Bilateral Internal Iliac Artery Occlusion for EVAR
- Volume 8 - Issue 1 - January 2011
- Posted on: 1/4/11
- 0 Comments
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Kristen Rhodes*, Paul Didomenico, MD, George Vatakencherry, MD
ABSTRACT: Purpose. Internal iliac artery occlusion can be an intentional or inadvertent complication of endovascular aneurysm repair, especially repair of abdominal aortic aneurysms (EVAR). Several studies have reported on side effects experienced by patients as a result of bilateral internal iliac artery occlusion, with buttock claudication and erectile dysfunction being the most frequent. A low incidence of serious side effects, including colonic and spinal cord ischemia, have been reported. In our study, we add the experience of 7 patients who underwent bilateral internal iliac artery occlusion at our institution in conjunction with endovascular repair of aneurysms of the abdominal aorta or common iliac arteries. Methods. A retrospective chart review was performed on patients who received embolization or experienced inadvertent occlusion of both internal iliac arteries. Patients were also contacted by phone and were asked about their experience with the procedures. Data regarding the incidence and severity of side effects as experienced by patients were compared to that obtained from published studies. Results. Between May 2000 and May 2010, 7 patients underwent procedures resulting in bilateral occlusion of the internal iliac arteries. Four of 7 patients (57%) experienced initial buttock claudication following the procedures; of these, claudication resolved by 18 months in 2 of 4 patients. Two of 7 patients (29%) reported experiencing new-onset impotence following the embolization procedures. There were no incidences of colonic or spinal cord ischemia. Conclusions. Bilateral internal iliac artery occlusion appears to have an acceptable incidence of side effects, with buttock claudication being the most common negative symptom.
VASCULAR DISEASE MANAGEMENT 2011;8:E1–E5
Key words: abdominal aortic aneurysm; iliac artery; iliac occlusions; aortic aneurysm stent graft
Endovascular repair of abdominal aortic aneurysms (EVAR) has become a robust alternative to open surgical repair in appropriately selected candidates. Reported lower morbidity, perioperative mortality and decreased duration of hospital stay1–3 have contributed to the increasing use of EVAR when feasible. Common iliac artery (CIA) aneurysms are present unilaterally or bilaterally in approximately 16% and 12% of patients with identified abdominal aortic aneurysms (AAA), respectively4 A potential obstacle to EVAR is distal aneurysms, including those affecting the common iliac artery and its branches. Common iliac or external iliac artery aneurysms may require that an aortic stent-graft be extended distally into the external iliac artery in order to provide adequate distal sealing of the graft. The presence of internal iliac artery (IIA) aneurysms may require occlusion by stent grafting or coiling. Disruption of flow to the IIA can also occur with unintentional traumatic interruption of the artery or distal migration of an aortic stent-graft that covers the IIA orifice. Thus, IIA occlusion can become an intentional or unintended complication of EVAR.
Reported complications of unilateral and bilateral IIA occlusion include buttock and thigh claudication, impotence and other more rare occurrences such as colonic ischemia, spinal cord ischemia and scrotal skin sloughing.5–7 The reported frequency of these side effects vary, but the majority of available data suggest that bilateral IIA occlusion results in increased morbidity as compared to unilateral occlusion.8–11 Rayt et al, in a study consisting of case series data pooled with data derived from 18 previously published studies, reported that the most common adverse effect experienced by patients who underwent bilateral IIA embolization was buttock claudication, occurring with a frequency of 35% (34 of 98 patients).8 In many of these studies, improvement or resolution of claudication was documented in some or most patients after 1, 6 or 12 months. New-onset erectile dysfunction or impotence was the second most commonly reported side effect, occurring in 24% (9 of 28) of those undergoing bilateral IIA embolization.8
In cases where bilateral IIA occlusion is necessary, it has previously been suggested that the use of staged embolizations, allowing a period of days to weeks to elapse between an initial embolization and a second embolization concurrent with stent-graft placement, may decrease the incidence of morbidity as compared to simultaneous bilateral embolization performed at the time of stent-graft placement. Staged embolizations may provide time for collateral pelvic circulation to develop, thus limiting the areas that are permanently or temporarily deprived of blood flow. However, the potential benefits of staged embolizations remain a point of contention, as conflicting outcomes have been reported in some studies.12,13
It has been suggested that another means to decrease morbidity in IIA embolization is by proximal occlusion of the artery, with use of techniques to prevent distal coil migration.12,14,15 Proximal artery occlusion may better allow for the development of collateral pelvic circulation, and thus reduce side effects of IIA occlusion in a manner similar to staged embolizations, i.e., by minimizing ischemia. In one study, the decrease in frequency of side effects reported when such methods were utilized was so impressive as to lead the author to suggest that proper technique might prevent many of the morbidities experienced with IIA embolization.14