From the Guidelines
For patients with asymptomatic small AAA and concomitant common iliac artery aneurysm(s) ≥3.5 cm, elective repair of both abdominal and iliac aneurysms is recommended. This approach is based on the most recent guidelines from the American Heart Association/American College of Cardiology joint committee on clinical practice guidelines, as outlined 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, patient's overall health, and the risk of rupture.
Key Considerations
- The size threshold for elective repair of iliac artery aneurysms is ≥3.5 cm, as rupture risk increases significantly at this diameter.
- Endovascular repair with stent grafts is often the preferred approach due to lower perioperative morbidity and mortality compared to open surgery.
- Preservation of at least one hypogastric artery is recommended during repair to decrease the risk of pelvic ischemia, if anatomically feasible.
- Medical management, including blood pressure control, statin therapy, smoking cessation, and antiplatelet therapy, is crucial in reducing aneurysm growth rates and cardiovascular risk.
Treatment Approach
When intervention is necessary, the choice between endovascular and open surgical repair depends on the patient's anatomy, overall health, and the specific characteristics of the aneurysm. Endovascular repair is generally favored for its minimally invasive nature and lower immediate risks, but it requires careful long-term follow-up to monitor for complications such as endoleaks. Open surgical repair may be preferred in certain cases, such as in younger patients with favorable anatomy or when endovascular approaches are not feasible.
Surveillance and Follow-Up
Following intervention, lifelong surveillance is necessary to detect potential complications. Imaging studies, such as ultrasound or CT angiography, should be performed at regular intervals (e.g., 1,6, and 12 months post-procedure, then annually) to monitor the aneurysm and the repair site for any signs of failure or growth.
Recent Guidelines
The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases also support the use of endovascular approaches for aorto-iliac lesions, highlighting the importance of lesion morphology and patient risk in the decision-making process 1. However, the most recent and highest quality study guiding the management of iliac artery aneurysms is the 2022 ACC/AHA guideline, which emphasizes the importance of elective repair for aneurysms ≥3.5 cm and the preservation of hypogastric arteries during repair 1.
From the Research
Treatment Guidelines for Iliac Artery Aneurysms
The treatment of iliac artery aneurysms can be managed through various approaches, including open surgical repair and endovascular treatment.
- Open surgical repair has been shown to have low mortality and morbidity rates when using a systematic operative approach 2.
- Endovascular treatment, including coil embolization and stent-graft placement, is a minimally invasive alternative to surgery and has been found to be safe and effective in treating iliac artery aneurysms 3.
- The choice of treatment depends on various factors, including the size and location of the aneurysm, as well as the patient's overall health and anatomy 4, 5.
Considerations for Treatment
When considering treatment for iliac artery aneurysms, several factors must be taken into account, including:
- The size and location of the aneurysm, with larger aneurysms carrying a higher risk of rupture 4.
- The involvement of the internal iliac artery and the status of the contralateral internal iliac artery 5.
- The presence of any symptoms, such as abdominal pain or claudication, which may affect the choice of treatment 2.
- The potential for pelvic ischemia or extrinsic compression of adjacent structures, which may require surgical repair 5.
Endovascular Treatment Options
Endovascular treatment options for iliac artery aneurysms include:
- Coil embolization, which involves blocking the flow of blood into the aneurysm using coils 3, 6.
- Stent-graft placement, which involves placing a stent-graft in the affected artery to exclude the aneurysm from blood flow 3.
- Percutaneous access to the superior gluteal artery under fluoroscopy, which can be used to treat aneurysms that are not accessible through standard endovascular approaches 6.