From the Guidelines
Surgical intervention, specifically endovascular aneurysm repair (EVAR) or open surgical repair, is strongly recommended for enlarging bilateral common iliac artery aneurysms measuring 6.8 cm due to the high risk of rupture and associated mortality. The decision between EVAR and open surgical repair should be based on individual patient factors, including anatomical suitability, comorbidities, and the ability to comply with long-term follow-up imaging requirements 1.
Key Considerations
- EVAR is generally preferred for its less invasive nature, involving the placement of stent grafts through small groin incisions to exclude the aneurysm from circulation 1.
- For bilateral iliac aneurysms, an aorto-bi-iliac or aorto-bi-femoral configuration may be required to adequately treat both sides.
- Open surgical repair involves replacing the diseased arterial segments with synthetic grafts through an abdominal incision and is indicated for patients who do not meet the anatomical criteria for EVAR or cannot comply with follow-up imaging requirements 1.
- Prior to intervention, patients should undergo comprehensive vascular imaging (CT angiography) to determine the exact anatomy and extent of the aneurysms.
- Surgical intervention is strongly indicated at this size (6.8 cm) because iliac aneurysms larger than 3-4 cm carry a significant risk of rupture, which is a life-threatening emergency with high mortality rates 1.
Post-Procedure Care
- Post-procedure, patients require lifelong surveillance with periodic imaging to monitor for complications such as endoleaks, graft migration, or development of new aneurysms 1.
- The choice between EVAR and open repair should consider the patient's overall health, life expectancy, and ability to adhere to the necessary follow-up regimen 1.
Evidence Summary
The 2022 ACC/AHA guideline for the diagnosis and management of aortic disease supports surgical intervention for iliac artery aneurysms larger than 3-4 cm due to the increased risk of rupture 1. Studies have shown that while EVAR and open surgical repair have similar long-term outcomes in terms of mortality, EVAR is associated with a lower procedural mortality rate but requires more frequent follow-up imaging to monitor for complications 1.
From the Research
Treatment Options for Enlarging Bilateral Common Iliac Artery Aneurysms
- The treatment of enlarging bilateral common iliac artery aneurysms measuring 6.8 cm can be approached through various methods, including open surgical and endovascular repair 2.
- Endovascular repair has emerged as a viable alternative to traditional open surgical repair, with the primary goal of excluding the aneurysm sac while maintaining perfusion of at least one internal iliac artery to prevent pelvic ischemia 3.
- The choice of treatment method depends on several factors, including the anatomy of the common iliac artery, involvement of the iliac bifurcation, and the need to preserve the ipsilateral internal iliac artery 2.
Endovascular Repair
- Endovascular repair can be accomplished using commercially available stent grafts, and techniques such as the modified sandwich technique can be employed to preserve pelvic blood flow in patients with unsuitable anatomy 3.
- The use of an aortic bifurcated unibody endograft in combination with a modified sandwich technique has been shown to be effective in treating bilateral isolated common iliac artery aneurysms with certain anatomical constraints 3.
- Endovascular repair has been associated with lower morbidity and mortality rates compared to open surgical repair, and can be considered as a first-line treatment for most anatomically suitable patients 4, 5.
Open Surgical Repair
- Open surgical repair is still a viable option for patients with enlarging bilateral common iliac artery aneurysms, particularly those with compressive symptoms or those with arteriovenous fistulas 4.
- Open surgical repair can be performed using a variety of techniques, including midline laparotomy and a transperitoneal approach with bifurcated aortoiliac graft replacement, or a lower lateral abdominal incision with a retroperitoneal approach and iliac replacement 5.
Recommendations
- Elective repair of asymptomatic patients with common iliac artery aneurysms ≥3.5 cm is recommended, as the expansion rate of these aneurysms is 0.29 cm/y, and hypertension predicts faster expansion 4.
- The choice of treatment method should be individualized based on the patient's anatomy, symptoms, and overall health status, and a multidisciplinary approach involving vascular surgeons, radiologists, and other specialists is recommended 2, 4, 5, 3, 6.