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21 Open Repair ofCommon Iliac Artery Aneurysm
anastomosed to the left common iliac artery
bifurcation. Patient’s postoperative course was
uneventful, and he was discharged on the fth
postoperative day. He was last seen in the clinic
on June 2019, and a duplex imaging showed patent aortic graft with satisfactory distal iliac anastomosis without any recurrence of an aneurysm.
Discussion
Isolated aneurysms of the iliac arteries are
extremely rare, comprising less than 2% of all
patients with aneurysmal disease. The primary
etiology is degenerative, but other causes such
as mycotic pathology, dissection, trauma,
Marfan syndrome, and other collagen vascular
diseases may result in the formation of an iliac
aneurysm. Repair is recommended for goodrisk patients with aneurysms larger than 3.5cm.
Both open and endovascular repair has been
performed with good results by a number of
investigators [1, 2]. The indication for repair is
to prevent rupture as operative mortality for a
ruptured iliac aneurysm ranges from 30% to
50% [2]. The selection criteria for open repairs
versus endovascular repairs depend on the anatomy of the aneurysm.
Endovascular repair has become the preferred
approach in patients presenting with isolated
iliac artery aneurysms [3, 4]. If there is an appropriate neck (usually 15 mm) in the proximal
common iliac artery, a unilateral iliac endograft
placement is satisfactory. In patients with less
than 15mm proximal neck of the common iliac
aneurysm, bifurcated aortic endograft is preferred. In most instances, the endograft limb is
placed in the external iliac artery landing zone
[2–4]. The ipsilateral internal iliac artery was
addressed usually with coil embolization, which
can be performed at the same setting or as a separate procedure.
Iliac branch excluder (IBE) device is used to
isolate the common iliac artery from systemic
blood ow and to preserve the blood ow to
external and internal iliac artery in patients with
common iliac or aortoiliac aneurysms. External
iliac artery diameter of 6.5–25 mm with a seal
zone length of 10 mm and internal iliac artery
diameter of 6.5–13.5mm with a seal zone length
of at least 10 mm is required to be eligible for
IBE device [5]. Iliac branch patency is excellent
(89.2% at 10years) with most occlusions occurring in patients with internal iliac artery aneurysms [5]. IBE endografting is a satisfactory
solution for endovascular repair of abdominal
aneurysm with associated common iliac aneurysms, isolated common iliac, and hypogastric
aneurysm.
In this patient, it was decided to perform
open infrarenal aortic repair as infrarenal aorta
was tortuous, and there was aneurysmal dilatation of right common iliac artery. A preferred
method of treatment in this instance was aortobiiliac graft reconstruction although in some
instances a unilateral iliac graft interposition
may be satisfactory if the infrarenal aorta and
the contralateral iliac artery do not show any
aneurysmal changes.
Invited Commentary fromJonathan
R.Thompson, MD, andIraklis
I.Pipinos, MD
The author does an excellent job presenting an
open solution to a case which would create challenges from an endovascular perspective.
Signicant tortuosity of the right common iliac
artery at the origin and dilation at the iliac bifurcation make an endovascular option less attractive. The wider distribution of the iliac branch
endoprosthesis and recent changes in reimbursement will make this a viable option for most
patients with iliac aneurysms. When an endovascular approach is not possible or not ideal, traditional open surgical repair is warranted and
should be in the armamentarium of all vascular
surgeons.
As the author points out, recommendations
for repair are based upon good-risk surgical
candidates. For patients with multiple comorbidities, a hard threshold of repair at 3.5cm for
isolated common iliac artery aneurysms might
not always be in the patient’s best interest. If
preoperative risk assessment straties the
References
83
patient into a group with signicant intraoperative and perioperative risk of morbidity and
mortality, delaying repair to a higher size threshold may be appropriate. Expected growth rate
for isolated iliac aneurysms is less clear and
may vary based upon size [6].
When planning for elective open repair of
aneurysms involving the iliac vessels, one should
strongly consider the immediate preoperative
placement of ureteral stents [7]. While this
doesn’t prevent ureteral injuries, in our hands this
helps identify a ureter which may otherwise be
difcult to nd. Aneurysms, by denition, have
an element of inammation, and this can make
dissection difcult and ureteral injury more
likely, particularly in pelvic aneurysms. While
we would approach the patient similar to the
authors with a transperitoneal approach given our
comfort with the reconstruction for aortobiiliac
grafts, others have suggested a retroperitoneal
approach, even for right-sided aneurysms [8]. For
this particular case, the aorta and proximal common iliac appear relatively normal in size. A
good option with less morbidity may have been a
retroperitoneal incision with or without reconstruction of the aorta. A limited iliac reconstruction can be performed through a relatively small
incision [9].
References
1. Sandhu RS, Pipinos II. Isolated iliac aneurysms.
Semin Vasc Surg. 2005;18:209–15.
2. Patel NV, Long GW, Cheema ZF, Rimar K, Brown
OW, Shanley CJ.Open versus endovascular repair of
isolated iliac artery aneurysms: a 12-year experience.
J Vasc Surg. 2009;49:1147–53.
3. Boules TN, Selzer F, Stanziale SF, Chomic A, Marone
LK, Dillavou ED, Makaroun MS.Endovascular management of isolated iliac artery aneurysms. J Vasc
Surg. 2006;44:29–37.
4. Chaer RA, Barbato JE, Lin SC, Zenati M, Kent KC,
Mckinsey JF. Isolated iliac artery aneurysms: a contemporary comparison of endovascular and open
repair. J Vasc Surg. 2008;47:708–13.
5. Parlani G, Simonte G, Farchioni L, Iselme G, Cieri
E, Lenti M, Cao P, Verzini F.Lesson learned with the
use of iliac branch devices: 10-year results in 150
consecutive patients. Euro J Vasc Endovasc Surg.
2016;52(3):402.
6. Santilli SM, Wernsing SE, Lee ES. Expansion rates
and outcomes for iliac artery aneurysms. J Vasc Surg.
2000;31:114–21.
7. Kusaka J, Matsumoto S, Hagiwara S, Koga H, Noguchi
T. Use of perioperative ureteral stent in abdominal aortic aneurysm with retroperitoneal brosis – a
report of two cases. Korean J Anesthesiol. 2012 Jul;
63(1):76–9.
8. Reilly JM, Sicard GA.Right retroperitoneal approach
to the aorta and its branches: part II.Ann Vasc Surg.
1994 May;8(3):318–23.
9. Wind GG, Valentine RJ.Anatomic exposures in vascular surgery. Chapter 12. 3rd ed: Lippincott Williams
& Wilkins © 2013.
Open Repair ofRuptured Common
Iliac Artery Aneurysm
22
Physical Examination
A 67-year-old female presented to the emergency room of the hospital with severe diffuse
abdominal pain and back pain in 2011. She
underwent CT scan of the chest and abdomen
and was found to have a 10cm transverse diameter left common iliac aneurysm with a large
retroperitoneal hematoma and 3.5cm right common iliac aneurysm (Fig. 22.1). Aorta was
extremely tortuous, and there was evidence of a
small right hypogastric artery aneurysm. It was
decided to perform open repair of ruptured left
common iliac aneurysm.
Procedure
Patient underwent emergent repair of ruptured
common iliac aneurysm under general anesthesia. A midline incision from the xiphoid to the
symphysis pubis was made. During the mobilization of the aorta, the blood pressure dropped
to 60mm systolic, and immediately a proximal
aortic clamp was applied below the renal arteries after Bookwalter retractor has been applied.
There was venous bleeding from the junction of
the right ovarian vein with inferior vena cava
which was controlled with 5-0 cardiovascular
polypropylene suture (Ethicon Summerville,
Fig. 22.1 CTA showing ruptured left common iliac aneurysm with surrounding retroperitoneal hematoma and intact
right common iliac aneurysm
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_22
85
86
Fig. 22.2 Follow-up CTA showing satisfactory aortoiliac reconstruction
22 Open Repair ofRuptured Common Iliac Artery Aneurysm
NJ). Aorta was mobilized, and right external
and right hypogastric arteries were separately
dissected and looped with a silastic loop. On the
left side, incision was made along a white line
of Toldt. A large left iliac aneurysm was
exposed, which had ruptured posteriorly. Left
external and internal iliac arteries were also
mobilized. Patient was given 5000units of heparin, and ACT was monitored. Patient needed
another supplemental dose of 2500units of heparin. An 18mm × 9 mm knitted Dacron graft
was selected. Proximal anastomosis was done to
the divided infrarenal aorta with 4-0 cardiovascular Prolene running suture. Right common
iliac artery aneurysm was divided, and anastomosis was done of the right limb of the Dacron
graft right common iliac artery just above its
bifurcation with 4-0 cardiovascular Prolene running suture. The left limb of the graft was
brought under the sigmoid colon and anastomosed to the left external iliac artery as left
hypogastric artery arose 2–3cm from origin of
external iliac artery because of the large size of
the aneurysm. Therefore, it was decided to ligate
the hypogastric artery and perform an end-toend anastomosis of the left external iliac artery
with 4-0 cardiovascular Prolene.
Patient developed ventilator-dependent
respiratory failure and pneumonia which
cleared with antibiotics, ventilatory support,
and chest physiotherapy. Patient’s other comorbidities included hypertension and coronary
artery disease. Patient was discharged on the
tenth postoperative day to the rehabilitation
center of the hospital.
Postoperative CT angiography 5 years later
showed satisfactory aortoiliac reconstruction
(Fig.22.2). Patient was seen in the ofce for follow- up in 2018 with evidence of mild diastolic
heart failure, and she is being managed medically
for her heart failure.
Discussion
Emergency open surgical repair of ruptured iliac
aneurysms is associated with mortality rate of
10–60% [1]. The mortality is signicantly
reduced (5%) following elective repair of an
asymptomatic iliac artery aneurysm [2]. The incidence of major postoperative complications following an open repair ranges from 3 to 22%
(16%) [2]. These postoperative complications
include lower extremity ischemia from distal
embolization, visceral and pelvic ischemia from
disruption of hypogastric ow, aortoenteric stula, graft infection, and ureteral and iliac vein
injury.
References
87
In this patient, because of the large size of
common iliac aneurysms with associated tortuosity, endovascular approach may have been technically difcult as the guide wires may be difcult
to advance and valuable time may be lost in
obtaining proximal control with ongoing blood
loss from the ruptured iliac aneurysm.
Good results using endovascular repair of isolated iliac artery aneurysms have been reported
from case series by Boules etal. and Chaer etal.
[3, 4].
Invited Commentary fromJonathan
R.Thompson, MD, andIraklis
I.Pipinos, MD
Rupture of a common iliac artery aneurysm, in
the acute phase, can sometimes be difcult to
distinguish from a ruptured aortic aneurysm due
to variation in the size of the retroperitoneal
hematoma. Treatment strategies should be based
around institutional experience with regard to
ruptured aneurysms. Many centers employ an
endovascular rst treatment strategy for true ruptured aneurysms where all patients are taken to
the hybrid suite rst [5]. Balloon occlusion of
the aorta, analogous to an aortic cross clamp, is
used for all unstable patients initially.
Endovascular or open therapy is then commenced accordingly.
When a surgeon is performing a laparotomy
for a ruptured aneurysm, it may be useful to
obtain supraceliac control of the aorta prior to
dissecting out the pararenal segment. As can happen, such as in the patient presented above, during the initial exposure of the aorta, the blood
pressure dropped. Obtaining supraceliac control
adds minimal morbidity and can help decrease
worry and stress during the dissection. Should
aortic injury occur during the dissection, a short
period of supraceliac clamping offers minimal
morbidity and may decrease the volume changes
and pressure swings if infrarenal control is not
yet available. Once the clamp can safely be
moved more distally, i.e., to the infrarenal neck, it
should be done.
Internal iliac arteries should always be revascularized when possible [6]. In the high stress
situation of a rupture, the internal and external
iliac bifurcation may not always be easily controlled to allow for a clear anastomosis. In this
scenario it is reasonable to perform the distal
anastomosis to the external iliac artery or even
the common femoral on the ipsilateral side if the
internal iliac is preserved on the contralateral
side. The internal iliac can then be ligated with a
small risk of complications. The goal for a ruptured aneurysm should always be life preservation for the patient. Other nuances which are
important in elective aneurysm repair, such as
inferior mesenteric artery reimplantation, accessory renal artery, preservation, etc., are less
important considerations during a ruptured
aneurysm.
References
1. Sandhu RS, Pipinos II. Isolated iliac aneurysms.
Semin Vasc Surg. 2005;18:209–15.
2. Patel NV, Long GW, Cheema ZF, Rimar K, Brown
OW, Shanley CJ.Open versus endovascular repair of
isolated iliac artery aneurysms: a 12-year experience.
J Vasc Surg. 2009;49:1147–53.
3. Boules TN, Selzer F, Stanziale SF, Chomic A, Marone
LK, Dillavou ED, Makaroun MS.Endovascular man-
agement of isolated iliac artery aneurysms. J Vasc
Surg. 2006;44:29–37.
4. Chaer RA, Barbato JE, Lin SC, Zenati M, Kent KC,
Mckinsey JF. Isolated iliac artery aneurysms: a con-
temporary comparison of endovascular and open
repair. J Vasc Surg. 2008;47:708–13.
5. Mehta M.Endovascular aneurysm repair for ruptured
abdominal aortic aneurysm: the Albany Vascular
Group approach. J Vasc Surg. 2010;52:1706–12.
6. Chaikof EL, Dalman RL, Eskandari MK, Jackson
BM, etal. The Society for Vascular Surgery practice
guidelines on the care of patients with an abdominal
aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2.
Open Repair ofRuptured Mycotic
Aneurysm oftheCommon Iliac
Artery
23
Physical Examination
A 47-year-old male presented to the hospital in
January 2018 with pain in the left groin and left
lower extremity of 2 weeks duration. Patient also
complained of left ank pain. Non-contrast CT
scan of the abdomen and pelvis revealed a mass in
the left pelvis with hydronephrosis and hydroureter. Duplex venous studies showed bilateral deep
venous thrombosis involving the femoral and
popliteal veins. Past medical history was positive
for hypertension, clipping of the intercranial
aneurysm, with history of intracerebral hemorrhage in 2014, seizure disorder, and organic mood
disorder. CTA of the abdomen and pelvis showed
a large left hypogastric aneurysm. Mycotic etiology was suspected but could not be proven. WBClabeled indium scan was negative for infection.
Procedure
Patient underwent coil embolization (AZUR®
detachable coils, tornado coils). Left hypogastric
artery was selected following puncture of the right
femoral artery with insertion of 6 French sheath.
Microcatheter (2.8 French PROGREAT® catheter – Terumo Somerset, NJ) was used to select
superior and inferior gluteal branches of the
hypogastric artery. Trull® glue and Amplatzer
occluder™ plug embolization of the left internal
iliac artery aneurysm was performed on January
18, 2018 (Fig.23.1), followed by deployment of
a 9 mm × 59 mm GORE
Endoprosthesis graft (W. L. Gore & Associates,
Newark, DE) from the left common iliac artery to
the mid-external iliac artery (Fig. 23.2). Right
femoral artery was closed with an Angio-Seal™
closure device.
Patient was lost to follow up but returned to
emergency room in February 2019 with severe
back pain and abdominal pain. CTA of the abdomen and pelvis revealed ruptured left common
iliac artery aneurysm and hypogastric aneurysm
with a large retroperitoneal hematoma with
associated left hydronephrosis (Fig. 23.3). He
also noticed weakness to the left lower extremity and his inability to put weight on the left
lower extremity. Patient was taken to the operating room on emergency basis and through a
transperitoneal midline incision. Extensive
venous congestion in the retroperitoneal was
encountered. Inferior mesenteric vein was
ligated and divided. Aorta was mobilized below
the renal arteries. Inferior mesenteric artery was
looped with silastic loop. Infrarenal aorta was
divided; it was small in caliber without any evidence of atheromatous plaque. The distal aorta
was ligated with 16 × 8mm knitted Dacron graft
(rifampin soaked) and was sutured end to end to
the infrarenal aorta, and distal anastomosis was
performed in an end-to-side fashion to the common femoral arteries. Left common and hypogastric artery (branches) was ligated with 3-0
®
VIABAHN®
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_23
89
90
Fig. 23.1 Coil embolization and glue into left hypogastric artery aneurysm
23 Open Repair ofRuptured Mycotic Aneurysm oftheCommon Iliac Artery
Fig. 23.2 Placement of covered stent (VIABAHN®)
cardiovascular polypropylene running sutures
(Ethicon). And the junction of the left external
iliac and common femoral artery was also suture
ligated. Patient remained hemodynamically
unstable during the operation and received ten
units of packed cells, six units of fresh frozen
plasma, and platelets.
Postoperative course was complicated by
infected hematoma questionable abscess in the
left lower quadrant of abdomen. Patient underwent drainage by intervention radiologist and
was started on intravenous vancomycin and
cefepime on March 16, 2019 (Fig. 23.4). Left
lower quadrant drainage did not grow any
Procedure
Fig. 23.3 CTA showing ruptured left common iliac aneurysm
91
Fig. 23.4 Percutaneous drain in the left lower quadrant
collection under CT guidance
microorganism although gram stain was positive
for polymorphic neutrophils. Patient was followed in the ofce, the left lower quadrant drain
was ultimately removed, he had some induration
of the left groin, and he was continued on apixaban (Eliquis) for deep venous thrombosis. Patient
did not come for follow-up for the next 3 months
and presented to an outside hospital with mycotic
aneurysm of the left groin (Fig.23.5 and 23.6).
There was no evidence of infection or any abnormality involving the aortic graft or the right limb.
Patient underwent ligation of the left femoral
mycotic aneurysm, application of wound vac,
and a left axillofemoral graft performed to the
proximal supercial femoral artery in July 2019.
In August 2019 the patient underwent excision
of aorto-bifemoral graft and small bowel resec-
Fig. 23.5 CTA (reformat) showing patent aorto-
bifemoral graft
tion. Right ureteral stent was placed, and aortoright iliac bypass was performed using 11 mm
cryopreserved graft. Small bowel resection
became necessary due to injury sustained during
lysis of the adhesions. Patch angioplasty of the
right common femoral artery was performed.
Omental pedicle graft was used to cover the aortoiliac bypass graft, and wound vac was applied
followed by Vicryl mesh which was placed. This
was followed by skin closure 1 week later.
Following axillofemoral graft patient continued to have infection in the groin with bleeding
92
Fig. 23.6 CTA showing air bubbles around the left limb
of the Dacron graft suggestive of graft infection
23 Open Repair ofRuptured Mycotic Aneurysm oftheCommon Iliac Artery
and probable intra-abdominal graft infection.
Patient underwent laparotomy with pre-op placement of ureteral stents. Due to extensive small
bowel adhesions, there was an injury to the small
intestine which was repaired. Aortofemoral
Dacron graft was explanted, and reconstruction
was performed with cryopreserved arterial homograft. Patient was continued on long-term antibiotics and transferred to an extended care facility
after 5weeks stay in the hospital.
Discussion
Mycotic aneurysms involving the aorta and iliac
arteries are quite infrequent. They are reported to
be around 1% of all aortic and iliac aneurysms
[1–2]. Common organisms responsible for
mycotic infection include Salmonella species and
E. coli [1, 2]. However, the optimal surgical man-
agement of infrarenal mycotic aortic and iliac
aneurysms remains controversial from a surgical
point of view. Extra-anatomic reconstruction is
considered as a treatment of choice as it avoids
the use of prosthetic grafts in infected tissues.
However, axillobifemoral grafts have low patency
rates, and there is risk of aortic stump bleeding.
Alternatively, in situ reconstruction is being
increasingly used for infected aortic iliac grafts
with the use of deep veins (femoral and popliteal
veins) as well as cryopreserved veins [2].
However, harvesting of femoral and popliteal
veins is contraindicated in the presence of acute
emergency such as rupture of the aneurysm [2].
Rifampicin is active against Staphylococcus;
therefore rifampicin-soaked grafts have shown
promise for patients with mycotic and aortic iliac
aneurysms as well as infected prosthetic graft.
Cryopreserved vein grafts are also used; however
there is a risk of rupture as well as aneurysmal
degeneration in these grafts. This case illustrates
that multiple operations often become necessary
for the repair of mycotic aneurysms involving
aorta and iliac arteries with associated high morbidity and mortality. Endovascular repair for
infected abdominal aortic and iliac aneurysms is
being used more frequently however; this repair
should be considered as a bridge to a denitive
repair. Long-term results of endovascular repair
in management of complex mycotic aneurysm
are not known.
This case illustrates that infection involving
one limb of Dacron graft almost always involves
the contralateral limb, thus necessitating total
graft explantation. In patients where only one
limb was removed, long-term follow-up is necessary in order to be certain that contralateral limb
remains uninvolved.
References
1. Hsu RB, Tsay YG, Wavy SS, Chu SH. Surgical treat-
ment for primary infected aneurysm of the descend-
ing thoracic aorta, abdominal aorta, and iliac arteries.
J Vasc Surg. 2002;36:746–50.
2. Nypaver TJ.Primary and secondary aorto enteric s-
tula. In: Hans SS, Shephard AD, Weaver MR, Bove
PG, Long GW, editors. Endovascular and open vascu-
lar reconstruction: a practical approach. Boca Raton:
CRC Press; 2018. p.257–62.
Rupture ofHypogastric Artery
Aneurysm
Hypogastric artery aneurysms are usually associated with aortic and common iliac aneurysm and
rarely occur in isolation [1–6]. Most hypogastric
aneurysms are incidentally detected on imaging
of the abdomen or pelvis for unrelated complaints. Those that present in extremis are associated with acute rupture and carry a high mortality
rate [1, 2].
Physical Examination
24
A 90-year-old male presented to his primary care
physician with complaints of left lower quadrant
pain and bulging mass. On physical examination
patient was found to have a palpable mass in the
left lower quadrant of the abdomen. A computerized tomographic scan (CT scan) of the abdomen
demonstrated a left spigelian hernia. A large incidental right internal iliac artery aneurysm measuring 4.4 × 5.5cm in cross section and extending
approximately 5.3cm in cranio-caudal length was
detected. Moderate thrombus was noted in aneurysmal wall (Fig.24.1 and 24.2). CT angiography
did not show accompanying aortic aneurysm.
Procedure
The patient underwent a retrograde aortography
via retrograde femoral approach. The previously
identied right hypogastric aneurysm was again
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_24
Fig. 24.1 Aortography showing right hypogastric artery
aneurysm
noted, along with a normal right common iliac
artery. Two tornado coils 14 × 8mm followed by
14 × 6mm were deployed into the outow tracts
of the aneurysm. We were unable to completely
occlude the outow vessels. However, nearcomplete occlusion was obtained, and we
believed that thrombosis following inow occlusion would result in satisfactory outcome. An
Amplatzer™ vascular plug 16mm × 12mm was
deployed at the mouth of the aneurysm. Postdeployment images demonstrated adequate
exclusion of the aneurysm.
93