Is Internal Iliac Artery Embolization Essential Prior to Endovascular Repair of Aortoiliac Aneurysms?

Abstract

Patients who undergo endovascular repair of aorto-iliac aneurysms (EVAR) require internal iliac artery (IIA) embolization (IIAE) to prevent type II endoleaks after extending the endografts into the external iliac artery. However, IIAE may not be possible in some patients due to technical factors or adverse anatomy. The aim of this study was to assess retrospectively whether patients with aorto-iliac aneurysms who fail IIAE have an increase in type II endoleak after EVAR compared with similar patients who undergo successful embolization. We retrospectively analyzed the records of 148 patients who underwent EVAR from December 1997 to June 2005. Sixty-one patients had aorto-iliac aneurysms which required IIAE before EVAR. Fifty patients had successful IIAE and 11 patients had unsuccessful IIAE prior to EVAR. The clinical and imaging follow-up was reviewed before and after EVAR. The endoleak rate of the embolized group was compared with that of the group in whom embolization failed. After a mean follow-up of 19.7 months in the study group and 25 months in the control group, there were no statistically significant differences in outcome measures between the two groups. Specifically, there were no type II endoleaks related to the IIA in patients where IIAE had failed. We conclude that failure to embolize the IIA prior to EVAR should not necessarily preclude patients from treatment. In patients where there is difficulty in achieving coil embolization, it is recommended that EVAR should proceed, as clinical sequelae are unlikely.

Systematic Review and Meta-analysis of the Effect of Internal Iliac Artery Exclusion for Patients Undergoing EVAR

“…The theoretical risk is that type II endoleaks from the untreated IIA will be a significant issue, and while results show that these endoleaks are relatively common, intervention was only required for 0.38% of covered IIAs. Treatment bias is likely to account for these impressive results: units may report covering the IIA only when pre-emptive embolisation had failed, 11,17 when the IIA is inadvertently covered, 11,17 when there is a 5 mm length of non-aneurysmal common iliac artery (CIA) above the IIA, 61 or when the IIA is < 5 mm in diameter. 44 The exact morphology of the distal CIA is likely to be important when coverage alone is performed.…”

Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome

“…25 The benefit of embolization of IIA prior to EVAR is disputable. [30][31][32] We demonstrated that embolization of IIA prior to EVAR is effective to prevent Type II endoleaks. Both ProxEmbX of unaffected IIA and DistEmbX of aneurysmatic IIA have a low risk of lifestyle-limiting side effects without significantly different clinical outcomes.…”

Challenging the Evidence for Pre-emptive Coil Embolisation of the Internal Iliac Artery during Endovascular Aneurysm Repair

“…11 To our knowledge, the present series is the first to report the results of a policy of routinely abandoning embolisation of the IIA. Previous studies on EVAR with IIA coverage for aortoiliac aneurysms applied a selective approach in deciding whether or not to embolise the IIA; Bharwani et al 22 and Farahmand et al 21 only included cases without coil embolisation in which attempted embolisation had technically failed or in which the IIA had been covered inadvertently. The group from the University of Wisconsin presented two reports on patients with and without coil embolisation, 24,25 but no reasons were provided for their decision whether or not to perform concomitant IIA embolisation.…”

“…18 It has been hypothesised that sole stent-graft coverage of the IIA's orifice provides the most proximal occlusion and may limit the symptoms of pelvic ischaemia. 21,22 Remarkably, higher incidences of pelvic ischaemia are reported in endovascular series with IIA coverage than in open surgical series with IIA ligation. 15 This difference may partly be due to adjunctive measures such as coil embolisation of the IIA, leading to occlusion of secondary branches and interrupting pelvic collateral circulation.…”