Management of Iliac Artery Aneurysms

1
Management of Iliac Artery Aneurysms
2
Etiology

• Idiopathic Remote collagen vascular disease
• Atherosclerosis, Smoking
• Infectious (TB, Syphilis, S. aureus, Salmonella,
  Klebsiella)
• Collagen diseases (Marfans, Ehlers-Danlos,
  Cystic Medial Necrosis)
• Takayasus, Kawasakis, Bechets, etc.

3
Incidence

• 0.03 lifetime incidence
• 0.3-1.9 of arterial aneurysms
• 75-95 present with AAA
• 7th-8th decade of life
• 8-91 malefemale 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 gt5cm
  repaired)
• lt3cm 0.05-0.15cm/year
• gt3cm 0.25-0.28cm/year

8
Natural History
Santelli et al. J Vasc Surg. 2000 31(1), 114-121
9
Surgical Intervention

• All series gt/ 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 gt2.5cm (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 lt3cm 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, doi10.1016/j.ejvs.200
  7.11.017.
• 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. 198910, 381-384.