The Fate of Small Aneurysms of the Internal Iliac Artery Following Proximal Ligation in Abdominal Aortic Aneurysm Repair

Abstract

To assess the natural history of small internal iliac artery aneurysms (IIAA) measuring 2.0-3.0 cm in diameter, proximally ligated in association with abdominal aortic aneurysm (AAA) repair, we examined 9 of 12 patients who underwent this type of surgery. Postoperative computed tomography scanning demonstrated that three IIAAs were still patent and the other six were thrombosed. An increase in the maximum diameter from that at the time of surgery was seen in four IIAAs. One patient suffered serious complications in that a dilated IIAA caused right ureteral obstruction and subsequent hydronephrosis accompanied by unilateral renal dysfunction. This was successfully treated by resection of the IIAA. The findings of this analysis led us to conclude that small IIAAs associated with AAA repair should be treated by either endoaneurysmorrhaphy or resection of the aneurysm after both proximal and distal ligation.

Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms

“…Natural history of IIAAs following proximal ligation has been infrequently reported with significant enlargement in nearly 50% of patients. 18 Two of 25 patients in our series presenting with isolated IIAAs (4.3 and 4.2 cm diameter) had undergone AAA repair by us 4 and 10 years previously when the small IIAAs were left untreated. Both patients underwent successful endovascular repair (Fig 7, C).…”

“…These aneurysms were often simply treated with proximal ligation and aortoiliac/femoral bypass when associated with AAAs and CIAAs, allowing subsequent growth of the IIAA sac from retrograde, cross-pelvic collateral flow. [17][18][19] The introduction of minimally invasive endovascular options have opened up other simpler, less morbid avenues of treatment with coil embolization of the outflow and therapeutic exclusion of the IIAA sac, but sacrifice of internal iliac artery (IIA) flow has also brought to light issues of acute and chronic pelvic ischemic syndromes.…”

Successful Percutaneous Coil Embolization of a Ruptured Internal Iliac Artery Aneurysm Remnant after Abdominal Aortic Aneurysm Repair via the Deep Iliac Circumflex Artery

“…1,2) In the present case, a 6 cm aneurysm redeveloped in an IIA aneurysm that had been excluded from the circulation by proximal ligation 16 years prior to the current presentation. Surgical access is considered difficult in patient with previous laparotomies and those with large bilateral IIA aneurysms, and coil embolization is an appropriate intervention in the present case.…”

“…1,2) Darling et al reported that 4% of excluded AAAs had persistent blood flow in the aneurysm sac and 0.6% of these aneurysm went on to rupture. 6) In the present case, the persistent flow may be related to the superior gluteal artery, the inferior gluteal artery and the obturator artery serving as inflow and outflow conduit, respectively.…”

“…Small aneurysms may be treated by ligating the proximal segment of the IIA while the distal runoff branches are left intact, but this exclusion may cause aneurysms to expand and even rupture. 1,2) Given its location deep in the pelvis, surgical ligation of all IIA branches for an internal iliac aneurysm is particularly invasive procedure. Ruptured IIA aneurysms are associated with a high mortality rate in the range of 33%-50%, 3) and transfusions are frequently required to counter blood loss.…”