Treatment of Iliac Artery Aneurysms

Indications for Repair

• The American College of Cardiology recommends elective repair for iliac artery aneurysms ≥3.5cm, with a 5cm aneurysm well above this threshold 1, 3
• The risk of rupture increases significantly with size, with ruptured iliac aneurysms having a median diameter of 6.8cm at presentation 1
• Symptomatic iliac aneurysms warrant immediate repair regardless of size, as per the American College of Cardiology guidelines 4
• Rupture of iliac aneurysms at diameters <4cm is rare, but rupture risk increases substantially above this size 1

Treatment Options

• Open repair is indicated for patients who are good or average surgical candidates, according to the American Heart Association 5, 6
• Open repair should be considered for patients who cannot comply with the long-term surveillance required after endovascular repair, as recommended by the American College of Cardiology 4
• Endovascular repair is a reasonable alternative, especially for patients at high risk for open surgery due to comorbidities, as suggested by the American Heart Association 5, 6
• Endovascular repair requires long-term surveillance imaging to monitor for endoleaks and aneurysm sac stability, as per the American College of Cardiology guidelines 7, 4

Technical Considerations

• When treating iliac aneurysms, preservation of at least one hypogastric (internal iliac) artery is recommended to decrease the risk of pelvic ischemia, according to the American Heart Association 1, 2
• Exclusion of internal iliac arteries can lead to significant complications, including buttock claudication (27% with unilateral exclusion, 36% with bilateral exclusion) 1, 3
• Exclusion of internal iliac arteries can also lead to erectile dysfunction (10% of men) and bowel ischemia (rare, <1%) 1

Post-Procedure Management

• Periodic long-term surveillance imaging is mandatory after endovascular repair to monitor for endoleaks, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention, as recommended by the American College of Cardiology 7, 4
• CT imaging is recommended at 1 month and 12 months post-procedure, and annually thereafter if stable, according to the American Heart Association 2

Pitfalls and Caveats

• Patients with iliac aneurysms should be evaluated for concomitant abdominal aortic aneurysms (AAA), as they frequently coexist, as per the American Heart Association 1
• Smoking cessation is strongly advised for all patients with aneurysms to reduce the risk of expansion, as recommended by the American College of Cardiology 7, 4
• Beta-blockers may be considered to reduce the rate of aneurysm expansion, according to the American College of Cardiology guidelines 4