From the Guidelines
Iliac artery aneurysms are a serious condition that requires prompt attention, and elective repair is recommended for asymptomatic aneurysms ≥3.5 cm in diameter, as stated in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The management of iliac artery aneurysms involves a multidisciplinary approach, considering the size of the aneurysm, symptoms, and overall patient health.
- For smaller, asymptomatic aneurysms, surveillance with regular imaging (ultrasound or CT angiography every 6-12 months) is recommended along with cardiovascular risk factor modification.
- When intervention is needed, endovascular repair with stent grafts is the preferred approach for most patients due to lower perioperative morbidity and mortality compared to open surgery, as seen in studies such as the EVAR trial 1.
- Open surgical repair, involving aneurysm resection and graft replacement, is reserved for younger patients with favorable anatomy or when endovascular repair isn't feasible.
- Medical management includes blood pressure control (target <140/90 mmHg) with antihypertensives like ACE inhibitors or ARBs, statin therapy (e.g., atorvastatin 20-80 mg daily) to stabilize atherosclerotic plaques, antiplatelet therapy (aspirin 81 mg daily), and smoking cessation.
- It is also important to consider pelvic perfusion when managing concomitant iliac disease, and preservation of at least one hypogastric artery is recommended, if anatomically feasible, to decrease the risk of pelvic ischemia 1.
- Emergency intervention is required for ruptured aneurysms or those causing acute thrombosis, compression symptoms, or embolization. The 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1 provides the most recent and highest quality evidence for the management of iliac artery aneurysms, and its recommendations should be followed to optimize patient outcomes.
From the Research
Overview of Iliac Artery Aneurysm
- Iliac artery aneurysms are rare but associated with significant morbidity and mortality when ruptured 2.
- The management and treatment approach for iliac artery aneurysms include open surgical repair and endovascular repair.
Open Surgical Repair
- Open surgical repair is a traditional treatment option for iliac artery aneurysms, with satisfactory short- and long-term postoperative results 3.
- However, open repair is associated with higher blood loss, longer hospital stay, and higher transfusion requirements compared to endovascular repair 4.
Endovascular Repair
- Endovascular repair is a minimally invasive treatment option for iliac artery aneurysms, with decreased length of stay, lower requirement for perioperative blood transfusion, and similar intermediate-term outcomes as open repair 2.
- Endovascular repair using iliac branch endoprosthesis (IBE) is feasible and associated with lower blood loss, shorter hospital stay, and lower transfusion requirements compared to open repair 4.
- However, endovascular repair may have a higher reintervention rate compared to open repair 5.
Comparison of Treatment Options
- Both open and endovascular repair are effective treatment options for iliac artery aneurysms, with no significant difference in overall survival 5.
- The choice of treatment option depends on individual patient factors, such as comorbidities, aneurysm morphology, and surgeon preference.
- Endovascular repair may be preferred for patients with high surgical risk or complex aneurysm morphology, while open repair may be preferred for patients with suitable anatomy and low surgical risk.