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Endovascular Treatment of Concurrent Bilateral Common and Internal Iliac Artery Aneurysms with Preserved Pelvic Circulation: Bilateral Iliac Branch Devices with Opposing Single Division Internal Iliac Artery Sparing
BRIEF REPORT
Endovascular Treatment of Concurrent Bilateral Common and Internal Iliac Artery Aneurysms with Preserved Pelvic Circulation: Bilateral Iliac Branch Devices with Opposing Single Division Internal Iliac Artery Sparing Ramsey Al-Hakim, MD, Libby Watch, MD, and Alex Powell, MD ABSTRACT An 83-year-old man with bilateral common iliac artery aneurysms (right, 3.0 cm; left, 2.7 cm), bilateral internal iliac artery aneurysms (right, 3.4 cm; left, 2.6 cm), and an abdominal aortic aneurysm (3.8 cm) was treated with an aortobi-iliac stent graft and bilateral iliac branch devices. The internal iliac components were extended into opposing posterior (left) and anterior (right) divisions of the internal iliac artery using stent grafts. Computed tomography angiography demonstrated that all aneurysms decreased or were stable in size with patent stent grafts at 1 month. The patient was asymptomatic without complications of pelvic ischemia at the last clinical follow-up at 6 months.
ABBREVIATIONS AAA ¼ abdominal aortic aneurysm, CIA ¼ common iliac artery, IIA ¼ internal iliac artery
Endovascular treatment of concurrent abdominal aortic and common iliac artery (CIA) aneurysms with internal iliac artery (IIA) sparing has been made technically feasible with the advent of iliac branch devices such as the GORE EXCLUDER Iliac Branch Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, Arizona) (1). However, these devices require adequate sealing in the IIA and thus have limitations in the setting of an IIA aneurysm. For example, the GORE EXCLUDER Iliac Branch Endoprosthesis instructions for use require an IIA diameter between 6.5 mm and 13.5 mm. Although IIA occlusion is an acceptable treatment option, this technique is associated with significant risks (2–10). The most common complication reported
From the Miami Cardiac & Vascular Institute, Baptist Hospital of Miami, 8900 N Kendall Drive, Miami, FL 33176. Received July 20, 2017; final revision received October 26, 2017; accepted October 29, 2017. Address correspondence to R.A.-H.; E-mail: [email protected]
with IIA embolization is gluteal claudication, with estimated rates from pooled clinical data of 28% and 42% after unilateral and bilateral IIA embolization, respectively (6). Other associated complications include erectile dysfunction (17%) and colonic ischemia (3.4%) (6). Anatomic and technical limitations frequently make IIA sparing very difficult, if not impossible, during endovascular treatment. Surgical options are also available but are more invasive and sometimes require complex reconstructions, including translocating the IIA to the external iliac artery or combining an aorto-uniiliac stent graft, femorofemoral bypass, and external iliacto-IIA endograft to preserve 1 hypogastric artery (11,12). This report describes endovascular treatment of bilateral CIA and IIA aneurysms with a modified technique using bilateral iliac branch devices with extension of the internal iliac components into opposing anterior and posterior divisions of the IIA to preserve pelvic circulation.
CASE REPORT
None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2018; 29:632–635 https://doi.org/10.1016/j.jvir.2017.10.031
An 83-year-old man presented with incidentally discovered bilateral CIA and IIA aneurysms (right CIA diameter, 2.6 cm; left CIA diameter, 2.7 cm; right IIA diameter, 3.4 cm; left IIA diameter, 2.0 cm) and an infrarenal
Volume 29 ▪ Number 5 ▪ May ▪ 2018
Figure 1. Pelvic angiogram demonstrates bilateral CIA aneurysms (arrows) and bilateral IIA aneurysms (arrowheads). A 3.8-cm AAA with mural thrombus was also identified on CT performed before the procedure.
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abdominal aortic aneurysm (AAA) measuring 3.8 cm. Given the complexity of required intervention for the 5 aortoiliac aneurysms, the initial management was conservative with serial imaging. However, repeat computed tomography (CT) performed 1 year later demonstrated an increase in size of multiple aneurysms, including the right CIA aneurysm increasing to 3.0 cm and the left IIA aneurysm increasing to 2.6 cm. The patient was physically active and denied any symptoms of claudication. An initial diagnostic angiogram was performed to delineate the complex pelvic anatomy for procedural planning (Fig 1). Subsequent angiograms were obtained with coil embolization of an aberrant left iliolumbar artery arising from the left IIA and coil embolization of a diminutive anterior division of the left IIA, successfully isolating the posterior division of the left IIA as the only branch arising from the left IIA (Fig 2a, b). Bilateral Gore 16-F sheaths (W.L. Gore & Associates, Inc) were placed through surgical cutdowns 4 weeks later. The patient was administered peripheral intravenous heparin with an activated clotting time goal > 200 seconds throughout the procedure. Embolization of the posterior division of the right IIA artery was performed using an 8-mm AMPLATZER Vascular Plug 4 (St. Jude Medical, Inc, St. Paul, Minnesota), isolating the anterior division of the right IIA artery as the only branch arising from the right IIA (Fig 2a). A 23 mm 14.5 mm 10 cm GORE EXCLUDER Iliac Branch Endoprosthesis was advanced into the right iliac artery and deployed. The internal iliac gate was cannulated, and an 8-mm-diameter 5-cm-long GORE VIABAHN Endoprosthesis (W.L. Gore &
Figure 2. Bilateral IIA ipsilateral oblique angiograms. (a) Right IIA angiogram demonstrates an IIA aneurysm extending to the bifurcation. The posterior division of the right IIA (red X) was occluded with an AMPLATZER Vascular Plug 4; the anterior division of the right IIA (white A) was spared as the extension target for the right iliac branch device internal iliac component (arrow) using a GORE VIABAHN Endoprosthesis. (b) Embolization of an aberrant iliolumbar branch from the left CIA (yellow X) and the anterior division of the left IIA (blue X) was performed with coils; the posterior division of the left IIA (white P) was spared as the extension for the left iliac branch device internal iliac component (arrow) using a GORE VIABAHN Endoprosthesis.
634 ▪ Endovascular Treatment of Bilateral CIA and IIA Aneurysms
Al-Hakim et al ▪ JVIR
Figure 3. Completion angiogram in the early (a) and delayed (b) phases demonstrates no endoleak (note the bowel gas artifact). The right IIA anterior division (arrowhead) and left IIA posterior division (arrow) are patent on the completion angiogram.
Associates, Inc) was deployed in the anterior division of the right IIA artery extending proximally into the right IIA aneurysm sac. An internal iliac component of the GORE EXCLUDER Iliac Branch Endoprosthesis (16 10 7 mm) was deployed overlapping the stent graft in the anterior division of the right hypogastric artery and the right iliac branch device internal iliac gate. A second 23 mm 14.5 mm 10 cm GORE EXCLUDER Iliac Branch Endoprosthesis was advanced into the left iliac artery and deployed. After cannulating the internal iliac gate, a 9-mm-diameter 5-cm-long GORE VIABAHN Endoprosthesis was deployed into the posterior division of the left IIA extending proximally into the left IIA aneurysm sac. An internal iliac component of the GORE EXCLUDER Iliac Branch Endoprosthesis (16 mm 10 mm 7 mm) was deployed overlapping the stent graft in the posterior division of the left IIA and the left iliac branch device internal iliac gate. A GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc) (26 mm 14.5 mm 12 cm) was deployed in an infrarenal location. The contralateral gate was cannulated, and the ipsilateral limb was released in the left CIA. A GORE EXCLUDER AAA Endoprosthesis contralateral leg (16 mm 27 mm 10 cm) was then deployed in the ipsilateral limb extending into the left CIA just above the bifurcation of the left iliac branch device. A second GORE EXCLUDER AAA Endoprosthesis contralateral leg (16 mm 27 mm 10 cm) was then deployed through the contralateral gate of the AAA endoprosthesis to the right common iliac artery with the inferior aspect just above the bifurcation of the right iliac branch device.
Figure 4. A 1-month follow-up CT scan with anteroposterior and oblique three-dimensional reconstructions demonstrates patent aortobi-iliac stent graft and bilateral iliac branch devices with no opacification of the abdominal aortic, bilateral CIA, or bilateral IIA aneurysm sacs.
A compliant balloon was then inflated at the overlapping endoprosthesis segments. A final angiogram demonstrated no endoleak and persistent flow into the right IIA anterior division and left IIA posterior division (Fig 3a, b). The patient was discharged on postoperative day 2 with no complications. The patient was previously prescribed aspirin 81 mg by mouth daily, which was continued through the procedure and at discharge. The patient was seen in the
Volume 29 ▪ Number 5 ▪ May ▪ 2018
clinic 1 month later with no signs or symptoms of erectile dysfunction, buttock claudication, or other complications of pelvic ischemia. Follow-up CT performed 1 month after the procedure demonstrated no endoleak and interval stable or decrease in size of all 5 aneurysms (Fig 4). Notably, the right IIA aneurysm was stable in size at 3.4 cm and the left IIA aneurysm was decreased in size to 2.3 cm (previously 2.6 cm). The right IIA anterior division and left IIA posterior division were patent. The patient was last evaluated 6 months after the procedure and continued to do well with no clinically apparent symptoms of pelvic ischemia.
DISCUSSION The described technique resulted in preservation of pelvic circulation with no complications at last known follow-up. Although iliac branch devices have broadened the range of patients with aortoiliac aneurysms that can be treated with endovascular techniques, the devices are limited by inability to create an adequate seal in the setting of an IIA aneurysm. However, by extending the internal iliac component of an iliac branch device into the first division branch artery of the IIA, pelvic arterial circulation might be preserved. The case presented here was particularly challenging, and options were limited given the bilateral IIA aneurysms and high risk of complication with bilateral IIA occlusion. In addition, the interval growth of the bilateral IIA aneurysms ultimately necessitated endovascular treatment after conservative management with serial imaging. However, in the setting of unilateral CIA and IIA aneurysms, this technique could be used as well (as opposed to IIA occlusion) and may decrease the risk of complications associated with unilateral IIA occlusion. In addition, at least 1 prior case report has described successful use of an iliac branch device to treat a CIA without an AAA (13). Using the technique described here, unilateral concurrent CIA and IIA aneurysms without an AAA could theoretically be treated with a single iliac branch device extended into the IIA anterior or posterior division branches. The GORE EXCLUDER Iliac Branch Endoprosthesis instructions for use require the CIA diameter to be 17 mm, which would limit treatment of an IIA using this technique without a CIA aneurysm. Prior studies have
635
demonstrated a 93.8% 6-month primary patency of the internal iliac limb of the GORE EXCLUDER Iliac Branch Endoprosthesis (1). However, the long-term patency of the internal iliac limb with the described technique is unclear and requires additional study with long-term follow-up. In conclusion, iliac branch devices with internal iliac limb extension into the anterior or posterior division of the IIA can be used to treat concomitant CIA and IIA aneurysms and may preserve pelvic circulation.
REFERENCES 1. van Sterkenburg SM, Heyligers JM, van Bladel M, et al. Experience with the GORE EXCLUDER iliac branch endoprosthesis for common iliac artery aneurysms. J Vasc Surg 2016; 63:1451–1457. 2. Lee CW, Kaufman JA, Fan CM, et al. Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases. J Vasc Interv Radiol 2000; 11:567–571. 3. Mehta M, Veith FJ, Darling RC, et al. Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 2004; 40:698–702. 4. Bratby MJ, Munneke GM, Belli AM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol 2008; 31:246–253. 5. Cynamon J, Lerer D, Veith FJ, et al. Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognized but possibly preventable complication. J Vasc Interv Radiol 2000; 11:573–577. 6. Lin P, Chen A, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg 2009; 22: 193–200. 7. Yano OJ, Morrissey N, Eisen L, et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001; 34:204–211. 8. Farahmand P, Becquemin JP, Desgranges P, et al. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008; 35:429–435. 9. Lee WA, O’Dorisio J, Wolf YG, et al. Outcome after unilateral hypogastric artery occlusion during endovascular aneurysm repair. J Vasc Surg 2001; 33:921–926. 10. Dalainas I. A word of caution before killing hypogastric arteries. Cardiovasc Intervent Radiol 2008; 31:835. 11. Lee WA, Nelson PR, Berceli SA, et al. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. J Vasc Surg 2006; 44:1162–1168. 12. Bergamini TM, Rachel ES, Kinney EV, et al. External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting. J Vasc Surg 2002; 35:120–124. 13. Ardita V, Giaguinta A, Veroux M, et al. Endovascular repair of bilateral common iliac artery aneurysms using GORE Excluder iliac branch endoprosthesis without aortobi-iliac stent graft conjunction. Medicine 2017; 96:e5977.
Endovascular Treatment of Concurrent Bilateral Common and Internal Iliac Artery Aneurysms with Preserved Pelvic Circulation: Bilateral Iliac Branch Devices with Opposing Single Division Internal Iliac Artery Sparing Ramsey Al-Hakim, MD, Libby Watch, MD, and Alex Powell, MD ABSTRACT An 83-year-old man with bilateral common iliac artery aneurysms (right, 3.0 cm; left, 2.7 cm), bilateral internal iliac artery aneurysms (right, 3.4 cm; left, 2.6 cm), and an abdominal aortic aneurysm (3.8 cm) was treated with an aortobi-iliac stent graft and bilateral iliac branch devices. The internal iliac components were extended into opposing posterior (left) and anterior (right) divisions of the internal iliac artery using stent grafts. Computed tomography angiography demonstrated that all aneurysms decreased or were stable in size with patent stent grafts at 1 month. The patient was asymptomatic without complications of pelvic ischemia at the last clinical follow-up at 6 months.
ABBREVIATIONS AAA ¼ abdominal aortic aneurysm, CIA ¼ common iliac artery, IIA ¼ internal iliac artery
Endovascular treatment of concurrent abdominal aortic and common iliac artery (CIA) aneurysms with internal iliac artery (IIA) sparing has been made technically feasible with the advent of iliac branch devices such as the GORE EXCLUDER Iliac Branch Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, Arizona) (1). However, these devices require adequate sealing in the IIA and thus have limitations in the setting of an IIA aneurysm. For example, the GORE EXCLUDER Iliac Branch Endoprosthesis instructions for use require an IIA diameter between 6.5 mm and 13.5 mm. Although IIA occlusion is an acceptable treatment option, this technique is associated with significant risks (2–10). The most common complication reported
From the Miami Cardiac & Vascular Institute, Baptist Hospital of Miami, 8900 N Kendall Drive, Miami, FL 33176. Received July 20, 2017; final revision received October 26, 2017; accepted October 29, 2017. Address correspondence to R.A.-H.; E-mail: [email protected]
with IIA embolization is gluteal claudication, with estimated rates from pooled clinical data of 28% and 42% after unilateral and bilateral IIA embolization, respectively (6). Other associated complications include erectile dysfunction (17%) and colonic ischemia (3.4%) (6). Anatomic and technical limitations frequently make IIA sparing very difficult, if not impossible, during endovascular treatment. Surgical options are also available but are more invasive and sometimes require complex reconstructions, including translocating the IIA to the external iliac artery or combining an aorto-uniiliac stent graft, femorofemoral bypass, and external iliacto-IIA endograft to preserve 1 hypogastric artery (11,12). This report describes endovascular treatment of bilateral CIA and IIA aneurysms with a modified technique using bilateral iliac branch devices with extension of the internal iliac components into opposing anterior and posterior divisions of the IIA to preserve pelvic circulation.
CASE REPORT
None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2018; 29:632–635 https://doi.org/10.1016/j.jvir.2017.10.031
An 83-year-old man presented with incidentally discovered bilateral CIA and IIA aneurysms (right CIA diameter, 2.6 cm; left CIA diameter, 2.7 cm; right IIA diameter, 3.4 cm; left IIA diameter, 2.0 cm) and an infrarenal
Volume 29 ▪ Number 5 ▪ May ▪ 2018
Figure 1. Pelvic angiogram demonstrates bilateral CIA aneurysms (arrows) and bilateral IIA aneurysms (arrowheads). A 3.8-cm AAA with mural thrombus was also identified on CT performed before the procedure.
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abdominal aortic aneurysm (AAA) measuring 3.8 cm. Given the complexity of required intervention for the 5 aortoiliac aneurysms, the initial management was conservative with serial imaging. However, repeat computed tomography (CT) performed 1 year later demonstrated an increase in size of multiple aneurysms, including the right CIA aneurysm increasing to 3.0 cm and the left IIA aneurysm increasing to 2.6 cm. The patient was physically active and denied any symptoms of claudication. An initial diagnostic angiogram was performed to delineate the complex pelvic anatomy for procedural planning (Fig 1). Subsequent angiograms were obtained with coil embolization of an aberrant left iliolumbar artery arising from the left IIA and coil embolization of a diminutive anterior division of the left IIA, successfully isolating the posterior division of the left IIA as the only branch arising from the left IIA (Fig 2a, b). Bilateral Gore 16-F sheaths (W.L. Gore & Associates, Inc) were placed through surgical cutdowns 4 weeks later. The patient was administered peripheral intravenous heparin with an activated clotting time goal > 200 seconds throughout the procedure. Embolization of the posterior division of the right IIA artery was performed using an 8-mm AMPLATZER Vascular Plug 4 (St. Jude Medical, Inc, St. Paul, Minnesota), isolating the anterior division of the right IIA artery as the only branch arising from the right IIA (Fig 2a). A 23 mm 14.5 mm 10 cm GORE EXCLUDER Iliac Branch Endoprosthesis was advanced into the right iliac artery and deployed. The internal iliac gate was cannulated, and an 8-mm-diameter 5-cm-long GORE VIABAHN Endoprosthesis (W.L. Gore &
Figure 2. Bilateral IIA ipsilateral oblique angiograms. (a) Right IIA angiogram demonstrates an IIA aneurysm extending to the bifurcation. The posterior division of the right IIA (red X) was occluded with an AMPLATZER Vascular Plug 4; the anterior division of the right IIA (white A) was spared as the extension target for the right iliac branch device internal iliac component (arrow) using a GORE VIABAHN Endoprosthesis. (b) Embolization of an aberrant iliolumbar branch from the left CIA (yellow X) and the anterior division of the left IIA (blue X) was performed with coils; the posterior division of the left IIA (white P) was spared as the extension for the left iliac branch device internal iliac component (arrow) using a GORE VIABAHN Endoprosthesis.
634 ▪ Endovascular Treatment of Bilateral CIA and IIA Aneurysms
Al-Hakim et al ▪ JVIR
Figure 3. Completion angiogram in the early (a) and delayed (b) phases demonstrates no endoleak (note the bowel gas artifact). The right IIA anterior division (arrowhead) and left IIA posterior division (arrow) are patent on the completion angiogram.
Associates, Inc) was deployed in the anterior division of the right IIA artery extending proximally into the right IIA aneurysm sac. An internal iliac component of the GORE EXCLUDER Iliac Branch Endoprosthesis (16 10 7 mm) was deployed overlapping the stent graft in the anterior division of the right hypogastric artery and the right iliac branch device internal iliac gate. A second 23 mm 14.5 mm 10 cm GORE EXCLUDER Iliac Branch Endoprosthesis was advanced into the left iliac artery and deployed. After cannulating the internal iliac gate, a 9-mm-diameter 5-cm-long GORE VIABAHN Endoprosthesis was deployed into the posterior division of the left IIA extending proximally into the left IIA aneurysm sac. An internal iliac component of the GORE EXCLUDER Iliac Branch Endoprosthesis (16 mm 10 mm 7 mm) was deployed overlapping the stent graft in the posterior division of the left IIA and the left iliac branch device internal iliac gate. A GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc) (26 mm 14.5 mm 12 cm) was deployed in an infrarenal location. The contralateral gate was cannulated, and the ipsilateral limb was released in the left CIA. A GORE EXCLUDER AAA Endoprosthesis contralateral leg (16 mm 27 mm 10 cm) was then deployed in the ipsilateral limb extending into the left CIA just above the bifurcation of the left iliac branch device. A second GORE EXCLUDER AAA Endoprosthesis contralateral leg (16 mm 27 mm 10 cm) was then deployed through the contralateral gate of the AAA endoprosthesis to the right common iliac artery with the inferior aspect just above the bifurcation of the right iliac branch device.
Figure 4. A 1-month follow-up CT scan with anteroposterior and oblique three-dimensional reconstructions demonstrates patent aortobi-iliac stent graft and bilateral iliac branch devices with no opacification of the abdominal aortic, bilateral CIA, or bilateral IIA aneurysm sacs.
A compliant balloon was then inflated at the overlapping endoprosthesis segments. A final angiogram demonstrated no endoleak and persistent flow into the right IIA anterior division and left IIA posterior division (Fig 3a, b). The patient was discharged on postoperative day 2 with no complications. The patient was previously prescribed aspirin 81 mg by mouth daily, which was continued through the procedure and at discharge. The patient was seen in the
Volume 29 ▪ Number 5 ▪ May ▪ 2018
clinic 1 month later with no signs or symptoms of erectile dysfunction, buttock claudication, or other complications of pelvic ischemia. Follow-up CT performed 1 month after the procedure demonstrated no endoleak and interval stable or decrease in size of all 5 aneurysms (Fig 4). Notably, the right IIA aneurysm was stable in size at 3.4 cm and the left IIA aneurysm was decreased in size to 2.3 cm (previously 2.6 cm). The right IIA anterior division and left IIA posterior division were patent. The patient was last evaluated 6 months after the procedure and continued to do well with no clinically apparent symptoms of pelvic ischemia.
DISCUSSION The described technique resulted in preservation of pelvic circulation with no complications at last known follow-up. Although iliac branch devices have broadened the range of patients with aortoiliac aneurysms that can be treated with endovascular techniques, the devices are limited by inability to create an adequate seal in the setting of an IIA aneurysm. However, by extending the internal iliac component of an iliac branch device into the first division branch artery of the IIA, pelvic arterial circulation might be preserved. The case presented here was particularly challenging, and options were limited given the bilateral IIA aneurysms and high risk of complication with bilateral IIA occlusion. In addition, the interval growth of the bilateral IIA aneurysms ultimately necessitated endovascular treatment after conservative management with serial imaging. However, in the setting of unilateral CIA and IIA aneurysms, this technique could be used as well (as opposed to IIA occlusion) and may decrease the risk of complications associated with unilateral IIA occlusion. In addition, at least 1 prior case report has described successful use of an iliac branch device to treat a CIA without an AAA (13). Using the technique described here, unilateral concurrent CIA and IIA aneurysms without an AAA could theoretically be treated with a single iliac branch device extended into the IIA anterior or posterior division branches. The GORE EXCLUDER Iliac Branch Endoprosthesis instructions for use require the CIA diameter to be 17 mm, which would limit treatment of an IIA using this technique without a CIA aneurysm. Prior studies have
635
demonstrated a 93.8% 6-month primary patency of the internal iliac limb of the GORE EXCLUDER Iliac Branch Endoprosthesis (1). However, the long-term patency of the internal iliac limb with the described technique is unclear and requires additional study with long-term follow-up. In conclusion, iliac branch devices with internal iliac limb extension into the anterior or posterior division of the IIA can be used to treat concomitant CIA and IIA aneurysms and may preserve pelvic circulation.
REFERENCES 1. van Sterkenburg SM, Heyligers JM, van Bladel M, et al. Experience with the GORE EXCLUDER iliac branch endoprosthesis for common iliac artery aneurysms. J Vasc Surg 2016; 63:1451–1457. 2. Lee CW, Kaufman JA, Fan CM, et al. Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases. J Vasc Interv Radiol 2000; 11:567–571. 3. Mehta M, Veith FJ, Darling RC, et al. Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 2004; 40:698–702. 4. Bratby MJ, Munneke GM, Belli AM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol 2008; 31:246–253. 5. Cynamon J, Lerer D, Veith FJ, et al. Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognized but possibly preventable complication. J Vasc Interv Radiol 2000; 11:573–577. 6. Lin P, Chen A, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg 2009; 22: 193–200. 7. Yano OJ, Morrissey N, Eisen L, et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001; 34:204–211. 8. Farahmand P, Becquemin JP, Desgranges P, et al. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008; 35:429–435. 9. Lee WA, O’Dorisio J, Wolf YG, et al. Outcome after unilateral hypogastric artery occlusion during endovascular aneurysm repair. J Vasc Surg 2001; 33:921–926. 10. Dalainas I. A word of caution before killing hypogastric arteries. Cardiovasc Intervent Radiol 2008; 31:835. 11. Lee WA, Nelson PR, Berceli SA, et al. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. J Vasc Surg 2006; 44:1162–1168. 12. Bergamini TM, Rachel ES, Kinney EV, et al. External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting. J Vasc Surg 2002; 35:120–124. 13. Ardita V, Giaguinta A, Veroux M, et al. Endovascular repair of bilateral common iliac artery aneurysms using GORE Excluder iliac branch endoprosthesis without aortobi-iliac stent graft conjunction. Medicine 2017; 96:e5977.