Managing Common Iliac and Internal Iliac Aneurysms during

Managing Common Iliac and Internal Iliac Aneurysms during EVAR Edward Woo Associate Professor Vice Chief/Program Director of Vascular Laboratory Division of Vascular Surgery and Endovascular Therapy University of Pennsylvania Health System Department of Surgery, University of Pennsylvania Health System

Disclosures § Cook, Medtronic, Gore, Atrium Department of Surgery, University of Pennsylvania Health System

Aorto. Iliac Aneurysms § Extension of aortic aneurysm § Common iliac arteries often involved – Unilateral – Bilateral § Internal iliac artery aneurysm § Up to 40% present with concomitant iliac aneurysms Ghosh J, Murray D, Paravastu S, et al. Contemporary management of aorto-iliac aneurysms in the endovascular era. Eur J Vasc Endovasc Surg. 2009; 37(2): 182 -188. Department of Surgery, University of Pennsylvania Health System

Enlarged but existent landing zone § Bell-bottom Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair. Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, Mc. Lafferty RB. J Vasc Surg. 2001 Feb; 33(2 Suppl): S 33 -8. Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow. Kritpracha B, Pigott JP, Russell TE, Corbey MJ, Whalen RC, Di. Salle RS, Price CI, Sproat IA, Beebe HG. J Vasc Surg. 2002 May; 35(5): 874 -81. Department of Surgery, University of Pennsylvania Health System

Iliac Limbs Department of Surgery, University of Pennsylvania Health System

Aneurysmal/Ectatic iliac LZ Department of Surgery, University of Pennsylvania Health System

Department of Surgery, University of Pennsylvania Health System

IIA Embolization

IIA Embolization § Downsides – – – Claudication-buttock, hip Impotence Spinal cord ischemia Colonic ischemia Pelvic ischemia Department of Surgery, University of Pennsylvania Health System

Department of Surgery, University of Pennsylvania Health System

Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm. Kwok PC, Chung TK, Chong LC, Chan SC, Wong WK, Chan MK, Chu WS. J Vasc Interv Radiol. 2001 Jun; 12(6): 761 -3. The authors report a rare neurologic complication after the implantation of a bifurcated stent-graft for abdominal aortic aneurysm. The stent-graft was extended to both external iliac arteries after embolization of both internal iliac arteries. The patient subsequently had weakness and numbness of both lower limbs with bowel and bladder incontinence. He probably had ischemic injury to the nerve roots or the lumbosacral plexus, which was related to extensive occlusion of their supplying arteries. The mechanism of spinal cord and neurologic ischemia after aortic stent-graft implantation is discussed. Department of Surgery, University of Pennsylvania Health System

Hybrid Surgical Approach § Revascularize and preserve IIA § EIA-IIA bypass via RP approach § Stay distal on EIA § Ligate proximal IIA § EVAR via EIA or CFA Department of Surgery, University of Pennsylvania Health System

Creative Techniques Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. Lobato AC. J Endovasc Ther. 2011 Feb; 18(1): 106 -11. External-to-internal iliac artery endografting for the exclusion of iliac artery aneurysms: an alternative technique for preservation of pelvic flow? van Groenendael L, Zeebregts CJ, Verhoeven EL, van Sterkenburg SM, Reijnen MMCatheter Cardiovasc Interv. 2009 Feb 1; 73(2): 156 -60. . Endovascular exclusion of bilateral common iliac artery aneurysms with preservation of internal iliac artery perfusion. Clarke MJ, Pimpalwar S, Wyatt MG, Rose JD. Eur J Vasc Endovasc Surg. 2001 Dec; 22(6): 559 -62. Hypogastric preservation with Viabahn stent graft during endovascular aneurysm repair. Friedman SG, Wun H. J Vasc Surg. 2011 Aug; 54(2): 504 -6. Epub 2011 Mar 2. Department of Surgery, University of Pennsylvania Health System

Fem-Fem

Preserve- Iliac Branch Device This is an experimental device Department of Surgery, University of Pennsylvania Health System

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

This is an experimental device

Internal Iliac Artery Aneurysm § Much less common § Preservation is difficult Department of Surgery, University of Pennsylvania Health System

Landing Zone § Bypass to IIA § Stent to distal IIA – Proximal-sandwich, periscope, bifur § Stent into Branch – Coil other branch

Conclusions § Iliac aneurysms can be commonly associated with AAA § Does it affect EVAR distal limbs § Does Internal need to be preserved – Best means Department of Surgery, University of Pennsylvania Health System