a successful staged hybrid repair of bilateral CIAA and IIAA using graft-to-stent anastomoses to preserve pelvic perfusion in complex aortoiliac aneurysmal disease.

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