What is the recommended approach for repairing a common iliac aneurysm?

From the Guidelines

The recommended approach for repairing a common iliac artery aneurysm is to use endovascular aneurysm repair (EVAR) as the preferred first-line treatment for most patients, due to its minimally invasive nature, shorter recovery time, and lower perioperative morbidity, as supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.

Key Considerations

• The size of the aneurysm is a critical factor in determining the need for intervention, with intervention generally indicated when the aneurysm reaches 3.0-3.5 cm in diameter, as suggested by the study by Huang et al 1.
• EVAR involves placing a stent graft through the femoral artery to exclude the aneurysm from circulation, and patients undergoing EVAR require lifelong surveillance with imaging to monitor for endoleaks or graft migration.
• Open surgical repair remains an important option for younger patients with longer life expectancy, those with unsuitable anatomy for EVAR, or when endovascular approaches fail.

Perioperative Management

• Antiplatelet therapy, typically aspirin 81mg daily, is recommended for patients undergoing EVAR or open repair.
• Statins are also recommended for cardiovascular protection.
• Appropriate blood pressure control is essential to reduce the risk of aneurysm rupture and other cardiovascular complications.

Choice of Repair

• The choice between EVAR and open repair should consider the patient's age, comorbidities, anatomical factors, and life expectancy, as EVAR offers better short-term outcomes while open repair may provide more durable long-term results, as supported by the study by Makaroun et al 1.
• The 2022 ACC/AHA guideline for the diagnosis and management of aortic disease recommends considering the patient's individual characteristics and preferences when making the decision between EVAR and open repair 1.

From the Research

Repair of Common Iliac Aneurysm

The recommended approach for repairing a common iliac aneurysm depends on various factors, including the size of the aneurysm, the patient's overall health, and the presence of any symptoms.

• The expansion rate of common iliac artery aneurysms (CIAAs) is approximately 0.29 cm/y, with hypertension predicting faster expansion 2.
• Elective repair of asymptomatic patients with CIAA ≥3.5 cm seems justified, as no rupture of a CIAA <3.8 cm was observed 2.
• Endovascular repair is a feasible and safe treatment option for isolated CIAAs, with a low mortality rate and excellent technical success rates 3.
• Consideration of increasing the diameter threshold for intervention of CIAA to 4 cm should be considered, as rupture of an isolated CIAA at <4 cm diameter is extremely low 3.

Treatment Options

There are several treatment options available for common iliac aneurysms, including:

• Open surgical repair (OR) 2, 4
• Endovascular repair (EVAR) 2, 3, 5, 4, 6
• Hybrid options, which combine elements of open surgical and endovascular repair 4
• The use of iliac branch stent grafts, which can be used with or without aortobi-iliac stent graft conjunction 5, 6

Outcomes and Complications

The outcomes and complications of common iliac aneurysm repair vary depending on the treatment option chosen.

• OR is associated with a higher risk of complications and mortality, particularly in emergency repairs 2.
• EVAR is associated with a lower risk of complications and mortality, but may be limited by anatomical constraints 2, 3, 6.
• The use of iliac branch stent grafts and modified sandwich techniques can help to overcome anatomical constraints and improve outcomes 5, 6.