Iliac Artery Aneurysms: a Contemporary Comparison of Endovascular and Open Repair

Rabih A. Chaer, MD,  Stephanie C. Lin, MD, Brian G. DeRubertis, MD, Nicholas J. Morrissey, MD, Leila Mureebe, MD, Peter L. Faries, MD, Roman Nowygrod, MD, K. Craig Kent, MD and James F. McKinsey, MD
New York Presbyterian Hospital, New York, NY

Objective(s): Iliac artery aneurysms are rare but associated with significant morbidity and mortality when ruptured. This study compares recent open and endovascular repairs of iliac aneurysms at a single institution.
Methods: Patients were identified and charts reviewed using ICD-9 and CPT codes for iliac artery aneurysm and open or endovascular repair performed between January 2000 and December 2005. Fisher’s exact test determined significance (p<0.05).
Results: 70 isolated iliac aneurysms were treated in 70 patients (60 men, mean age 71): 52 common iliac, 3 external iliac, and 15 internal iliac. There were 19 open and 51 endovascular repairs. Thirteen patients were symptomatic (19%) (flank pain, claudication, distal embolization, ureteral obstruction). Seven presented with acute ruptures and were treated by open (4) or endovascular (3) repair. Preoperative co-morbidities were similar between the two groups (table 1). Mean preoperative aneurysm diameter was 4.6±16 cm. In the open group, there were 16 aortoiliac recosntructions and 3 ligations with extra-anatomic bypass. Endovascular repairs included 11 aortobi-iliac and 3 aortouni-iliac stent grafts, and 37 selective iliac procedures; 59% required hypogastric embolization (2 bilateral). There were no conversions to open repair. Major perioperative complications included 2 deaths in the open group from cardiovascular complications, both after ruptured aneurysm repair, and 3 deaths in the endo group (1 colonic infarction, 2 cardiovascular) (p=NS). Postoperative complications were less frequent in the endo group, although this did not reach statistical significance (table 2). Re-exploration for bleeding was required in 2 patients in the open group. The mortality was 50% in the open group and 33% in the endo group for patients presenting with a ruptured aneurysm (p=NS). Transfusion requirement was significantly higher in the open group (42%) than in the endo group (6%) (p=0.03). Long-term complications included 2 limb thromboses following repair with a bifurcated stent graft which were treated with thrombolysis plus stenting or a fem-fem bypass. Three endoleaks were identified on postop CT scan: 2 were treated by coil embolization (type II), 1 by limb extension (distal type I). No patients presented with claudication following hypogastric coil embolization. There were no postoperative ruptures or aneurysm related death. The mean postoperative length of stay was 5.2±2.3 days (open) and 1.3±1.0 days (endo) (p=0.04). The mean follow-up was 12.4 months.
Conclusions: Endovascular repair of iliac artery aneurysms is safe and results in decreased length of stay, lower requirement for peri-operative blood transfusion, and similar intermediate term outcomes as open repair. The need for secondary interventions appears to be less frequent than following endovascular repair of abdominal aortic aneurysms.