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Ghoneim et al. Vessel Plus 2020;4:38 I http://dx.doi.org/10.20517/2574-1209.2020.35 Page 7 of 9

Contrary, multiple reports showed that coverage of the IIA could be tolerated without devastating
complications. Buttock claudication, the most common complications, is likely reversible after a short
period with persistent buttock claudication in less than half of patients. Similarly, reports of the devastating
complications, bowel and spinal cord ischemia, seem to be exaggerated and true occurrence seem to be
exceedingly rare in the literature [13,17,19,20] .

[21]
Mehta et al. reported that the innocence of bilateral IIA coverage and the selective sacrifice of one or
both hypogastric arteries could be done safely during EVAR, even in patients with challenging anatomy.
Based on them, associated comorbidities, such as shock, distal embolization or inability to salvage collateral
branches from the EIA and femoral arteries, may have contributed to the increased morbidity in the
[21]
previous IIA interruption reports .

Additionally, surgical ligation of one or both IIAs is occasionally needed, for instance in renal
transplantation, and life-threatening conditions such as gynecological emergencies have been performed
[22]
without adverse effects. Iliopoulos et al. studied the circulation of IIA during various open aortoiliac
surgeries and found that the ipsilateral EIA branches and common femoral arteries contribute to IIA
circulation more than the contralateral IIA. This was proved in the acute setting, and it is likely to be right
in the long term .
[22]

Furthermore, the preservation of the superior-inferior gluteal system is crucial for the pelvic viscera to
maintain the collateral circulation from the ipsilateral deep femoral artery via the inferior gluteal artery
[23]
and prevent buttock claudication. Fujioka et al. recommended that deep femoral arterioplasty during
EVAR may be needed in those with an advanced stenotic lesion at its origin as a valuable means to decrease
buttock claudication following the IIA occlusion.

In the current study, we tried hard to preserve the IIA if there was a sufficient landing zone. In those cases
where we covered one or two IIAs, there were no significant differences in complications. There was no
bowel ischemia and spinal cord ischemia in either group; however, there was one patient who suffered
buttock claudication in the IIA coverage group.

Data about buttock claudication should be analyzed cautiously as most of the studies are not comprehensive
and do not objectively assess the symptoms [13,17,24] . Fujioka et al. reported no buttock claudication in their
[23]
study with 71 patients following the embolization of the IIA proximally and two weeks before the EVAR,
[17]
allowing the collateral to form properly. Based on the study by Bosanquet et al. , catastrophic ischemic
events such as gluteal, bowel and spinal ischemia are rare (< 1%), and the actual rate rates could be less
[17]
than those reported. In their systematic analysis , they showed a clear reduction in reporting of these
complications in papers published before 2007 (3.6%) compared to those published after 2007 (0.9%) (P
< 0.001). The reasons could be multifactorial, such as increased plugs use, a greater understanding of the
IIA circulation, and enhanced operator experience [13,17,23] . Additionally, the etiology and assessment of
these reported complications may be complicated as the majority of the patients were of advanced age with
common comorbidities, such as diabetes [8,17,25,26] .

In our case, the procedure time, HDU stay and total hospital stay were significantly higher in the IIA
sacrifice group compared to the IIA salvage group. However, there was no statistically significant difference
in the postoperative complications from sacrificing IIAs.

Study limitations
Our study is a retrospective study, and we were limited to a small number of patients. Similarly, we did
not use IBD in our patients. The usage of IBD could be jeopardized by the diameter of IIAs, as there was a