Australia & New Zealand Society of Vascular Surgeons

Introduction and Objective In the presence of an abdominal aortic aneurysm (AAA) the incidence of iliac artery dilatation beyond 20mm is 24%. Options for endovascular management of iliac involvement include: 1) flare the graft to the calibre of the ectatic common iliac artery, 2) occlude the internal iliac artery and extend the graft into the external iliac artery, 3) insert a branched stent graft into the iliac system, and 4) perform a aorto-uni-iliac repair with femoral crossover and exclude the common iliac artery by surgical or endovascular means. Methods 1). A review of patients who under-went endoluminal grafting for AAA between August 1994 and December 1998 to obtain the prevalence ratios of iliac disease. Those patients in which at least one or both common iliac arteries measured between 12-22 mm and in whom a flared graft was deployed were studied. Early and late complications, especially distal endoleak and progressive iliac dilatation, were assessed. Technical details included oversizing the graft, using ‘controlled deployment’, to ensure the distal landing zone was at the common iliac bifurcation. 2). Review of cases and reports of branched stent grafting and iliac exclusion. Results Seventy-one patients undergoing AAA repair had 130 flared grafts deployed in one or both CIAs. 65% were deployed in arteries greater than 16mm. Distal endoleak was demonstrated or suspected in the early post-operative course in six patients. Two patients required intervention, three sealed spontaneously and one patient refused further intervention after failed endovascular correction. Follow-up five year survival for flared graft was 43%: two died as a result of aneurysm rupture, one died from a proximal migration of the limb out of the iliac artery and the other died from incomplete seal with persisting endoleak – the iliac limb was deployed short and only covered the proximal iliac artery. The remainder died of unrelated conditions. Fifty-five iliac arteries were available for long-term follow-up. There were no late distal endoleaks and only two arteries showing progressive dilatation – one requiring extension into the external iliac. There were two iliac limb occlusions, one treated by fem-fem bypass and the other conservatively. Branched stent grafts and bifurcated modules with extension limbs into the internal iliac artery are being developed and small series and anecdotal reports indicate improved performance. Discussion Ectatic iliac arteries can be treated using flared grafts. Provided the flared limb is deployed to cover the full length of the common iliac artery and oversized, there appears to be little tendency for the ectatic iliac to enlarge or become aneurysmal. Examples of methods to occlude or preserve the iliac artery are presented and the indications for each are discussed. 1 Norman PE, Lawrence-Brown MMD, Semmens JB, Mai Q. An embryological basis to the anatomical distribution of aorto-iliac aneurysmal disease. Euro J Vasc Endovasc Surg. 2003;25:82-4.