How to manage a 3.1x2.6 cm right common iliac artery aneurysm in a patient with a liver transplant?

From the Guidelines

Management of a 3.1x2.6 cm right common iliac artery aneurysm in a liver transplant recipient should focus on surveillance with regular imaging every 6-12 months, blood pressure control, statin therapy, smoking cessation, and antiplatelet therapy, with consideration for endovascular repair if the aneurysm reaches 3.5 cm or demonstrates rapid growth. The patient's liver transplant history necessitates a multidisciplinary approach with vascular surgery and transplant hepatology consultation to ensure optimal management. According to the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1, common iliac artery aneurysms grow at an average rate of 2.9 mm/y, and no iliac aneurysm ≤3.8 cm ruptured in a large single-center case series. Key considerations in management include:

• Surveillance with non-contrast CT or MRA every 6-12 months to minimize nephrotoxicity risks
• Blood pressure control targeting <130/80 mmHg with medications like amlodipine 5-10 mg daily or lisinopril 10-20 mg daily, while avoiding ACE inhibitors if renal function is compromised
• Statin therapy (atorvastatin 20-40 mg daily) and smoking cessation to reduce atherosclerotic progression
• Antiplatelet therapy with aspirin 81 mg daily, unless contraindicated by bleeding risks
• Careful medication selection to avoid interactions with immunosuppressants like tacrolimus or cyclosporine If the aneurysm reaches 3.5 cm or demonstrates rapid growth (>0.5 cm/year), endovascular repair with a covered stent is typically preferred over open surgical repair due to lower perioperative risks in transplant patients with potential adhesions and immunosuppression, as suggested by the principles outlined in the management of iliac artery occlusive disease 1. Regular follow-up with both vascular surgery and transplant teams is necessary to monitor both the aneurysm and graft function.

From the Research

Management of Right Common Iliac Artery Aneurysm

Overview of Treatment Options

The management of a 3.1x2.6 cm right common iliac artery aneurysm in a patient with a liver transplant involves careful consideration of the patient's overall health and the risks associated with the aneurysm. Key factors to consider include:

• The size of the aneurysm: Aneurysms larger than 3 cm are generally considered for treatment due to the increased risk of rupture 2, 3.
• The patient's medical history: The presence of a liver transplant may impact the choice of treatment, with endovascular repair potentially being preferred to minimize the risk of complications 4.
• The anatomy of the aneurysm: The involvement of the internal iliac artery and the status of the contralateral internal iliac artery are important considerations in determining the best treatment approach 5.

Treatment Approaches

Treatment options for a right common iliac artery aneurysm include:

• Endovascular repair: This is a minimally invasive procedure that involves the placement of a stent graft to exclude the aneurysm from the circulation. Endovascular repair has evolved as the first choice treatment option for patients with anatomically suitable iliac artery aneurysms 5, 3, 6.
• Open surgical repair: This involves a traditional open surgery approach to repair the aneurysm. Open repair may be preferred in cases where endovascular treatment is not feasible or in patients with compressive symptoms or arteriovenous fistulas 3, 6.

Considerations for Patients with Liver Transplant

In patients with a liver transplant, the choice of treatment must take into account the potential risks and complications associated with the transplant. Endovascular repair may be preferred due to its minimally invasive nature, which can help to reduce the risk of complications and promote faster recovery 4.

Key Points to Consider

• The size of the aneurysm is an important factor in determining the need for treatment, with aneurysms larger than 3 cm generally considered for repair 2, 3.
• Endovascular repair is a viable treatment option for patients with anatomically suitable iliac artery aneurysms, including those with a liver transplant 5, 4, 3, 6.
• Open surgical repair may be preferred in certain cases, such as those with compressive symptoms or arteriovenous fistulas 3, 6.