What is the management approach for a patient with an iliac (Internal Iliac Artery) aneurysm?

From the Guidelines

For patients with an iliac aneurysm, a tailored approach based on aneurysm size, symptoms, and patient factors is recommended, with elective repair of both abdominal and iliac aneurysms suggested for asymptomatic small AAA and concomitant common iliac artery aneurysm(s) ≥3.5 cm, as indicated by the 2022 ACC/AHA guideline 1.

Management Approach

The management of an iliac aneurysm requires consideration of several factors, including aneurysm size, symptoms, and patient-specific factors.

• For aneurysms smaller than 3 cm, watchful waiting with regular ultrasound or CT surveillance every 6-12 months is typically recommended.
• For aneurysms larger than 3 cm, symptomatic aneurysms, or those showing rapid growth (>0.5 cm/year), intervention is indicated.

Intervention Options

• Endovascular repair is the preferred first-line treatment, involving either coil embolization of the internal iliac artery or placement of a covered stent graft.
• If endovascular approaches aren't feasible due to anatomy or other factors, open surgical repair may be necessary, which can include aneurysm resection with or without revascularization.

Importance of Cardiovascular Risk Factor Control

During either management approach, aggressive control of cardiovascular risk factors is essential, including:

• Blood pressure management (target <130/80 mmHg) with medications like ACE inhibitors or ARBs.
• Statin therapy regardless of baseline cholesterol levels.
• Smoking cessation.
• Antiplatelet therapy (typically aspirin 81 mg daily). These interventions are crucial because iliac aneurysms often coexist with other vascular disease, and controlling these risk factors helps prevent aneurysm growth and reduces overall cardiovascular risk, as supported by the 2022 ACC/AHA guideline 1 and other studies 1.

Preservation of Hypogastric Artery

When treating common iliac artery aneurysms or ectasia as part of AAA repair, preservation of at least 1 hypogastric artery is recommended, if anatomically feasible, to decrease the risk of pelvic ischemia, as indicated by the 2022 ACC/AHA guideline 1.

From the Research

Management Approach for Iliac Aneurysm

The management approach for a patient with an iliac (Internal Iliac Artery) aneurysm involves several considerations, including:

• Determination of proximal neck, involvement of the internal iliac artery, and status of the contralateral internal iliac artery 2
• Clinical presentation, which can be confusing, and the use of ultrasound or CT imaging to establish the diagnosis and anatomical extent of disease 2
• The risk of rupture and death associated with isolated iliac artery aneurysms 2

Treatment Options

Treatment options for iliac aneurysms include:

• Endovascular repair, which has evolved as the first choice treatment option for patients with anatomically suitable iliac artery aneurysms 2
• Surgical repair, which may be the preferred option in uncommon circumstances when endovascular treatment may result in significant pelvic ischemia or the primary symptoms are related to extrinsic compression of adjacent structures 2
• Open repair, which can be used to treat isolated internal iliac artery aneurysms, but may be associated with higher morbidity and mortality rates compared to endovascular repair 3, 4, 5, 6
• Endovascular repair with iliac branch endoprosthesis (IBE), which is a novel treatment option that has shown promising results in terms of reducing blood loss, length of hospital stay, and transfusion requirements 3

Outcomes and Complications

Outcomes and complications of iliac aneurysm treatment include:

• Perioperative mortality, which can be higher for open repair compared to endovascular repair 3, 4, 5, 6
• Length of hospital stay, which can be shorter for endovascular repair compared to open repair 3, 4, 6
• Blood loss and transfusion requirements, which can be lower for endovascular repair compared to open repair 3, 4
• Buttock claudication, which can occur as a complication of hypogastric artery exclusion during endovascular repair 5
• Reintervention rates, which can be higher for endovascular repair compared to open repair 6