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Management of Iliac Artery Aneurysms

Management of Iliac Artery Aneurysms. Etiology. Idiopathic – Remote collagen vascular disease Atherosclerosis, Smoking Infectious (TB, Syphilis, S. aureus, Salmonella, Klebsiella) Collagen diseases (Marfan’s, Ehlers-Danlos, Cystic Medial Necrosis) Takayasu’s, Kawasaki’s, Bechet’s, etc.

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Management of Iliac Artery Aneurysms

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  1. Management of Iliac Artery Aneurysms

  2. Etiology • Idiopathic – Remote collagen vascular disease • Atherosclerosis, Smoking • Infectious (TB, Syphilis, S. aureus, Salmonella, Klebsiella) • Collagen diseases (Marfan’s, Ehlers-Danlos, Cystic Medial Necrosis) • Takayasu’s, Kawasaki’s, Bechet’s, etc.

  3. Incidence • 0.03% lifetime incidence • 0.3-1.9% of arterial aneurysms • 75-95% present with AAA • 7th-8th decade of life • 8-9:1 male:female ratio • Common Iliac Artery - 70% • Internal Iliac Artery - 20% • External Iliac Artery - 10% • Bilateral Disease – 20-60%

  4. Complications • Rupture • Distal embolization • Thrombosis • Urologic symptoms secondary to ureteral compression • Pain from compression of adjacent nerves and vicera (Rare)

  5. Complications • 106 Patients • 59 presented with intact IAA (mean 3.9cm) • 10 presented with rupture (mean 7.2cm) • 37 unoperated on (mean 3.2cm) • 12 enlarged • 3 ruptured (smallest 3.5cm) Kasirajan V et al. Card Surg. 1998: 6(2), 171-177.

  6. Natural History • Santilli et al, 2000 (U. of Minnesota) • 189 patients in VA system (2 women) with 323 iliac artery aneurysms • 47 patients with isolated IAA • Followed with USG or CT at 6 month intervals • Average f/u: 31.4 months (4.2 studies) • Survival: 96.3% at 1 year, 88.5% at 2 years, 72.3% at 3 and 4 years

  7. Natural History • Average rate of expansion: 0.118 +/- 0.017 cm/year • No expansion in 37.5% • All IAA between 4 and 4.9cm expanded (All >5cm repaired) • <3cm: 0.05-0.15cm/year • >3cm: 0.25-0.28cm/year

  8. Natural History Santelli et al. J Vasc Surg. 2000: 31(1), 114-121

  9. Surgical Intervention • All series >/= 5 patients between 1961 and 1997 • 367 patients with 500 IIAs • Mean age 68 years • Symptomatic: 208 (62%) • Asymptomatic: 123 (38%) • Rupture: 108 (29%) • Emergent mortality: 40% • Elective mortality: 7% Krupski et al, J Vasc Surg. 1998: 28(1)

  10. Surgical Intervention • Krupski et al, 1998 (U. of Colorado) • 21 patients (17 men, 4 women) • Mean age 69 years (38-87) • 52% unilateral disease, 57% symptomatic • Aneurysm >2.5cm (2.5-12cm, mean 5.6 +/- 2cm) • Smoking 71%, HTN 67%, CAD 52%, Prior CABG 19% • Mean follow up 5.5 years (2 months - 13 years)

  11. Surgical Intervention • Krupski et al. • 19 open repairs, 0 perioperative deaths • 17 Elective • 1 - Right LE compartment syndrome • 2 Emergent • 1 - C. diff requiring colectomy • 1 - Multisystem Organ Failure due to rupture/shock

  12. Surgical Intervention • Krupski et al. • 2 Endovascular repairs • 1 - required femorofemoral bypass due to stent occlusion • 1 - died from rupture 2 years post coiling

  13. Conclusions • Rupture under 3cm very rare • High risk of rupture for aneurysms greater than 5cm with a correlation between increasing size and increasing risk of rupture • Many aneurysms remain stable - safe to monitor patients yearly with aneurysms <3cm and every 6 months 3-3.5cm • Surgical risk for otherwise uncomplicated patients now generally very low • Further need for long term comparison of open vs. endovascular repair

  14. References • Santilli SM, Wernsing SE, Lee ES. Expantion rates and outcomes for iliac artery aneurysms. Journal of Vascular Surgery. 2000: 31(1), 114-121. • Kasirajan V et al. Management of isolated common iliac artery aneurysms. Cardiovascular Surgery. 1998: 6(2), 171-177. • Dorigo W et al. The Treatment of Isolated Iliac Artery Aneurysm in Patients with Non-aneurysmal Aorta. European Journal of Vascular and Endovascular Surgery. 2008, doi:10.1016/j.ejvs.2007.11.017. • Krupski WC et al. Contemporary management of isolated iliac aneurysms. Journal of Vascular Surgery. 1998: 28(1). • Brunkwall J et al. Solitary aneurysms of the iliac artery system: an estimate of their frequency and occurance. Journal of Vascular Surgery. 1989:10, 381-384.

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