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Page 6 of 9 Ghoneim et al. Vessel Plus 2020;4:38 I http://dx.doi.org/10.20517/2574-1209.2020.35

Figure 3. Overall survival at three years

guidelines recommend preserving at least one IIA to maintain the circulation of the pelvis to avoid buttock
[7]
claudication and bowel ischemia .
The options of preserving IIA include the FL, which can accommodate up to 25 mm CIA; iliac branched
devices (IBD); and EIA to IIA bypass either surgically or by endovascular means. Unfortunately, all of
[8]
these solutions are associated with significant operation time and contrast amount . In addition, the
FL technique could be linked with a high rate of dilatation with Type Ib endoleak, five times more than
[9]
the corresponding less than 20 mm CIA diameter . Additionally, the difficulty in later usage of IBD
necessitates the usage of trans-axillary access with increased risk of stroke [9,10] .

Anatomical limitations prohibit the usage of IBD in many iliac aneurysms as IBD necessitates certain
[8]
anatomical features that are only applicable in 40% of CIA aneurysmal anatomy . Additionally, added
financial burden should be taken into account when treating AAA, particularly when compared to the
open surgery [8,11-14] . Similarly, these newer IBD devices have limited evidence on long-term outcomes.
Furthermore, the high cost and longer procedure time, absence of the extended follow-up outcomes and
poor quality of life may hinder the application of IBD in AAA treatment [14-17] .

The surgical option to revascularize the IIA can also increase the complexity and morbidity of the EVAR.
Despite being effective in flow preservation, repositioning of IIA could increase the morbidity and recovery
time, increasing the risk of ureteric and venous injuries, primarily in obese patients with IIA aneurysm [8,18] .