Treatment of Right Common Iliac Artery Aneurysms

Open or endovascular repair is indicated for common iliac artery aneurysms ≥3.5 cm in diameter to prevent rupture. 1

Size Thresholds for Intervention

Elective repair is recommended for common iliac artery aneurysms ≥3.5 cm in diameter, as rupture at diameters <4 cm is rare but rupture risk increases substantially above this size 1, 2
In patients with symptomatic iliac aneurysms, repair is indicated regardless of diameter 1, 2
For patients with smaller asymptomatic common iliac aneurysms (<3.5 cm), regular monitoring with ultrasound or CT scans is appropriate 3
The median expansion rate of common iliac artery aneurysms is approximately 0.29 cm/year, with hypertension predicting faster expansion (0.32 vs 0.14 cm/year) 3

Endovascular repair (EVAR) is indicated as first-line treatment for most anatomically suitable patients requiring common iliac aneurysm repair 2, 3
EVAR offers lower perioperative complication rates and shorter hospital stays compared to open repair 3
EVAR requires mandatory long-term surveillance imaging to monitor for endoleaks and aneurysm sac stability 1, 2
Follow-up imaging typically includes CT at 1 month and 12 months post-procedure, and annually thereafter if stable 2

Open repair is indicated for patients who are good surgical candidates but cannot comply with the periodic long-term surveillance required after endovascular repair 1, 2
Open repair should be considered for patients with compressive symptoms or arteriovenous fistulas 3
Open repair has similar long-term patency rates to EVAR (99.6% vs 100% at 3 years) 3

When treating common iliac artery aneurysms, preservation of at least one hypogastric (internal iliac) artery is recommended to decrease the risk of pelvic ischemia 1, 2
Exclusion of internal iliac arteries can lead to significant complications, including buttock claudication (27% with unilateral exclusion, 36% with bilateral exclusion) 2
For cases where the proximal sealing zone diameter is larger than the distal sealing zone, specialized techniques such as reverse-tapered devices may be needed 4
Various endograft configurations can be used, including coil occlusion of the hypogastric artery with extension into the external iliac artery, or "bell-bottom" endograft limbs placed at the common iliac bifurcation 5

Patients with common iliac artery aneurysms should be evaluated for concomitant abdominal aortic aneurysms (AAA), as they frequently coexist (up to 86% of cases) 2, 3
In patients with both aortic and iliac aneurysms, the iliac aneurysm may reach a size appropriate for elective repair before the AAA does 1
Smoking cessation is strongly advised for all patients with aneurysms to reduce the risk of expansion 1, 2
Beta-adrenergic blocking agents may be considered to reduce the rate of aneurysm expansion 1, 2

30-day mortality rates are similar between open repair and EVAR for elective procedures (approximately 1%), but significantly higher for emergency repairs (approximately 27%) 3
Freedom from reintervention at 3 years is similar between open repair and EVAR (83% vs 69%) 3
Potential complications of EVAR include endoleaks, which may require additional interventions 2, 6
Buttock claudication remains a concern after EVAR, particularly if internal iliac artery flow cannot be preserved 2, 3

Failure to recognize and treat concomitant aneurysms can lead to subsequent rupture and mortality 1, 3
Inadequate long-term surveillance after EVAR can miss endoleaks or aneurysm sac enlargement 1, 2
Bilateral internal iliac artery exclusion should be avoided when possible due to high risk of pelvic ischemia complications 1, 2
Patients with hypertension require more aggressive monitoring due to faster aneurysm expansion rates 3