From the Guidelines
Intervention for bilateral common iliac artery (CIA) aneurysms is recommended when the aneurysm diameter reaches 3.5 cm or larger, as stated in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. This recommendation is based on the balance between procedural risks and rupture risk, as rupture of iliac aneurysms at diameters <4 cm is rare 1. When treating common iliac artery aneurysms, preservation of at least 1 hypogastric artery is recommended, if anatomically feasible, to decrease the risk of pelvic ischemia 1. Some key points to consider when deciding on intervention for bilateral CIA aneurysms include:
- Aneurysm size: 3.5 cm or larger is the recommended threshold for intervention 1
- Presence of symptoms: such as abdominal or back pain, distal embolization, or compression of adjacent structures
- Rapid growth: greater than 0.5 cm in 6 months
- Patient factors: including age, comorbidities, anatomy, and surgical risk
- Choice of repair: open surgical repair or endovascular aneurysm repair, with endovascular approaches being increasingly preferred due to lower perioperative morbidity and mortality 1. It's worth noting that the 2013 management of patients with peripheral artery disease compilation of 2005 and 2011 ACCF/AHA guideline recommendations also provides guidance on symptomatic aortic or iliac aneurysms, but the 2022 ACC/AHA guideline provides more specific and updated recommendations for bilateral CIA aneurysms 1.
From the Research
Criteria for Intervention on Bilateral Common Iliac Artery Aneurysms
The decision to intervene on bilateral common iliac artery aneurysms (CIAAs) depends on several factors, including the size of the aneurysms, the presence of symptoms, and the patient's overall health.
- The size of the aneurysm is a critical factor in determining the need for intervention. Studies have shown that the expansion rate of CIAAs is approximately 0.29 cm/y, and hypertension can predict faster expansion 2.
- Symptomatic patients, such as those with buttock claudication or compressive symptoms, may require earlier intervention 2.
- The presence of associated internal iliac artery aneurysms (IIAAs) or other vascular conditions may also influence the decision to intervene 2.
Intervention Techniques
Several techniques are available for the intervention of bilateral CIAAs, including:
- Endovascular repair using bifurcated-unibody stent grafts or aortic bifurcated unibody endografts 3, 4
- Open surgical repair, which may be preferred in certain cases, such as those with compressive symptoms or arteriovenous fistulas 2
- Embolization of the internal iliac artery using detachable latex balloons, followed by implantation of an endovascular Y-stent 5
Considerations for Intervention
When considering intervention for bilateral CIAAs, several factors must be taken into account, including:
- The risk of pelvic ischemia, which can occur if both internal iliac arteries are occluded 4, 5
- The need to preserve blood flow to the internal iliac arteries, which can be achieved using techniques such as the modified sandwich technique 4
- The potential for complications, such as endoleaks or sac expansions, which can be monitored using imaging studies 3, 4, 6