When Should the Internal Iliac Arteries be Preserved in Patients Undergoing Endovascular or Open Repair of Aortoiliac Aneurysms?

Abstract

Internal iliac artery (IIA) occlusion during aortic aneurysm repair has been associated with considerable morbidity. We analyzed the consequences of interrupting one or both IIAs in the standard surgical or endovascular treatment of aortoiliac aneurysms (AIAs). From 1992 to 2000, 158 patients with abdominal aortic aneurysms (n = 66), iliac aneurysms (n = 28), or AIAs (n = 64) required interruption of one (n = 134) or both (n = 24) IIAs as part of their endovascular (n = 110 ) or open repair (n = 48). Endovascular treatment was performed with a variety of industry- or surgeon-made grafts in combination with coil embolization of the IIAs. The standard surgical techniques included oversewing or excluding the origins of the IIAs, and extending the prosthetic graft to the external iliac or femoral artery. There were no cases of buttock necrosis, ischemic colitis requiring laparotomy, or death when one or both IIAs were interrupted. Persistent buttock claudication occurred after 16 (12%) of the unilateral and 3 (13%) of the bilateral IIA interruptions. Impotence occurred in 7 (9%) of the unilateral and 2 (11%) of the bilateral IIA interruptions. Minor neurological deficits of the lower extremity were observed in 2 (1.5%) of the patients with unilateral IIA interruption. Although IIA flow should be preserved if possible, selective interruption of one or both IIAs can usually be accomplished safely during endovascular and open repair of anatomically challenging AIAs. We believe other comorbid factors, such as shock, distal embolization, or the failure to preserve collateral branches from the external iliac and femoral arteries, may have contributed to the morbidity in other reports of IIA interruption.

Keywords

Internal iliac artery aortoiliac aneurysm pelvic ischemia

Get full access to this article

View all access options for this article.

References

Armon MP , Wenham PW , Whitaker SC , et al. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1998; 1503:255-257

Clark SL , Phelan JP , Yeh SY , et al. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol 1985;66(3):353-356

Bao ZM Ligation of the internal iliac arteries in 110 cases as a hemostatic procedure during suprapubic prostatectomy [letter]. J Urol 1980;124(4):578

Agolini SF , Shah K. , Jaffe J. , et al. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage [see comments]. J Trauma 1997;43(3): 395-399

Andriole GL , Sugarbaker PH Perineal and bladder necrosis following bilateral internal iliac artery ligation . Report of a case. Dis Colon Rectum. 1985 ;28(3):183-184

Senapati A. , Browse NL Gluteal necrosis and paraplegia following postoperative bilateral internal iliac artery occlusion. J Cardiovasc Surg (Torino) 1990;31(2):194-196

Gloviczki P. , Cross SA , Stanson AW , et al. Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction . Am J Surg 1991;162(2):131-136

Cikrit DF , O'Donnell DM , Dalsing MC , et al. Clinical implications of combined hypogastric and profunda femoral artery occlusion. Am J Surg 1991;162(2):137-140; discussion 140-141

Paty PK , Shah DM , Chang BB , et al. Pelvic ischemia following aortoiliac reconstruction. Ann Vasc Surg 1994;8(2):204-206

10.

Veith FJ , Hobson RW , Williams RA , Wilson SE Vascular Surgery, Principles and Practice, 2nd ed., Vol. 1. New York: McGraw-Hill ; 1994:1156-1173

11.

Ohki T. , Veith FJ , Sanchez LA , et al. Varying strategies and devices for endovascular repair of abdominal aortic aneurysms. Semin Vasc Surg 1997;10(4):242-256

12.

Picone AL , Green RM , Ricotta JR , et al. Spinal cord ischemia following operations on the abdominal aorta . J Vasc Surg 1986;3(1):94-103

13.

Iliopoulos JI , Howanitz PE , Pierce GE , et al. The critical hypogastric circulation . Am J Surg 1987;154(6):671-675

14.

Kalliafas S. , Albertini JN , Macierewicz J. , et al. Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms. J Vasc Surg 2000;31:1185-1192

15.

Iliopoulos JI , Hermreck AS , Thomas JH , Pierce GE Hemodynamics of the hypogastric arterial circulation . J Vasc Surg 1989;9(5):637-641; discussion 641-642

16.

Zelenock GB , Strodel WE , Knol JA , et al. A prospective study of clinically and endoscopically documented colonic ischemia in 100 patients undergoing aortic reconstructive surgery with aggressive colonic and direct pelvic revascularization, compared with historic controls. Surgery 1989 ;106(4):771-779; discussion 779-780

17.

Johnston KW Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality . J Vasc Surg 1989;9(3):437-447

18.

Cynamon J. , Lerer D. , Veith FJ , et al. Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognizable but possibly preventable complication. J Vasc Intery Radiol 2000;11(50):573-577

19.

Karch LA , Hodgson KJ , Mattos MA , et al. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2000;32:676-683

20.

Criado FJ , Wilson EP , Valazquez OC , et al. Safety of coil embolization of the internal iliac artery in endovascular grafting of abdominal aortic aneurysms. J Vasc Surg 2000;32: 684-688

21.

Parodi JC Relocation of iliac artery bifurcation to facilitate endoluminal treatment of AAA. J Endovasc Surg 1999;6:342-347