Common Iliac aneurysmorrhaphy with concurrent ileo-femoral bypass: A novel approach to internal iliac artery preservation during EVAR

RD Moore MD MSC FRCSC, Wesam Abuznadah MD, Mona Motamedi BA(Hons)
University of Calgary Division of Vascular Surgery, Calgary, Alberta

Purpose: To demonstrate the technique, safety and efficacy involved in a novel approach to managing the internal-external iliac bifurcation during EVAR with concurrent bilateral common iliac artery aneurysm.

Study Design: Case series of 3 male patients (mean age 67 years) with AAA and concomitant bilateral common iliac artery aneurysm treated with this approach using a bifurcated endovascular aortic graft.

Background: Management of the internal iliac arteries during endovascular repair for aortic aneurysms with bilateral common iliac arteries is controversial, with some authors reporting good results with bilateral internal iliac embolization and coverage (J Vasc Surg 2004;40:698-702) Most series have demonstrated the need to preserve flow through at least one internal iliac artery during endovascular repair in order to minimize the negative outcomes associated with pelvic ischemia. Multiple reperfusion techniques have been described (J Vasc Surg 2006;44:1162-9),  but all are associated with difficulties related to the angulation, calcification, or depth in the pelvis of the iliac branches, and are limited by the useable length of the hypogastric trunk and external iliac for reconstructions and /or stent deployment.

 Methods: A limited flank incision to expose the iliac bifurcation was completed, followed by placement of an end-side or end-end ileo-femoral bypass from the proximal iliac aneurysm. This rifampicin-soaked prosthesis was then tunneled extra-peritoneally to the ipsilateral groin incision for endovascular stent access, and distal graft limb deployment.  The iliac aneurysm was then opened distally to within 1cm of the bifurcation, and a 14Fr sheath obturator or Coon’s tip dilator was passed from the common femoral arteriotomy retrograde and manually directed into the orifice of the internal iliac artery. Endarterectomy of the bifurcation was performed as required for calcification or stenosis. The distal common iliac aneurysm was then oversewn on the mandrill to maintain the lumen and create the internal-external bypass. After completion of EVAR the ileofemoral graft was anastamosed to the femoral artery and the internal-external bypass was then perfused through retrograde flow. The contralateral internal iliac was embolized and covered with endograft limb to achieve endoseal.

Results: Mean follow-up at time of reporting was 150 days. No patients demonstrated ischemic colitis, sacral plexopathy, graft occlusion, nor any peri-operative or delayed mortality. There was no ipsilateral proximal claudication reported. Two patients demonstrated pre-discharge Type II endoleaks, which are being observed, and one patient developed a retroperitoneal hematoma requiring transfusion.

Conclusion: Common iliac aneurysmorrhaphy is a novel, safe and effective approach in managing patients with AAA and concomitant bilateral common iliac artery aneurysms, and allows for preservation of internal iliac perfusion. This technique is more attractive than other bypass techniques (e.g.internal-external bypass ) because of the easier superficial pelvic dissection required, the ability to accommodate even very short hypogastric trunks, the ability to utilize endarterectomy at the iliac bifurcation to enhance patency, the use of the autogenous circulation for the reconstruction, and the unlimited prosthetic distal landing zone created for limb deployment. The need for larger series and long term outcome is justified.