Intentional covering of the hypogastric artery during endovascular repair of aortic-iliac aneurysms

Aim. The purpose of this study is to assess the short to mid-term results of 5-years experience after intentional occlusion of patent internal iliac artery (IIA) in order to facilitate endovascular repair of aorto-iliac aneurysms, paying particular attention to type II endoleak, bowel ischemia and device migration. Methods. From November 1998 to November 2003, we performed endovascular repair for aorto-iliac aneurysms in 210 patients. Forty patients underwent intentional occlusion of one (33 patients) or both (7 patients) IIA. In 1 case we assess the unintentional blocking of both IIA. A contrast-enhanced abdominal CTscan was performed to define the aorto-iliac anatomy and the cases for which an occlusion of the hypogastric vessel for the aneurysm exclusion was required. In all these cases a preliminary angiography was performed in order to identify vascular anatomy that may predict postoperative pelvic ischemia. Hypogastric artery embolization was performed before endovascular aneurysm exclusion only in 4 patients. Results were assessed with CT scan and plain abdominal X-ray at 2, 6 and 12 months after treatment and annually thereafter. The 8 patients with bilateral occlusion of IIA underwent a sigmoid colonoscopy before hospital discharge and 1 month after procedure. Results. All the procedures were technically successful in excluding aneurysms as intended, without arterial injury, endoleak, colon ischemia, or death. The sigmoid colonoscopy was negative for bowel ischemia. During the follow-up period we observed 5 cases of buttock claudication: 2 cases related to limb occlusions ipsilaterally to the covered IIA, one treated with femoro-femoral by-pass and the other with thromboembolectomy; 3 cases in presence of normal graft patency. Two of them actually don't present an invalidant claudication. We observed 1 endoleak type 1, treated with a cuff, and 3 type 2. Of these, 1 resolved spontaneously, 1 required a late conversion and the latter is under observation. Conclusion. In our experience the intentional covering of IIA appears to be safe, and preliminary hypogastric embolization is to be reserved to selected patients. Careful follow-up over the longer term is necessary to confirm these favourable results.