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Page 2 of 9 Ghoneim et al. Vessel Plus 2020;4:38 I http://dx.doi.org/10.20517/2574-1209.2020.35

Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.

Keywords: Abdominal aortic aneurysm, Iliac artery aneurysm, endovascular abdominal aortic aneurysm repair,
clinical outcomes

INTRODUCTION
Endovascular aneurysm repair (EVAR) has become progressively common in abdominal aortic aneurysm
(AAA) repair. Concomitant aneurysm of the common iliac arteries (CIAs) is seen in around one-third
[1,2]
of AAA patients . Internal iliac artery (IIA) embolization and extension of the endograft limb into
the external iliac artery (EIA) can widen the indications for EVAR. However, the endovascular repairs
of abdominal aortic aneurysms in patients with aneurysmal extensions to the iliac bifurcation could be
[3]
associated with higher complications and/or secondary procedures .

The optimal endovascular management of the IIA occlusion in aortoiliac aneurysms is controversial.
Unilateral occlusion of IIA is relatively safe, but bilateral IIA occlusion could be associated with
complications, such as ischemic colitis or neurologic impairment. Therefore, revascularization of at least
one of the hypogastric flows might be necessary to maintain pelvic perfusion where the stent-grafts are
extended into the bilateral EIAs . Different techniques are utilized to preserve IIA patency; however,
[1,4]
most surgical procedures are limited by the increased cost, contrast use and operative time leading to
[5]
unnecessary radiation exposure . Therefore, in this study, we aimed to assess the operative outcomes of
IIA coverage during EVAR in our tertiary vascular referral center.

METHODS
This is a retrospective observational study of patients who had elective EVAR from 2002 to 2018 in our
tertiary vascular referral center. The study was approved by our Institutional Research Ethics Committee.
All patients were identified from our medical records and any missing data were obtained from the
institutional patient administration system, and archiving of the picture and communication system. We
excluded patients with ruptured AAA, aortoiliac occlusive disease and focal abdominal dissection.

[6]
Postoperative complications are reported based on the Society for Vascular Surgery reporting guidelines .

Outcomes
Primary outcomes included 30-day mortality and overall survival. Secondary outcomes included freedom
from reintervention, aneurysm-related survival and complication rates (new-onset buttock claudication,
erectile dysfunction and intestinal ischemia).

Following discharge, follow-up was performed with physical examination and aortic computed tomography
angiography (CTA) at six weeks and duplex ultrasound (DUS) imaging at six and twelve months in the first
year and annually after that. In selective patients, repeat control CTA was performed if there was evidence
of sac expansion and/or endoleak in DUS.

Operative procedures
All patients underwent surgery under general anesthesia. Different stent-grafts were used: AneuRx, Talent,
Endurant and Endurant II (Medtronic, Santa Rosa, Calif); Excluder (W.L. Gore & Associates, Flagstaff,
Ariz); and Powerlink, AFX and AFX 2 (Endologix, Irvine, Calif). Endograft selection was made based
on the preference of the surgeon and vascular anatomy. An iliac limb ≥ 20 mm in distal diameter was
considered as a flared limb (FL). The FL extensions were chosen from large-diameter iliac extension limbs
with range of 20-28 mm.