Transcript Management of Iliac Aneurysms

Management of Iliac
Artery Aneurysms
Etiology
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Idiopathic – Remote collagen vascular disease
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Atherosclerosis, Smoking
Infectious (TB, Syphilis, S. aureus, Salmonella,
Klebsiella)
Collagen diseases (Marfan’s, Ehlers-Danlos,
Cystic Medial Necrosis)
Takayasu’s, Kawasaki’s, Bechet’s, etc.
Incidence
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0.03% lifetime incidence
0.3-1.9% of arterial aneurysms
75-95% present with AAA
7th-8th decade of life
8-9:1 male:female ratio
Common Iliac Artery - 70%
Internal Iliac Artery - 20%
External Iliac Artery - 10%
Bilateral Disease – 20-60%
Complications
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Rupture
Distal embolization
Thrombosis
Urologic symptoms secondary to ureteral
compression
Pain from compression of adjacent nerves and
vicera (Rare)
Complications
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106 Patients
59 presented with intact IAA (mean 3.9cm)
 10 presented with rupture (mean 7.2cm)
 37 unoperated on (mean 3.2cm)
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12 enlarged
 3 ruptured (smallest 3.5cm)
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Kasirajan V et al. Card Surg. 1998: 6(2), 171-177.
Natural History
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Santilli et al, 2000 (U. of Minnesota)
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189 patients in VA system (2 women) with 323 iliac
artery aneurysms
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47 patients with isolated IAA
Followed with USG or CT at 6 month intervals
 Average f/u: 31.4 months (4.2 studies)
 Survival: 96.3% at 1 year, 88.5% at 2 years, 72.3% at
3 and 4 years
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Natural History
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Average rate of expansion: 0.118 +/- 0.017
cm/year
No expansion in 37.5%
All IAA between 4 and 4.9cm expanded (All
>5cm repaired)
<3cm: 0.05-0.15cm/year
>3cm: 0.25-0.28cm/year
Natural History
Santelli et al. J Vasc Surg. 2000: 31(1), 114-121
Surgical Intervention
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All series >/= 5 patients between 1961 and 1997
367 patients with 500 IIAs
Mean age 68 years
Symptomatic: 208 (62%)
Asymptomatic: 123 (38%)
Rupture: 108 (29%)
Emergent mortality: 40%
Elective mortality: 7%
Krupski et al, J Vasc Surg. 1998: 28(1)
Surgical Intervention
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Krupski et al, 1998 (U. of Colorado)
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21 patients (17 men, 4 women)
Mean age 69 years (38-87)
52% unilateral disease, 57% symptomatic
Aneurysm >2.5cm (2.5-12cm, mean 5.6 +/- 2cm)
Smoking 71%, HTN 67%, CAD 52%, Prior CABG 19%
Mean follow up 5.5 years (2 months - 13 years)
Surgical Intervention
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Krupski et al.
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19 open repairs, 0 perioperative deaths
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17 Elective
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1 - Right LE compartment syndrome
2 Emergent
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1 - C. diff requiring colectomy
1 - Multisystem Organ Failure due to rupture/shock
Surgical Intervention
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Krupski et al.
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2 Endovascular repairs
1 - required femorofemoral bypass due to stent occlusion
 1 - died from rupture 2 years post coiling
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Conclusions
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Rupture under 3cm very rare
High risk of rupture for aneurysms greater than 5cm
with a correlation between increasing size and
increasing risk of rupture
Many aneurysms remain stable - safe to monitor
patients yearly with aneurysms <3cm and every 6
months 3-3.5cm
Surgical risk for otherwise uncomplicated patients now
generally very low
Further need for long term comparison of open vs.
endovascular repair
References
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Santilli SM, Wernsing SE, Lee ES. Expantion rates and outcomes for iliac artery aneurysms.
Journal of Vascular Surgery. 2000: 31(1), 114-121.
Kasirajan V et al. Management of isolated common iliac artery aneurysms. Cardiovascular Surgery.
1998: 6(2), 171-177.
Dorigo W et al. The Treatment of Isolated Iliac Artery Aneurysm in Patients with Nonaneurysmal Aorta. European Journal of Vascular and Endovascular Surgery. 2008,
doi:10.1016/j.ejvs.2007.11.017.
Krupski WC et al. Contemporary management of isolated iliac aneurysms. Journal of Vascular
Surgery. 1998: 28(1).
Brunkwall J et al. Solitary aneurysms of the iliac artery system: an estimate of their frequency and
occurance. Journal of Vascular Surgery. 1989:10, 381-384.