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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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etiology
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.
incidence
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%
complications
Complications
  • Rupture
  • Distal embolization
  • Thrombosis
  • Urologic symptoms secondary to ureteral compression
  • Pain from compression of adjacent nerves and vicera (Rare)
complications5
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.

natural history
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
natural history7
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
natural history8
Natural History

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

surgical intervention
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)

surgical intervention10
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)
surgical intervention11
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
surgical intervention12
Surgical Intervention
  • Krupski et al.
    • 2 Endovascular repairs
      • 1 - required femorofemoral bypass due to stent occlusion
      • 1 - died from rupture 2 years post coiling
conclusions
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
references
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.