- Email: [email protected]
Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms
Accepted Manuscript Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms Karathanos Christos , MD, MSc, PhD Xanthopoulos Dimitrios , MD, PhD Kaperonis Elias , MD PhD Konstantopoulos Theophanis , MD Exarchou Maria , MD, MSc Papavassiliou Vasilios , MD, PhD PII:
S0890-5096(14)00253-2
DOI:
10.1016/j.avsg.2014.04.010
Reference:
AVSG 2013
To appear in:
Annals of Vascular Surgery
Received Date: 30 October 2013 Revised Date:
10 March 2014
Accepted Date: 1 April 2014
Please cite this article as: Christos K, Dimitrios X, Elias K, Theophanis K, Maria E, Vasilios P, Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms, Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms
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Case report
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Karathanos Christos MD, MSc, PhD, Xanthopoulos Dimitrios MD, PhD, Kaperonis Elias MD PhD, Konstantopoulos Theophanis MD, Exarchou Maria MD, MSc,
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Papavassiliou Vasilios MD, PhD
Department of Vascular Surgery, Sismanoglio, General Hospital of Athens, Athens,
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Greece
Short Title: “Bilateral Hypogastric Artery Aneurysms”
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We declare that this is an original work, there has been no duplicate publication or
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submission of any part of the work. All authors have read and approved the manuscript, and there is no financial arrangement or other relationship that could be construed as a conflict of interest.
ACCEPTED MANUSCRIPT Author for correspondence and reprints request: Christos Karathanos MD, MSc, PhD Department of Vascular Surgery
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Sismanoglio, General Hospital of Athens Sismanogliou 1, 15126 Marousi, Athens, Greece
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Tel: +302132058289, Fax: +302106137326
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e-mail: [email protected]
ACCEPTED MANUSCRIPT Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms
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ABSTRACT Bilateral hypogastric artery aneurysms (HAAs) are relatively rare conditions that pose increased management difficulties. We report a case of one-stage
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endovascular repair of bilateral HAAs preserving pelvic circulation. A 67-year-old asymptomatic man with bilateral HAAs (4-cm right and 3.9-cm left) was successfully
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treated with an endovascular approach. The aneurysmal sac of the right hypogastric artery (HA) was embolized first, and two covered stent grafts were deployed into the HA. Coil embolization of the left HAA was then performed followed by the deployment of a covered stent graft to the common and external iliac arteries. Final
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angiography revealed complete exclusion of the aneurysms without endoleaks and with preservation of the pelvic flow. At the 18-month follow-up, the patient remained asymptomatic with good patency of the stent grafts. This case demonstrates an
EP
alternative endovascular approach for the treatment of bilateral HAAs that minimizes
AC C
the risk of ischemic complications by preserving pelvic circulation. Key words: hypogastric artery, internal iliac artery, aneurysm, endovascular repair, one stage, embolization, stent
ACCEPTED MANUSCRIPT INTRODUCTION Hypogastric artery aneurysms (HAAs) are uncommon, representing 0.4% of all intra-abdominal aneurysms.1 Most patients with an HAA are asymptomatic and are incidentally diagnosed. Despite their rarity, HAAs have a high risk of rupture, with
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significant associated mortality rates of up to 50% in emergency operations.2
The natural history of an HAA is continuing enlargement and rupture, and early 2,3
Because of their
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repair when the diameter exceeds 3 cm is recommended.
anatomical position deep within the pelvis, open repair is technically challenging and
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has considerable perioperative morbidity and mortality.2,3 Minimally invasive endovascular repair for aneurysm exclusion might be an alternative treatment.4,5 Bilateral HAAs are even more rare and pose increased management difficulties.
the pelvic circulation.
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CASE REPORT
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We report a successful one-stage endovascular repair of bilateral HAAs, preserving
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A 67-year old asymptomatic male presented with bilateral HAAs detected on a surveillance abdominal ultrasound. The patient had a history of severe hypertension and coronary artery disease. A contrast-enhanced abdominal computed tomography (CT) scan showed a 4-cm maximum diameter right HAA and a 3.9-cm left HAA (Fig 1). Digital subtraction angiography confirmed the CT scan findings (Fig 2). There was a potential proximal landing zone for a stent graft of at least 2-cm within each common iliac artery. The common iliac arteries and the abdominal aorta were of normal diameter.
ACCEPTED MANUSCRIPT The decision was made to treat these aneurysms using an endovascular approach. The procedure was performed under epidural anesthesia in an operating room equipped with mobile C-arm fluoroscopy. The right side was treated first via a left common femoral artery (CFA) surgical approach, and 5000 units of heparin was
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administered intravenously. An 8-F sheath was introduced, and angiography was performed. Under fluoroscopy, an angled tip of a 0.035 in wire and a 5-F vertebral catheter were introduced to the right HA. The tip of the catheter was placed into the
SC
aneurysm sac, and two embolic coils 8 x 50 mm (0,035” MReye IMWCE 35-5-8-, Cook, Bloomington, IN, USA) were successfully deployed, using the stiff end of a
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straight guidewire. A balloon expandable covered stent graft 6 x 22 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA) was placed into the HA. A type -Ia endoleak was indentified and a second covered stent, 7 x 22 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA)
was deployed into the HA. The
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confirmatory angiography was then performed and no endoleaks were observed, whereas the HA patency to the distal branches was preserved (Fig 3). The left HAA was treated similarly to the procedure previously described through the ipsilateral
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CFA. Three coils, 5 x 30 mm (0.035” MReye, IMWCE 35-3-5- , Cook, Bloomington,
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IN, USA) were used to embolize the aneurysmal HA close to the bifurcation followed by the deployment of an V12 Atrium stent graft 12 x 41 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA) to the common and external iliac arteries. The completion angiography revealed a satisfactory result with complete exclusion of both aneurysms, no endoleaks and preservation of the pelvic flow. The radiation time was 7 min, and the total contrast used was 120 ml. The patient tolerated the procedure well and was discharged with antiplatelet therapy on the third postoperative day.
ACCEPTED MANUSCRIPT At the 18-month follow-up, the patient remained asymptomatic, and a contrastenhanced CT scan revealed decreases in the HAAs sizes and good patency of the stent grafts with preservation of the pelvic flow (Fig 4).
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DISCUSSION Hypogastric artery aneurysms most commonly coexists with aorto-iliac aneurysms. Isolated HAA represents a rare and challenging clinical condition with a
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reported incidence of 0.03% in autopsy series.6 Bilateral HAAs are even more rare and are a more complicated clinical entity. Although they are commonly caused by
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atherosclerosis, other causes include trauma, infection or collagen disorders such as Marfan and Ehlers-Danlos syndromes. They usually appear in the seventh decade with a 6:1 male predominance. The natural history of HAA is not well defined, although aneurysms that are more than 3 cm in diameter, symptomatic or expanding
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by more than 1 cm/year are hypothesized to be associated with a significant risk of rupture.2 There is variability in the literature as the percentage that are thought to be asymptomatic ranges from 29% to 78%.7,
8, 9,10
Although HAAs are normally
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asymptomatic, they could cause symptoms from compression to adjacent organs including the ureter, bowel, nerves and iliac veins.2,7 HAAs could also rupture or,
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thrombose, and clots formed within an HAA could embolize.2,7 Open surgical repair of HAAs might involve ligation, excision or
endoanneurysmorrhaphy. Proximal ligation involves limited dissection in the pelvis, which reduces the risk of bleeding; however, the aneurysm might continue to refill by a retrograde flow. Proximal and distal ligation is an effective treatment, with less risk of aneurysm enlargement and more risk of operative blending. Excision of the entire aneurysm is not recommended because of a significant risk of hemorrhage or damage
ACCEPTED MANUSCRIPT to nearby structures.1 Endoanneurysmorrhaphy is only suitable for unilateral HAA because the risk of buttock necrosis in bilateral aneurysms ligation is very high.7 Unilateral HAA ligation
is usually well tolerated. The patency of the inferior
mesenteric artery (IMA) should be evaluated in patients with bilateral HAAs. In cases
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of proximal IMA occlusion, ligation of the HAAs should be followed by an interposition graft to preserve pelvic circulation.5,7 The deep location of the HAs within the pelvis causes these procedures to be technically difficult, with considerable
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morbidity and mortality rates up to 11% in elective cases and 50% in emergency
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cases.2,7
Endovascular repair of HAA was first described by Perdue in 1983 with elective coil embolization of the aneurysm sac.11 Other endovascular techniques include stent graft deployment along the common and external iliac arteries with or without coil embolization.3,7 Stents could be deployed to the HA to exclude the aneurysm from
complications, in
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circulation. Antoniou et al. reported no differences in the technical success and late the different endovascular procedures.5 Although patients,
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especially elderly patients with significant co-morbidities, are likely to benefit from an endovascular approach, there are some limitations. Endovascular treatment could
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not be performed in cases with compression to adjacent organs because, reduction in aneurysm diameter is frequently slow, and surgical decompression is required.7 Other anatomic considerations that might influence endovascular treatment include the following: length of the proximal and distal landing zone <1.5 cm, the length and diameter of the main HA trunk, the concomitant involvement of the CIA and/or abdominal aorta, tortuous iliac anatomy, heavily calcified iliac arteries, external iliac artery occlusion, CIA dissection and a previous abdominal aorta aneurysm open repair complicated by a CIA anastomotic false aneurysm.12,13
ACCEPTED MANUSCRIPT In cases of bilateral HAAs, several procedures have been described. The key objective of all the treatment options is to exclude the aneurysm from circulation and to preserve pelvic circulation. The interruption of blood flow in both HAs is controversial. Bilateral occlusion of HAs might lead to complications including pelvic
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ischemia, buttock claudication to gluteal necrosis, colonic ischemia and sexual dysfunction.14 Some authors suggest that a staged endovascular coil embolization could reduce the ischemic postoperative complications because of improved collateral
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flow across the pelvis in the period between procedures.15 Iliopoulos et al reported that there was no difference in the incidence of buttock claudication following the ipsilateral external iliac artery
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sequential or one-stage embolization because
branches provide more significant collateral than does the contralateral HA.16 Others procedures preserve at least one HA, and revascularization of the remaining trunk with an external to internal iliac artery bypass is proposed.7 The hypogastric artery
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branched endovascular stent graft or “sandwich technique” described by Lobato are alternative endovascular approaches to preserve pelvic circulation.13
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A systematic Medline search was undertaken to identify articles reporting on simultaneous endovascular treatment of bilateral HAAs. Because of the rarity of this
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condition, only four case reports were indentified. In all but one case the aneurysms were successfully excluded from circulation without evidence of an endoleak.5,17,18,19 In a case with left HAA rupture that was treated urgently, residual filling of the aneurysm sac was seen without a need for conversion to open surgery.5 Two patients developed transient buttock claudication symptoms, and the first was treated with a bilateral coil embolization and the other with stent grafts deployment. None of the patients developed an aneurysm related complication during follow-up.
ACCEPTED MANUSCRIPT Although there have been no large series of patients with bilateral HAAs, there are several studies regarding bilateral HAs interruption outcomes in the treatment of complex aortoiliac aneurysms.14,20,21,22 Most of the studies reported that morbidity from interruption of pelvic circulation could be limited. This limitation could be
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achieved by occlusion of the HAs at their origin, avoiding distal branch embolization and preserving the collateral branches of the external iliac and femoral arteries.5,16
In this case, we successfully excluded both HAAs from circulation, maintaining
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the patency of the right HA and the left pelvic collateral circulation. The right HA
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aneurysm sac was embolized first, with coils to decrease the potential for retrograde perfusion, and a stent graft was deployed across the HA to exclude the aneurysm. We selected the coil and cover technique because of the inadequate HAA proximal neck. We embolized the left HAA and covered the orifice of the artery because the aneurysm extended near the bifurcation. With the coil and cover technique, stenting is
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the equivalent of proximal ligation, and coiling is equivalent to distal ligation.7,23 We avoided embolization of the distal branches and no ischemic complications occurred.
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To our knowledge, the exclusion of bilateral HAAs with this technique has not been previously published. To reduce graft related complications and minimize the risk of
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vessel injury, flexible and smaller endografts should be used in patients with suitable anatomy. This case correlates with the previous studies that show that the level of the anatomic occlusion or embolization of the HA and their branches have more significant effects on ischemic complications than the type (embolization or stent graft), and the time (sequential or simultaneous) of the procedure.
14,16,21,22
studies are needed to clarify the safety of bilateral proximal occlusion of HAs.
Larger
ACCEPTED MANUSCRIPT CONCLUSIONS Endovascular treatment of HAAs could safely be performed, even in cases with bilateral involvement. This case demonstrates an alternative endovascular approach
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that minimizes the risk of ischemic complications from the interruption of the pelvic circulation. A larger series with longer follow-up is needed to determine the efficacy
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of this method.
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Conflicts of interest/funding: none.
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ACKNOWLEDGMENT
ACCEPTED MANUSCRIPT REFERENCES 1.
Short DW. Aneurysms of the internal iliac artery. Br J Surg. 1966;53:17-20
2.
Richardson JW, Greenfield LJ. Natural history and management of iliac
3.
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aneurysms. J Vasc Surg 1998;8:165-171 Sandlu RS, Pipinos II. Isolated iliac artery aneurysms. Semin Vasc Surg
2005;18:209-15 4.
Tsilimparis N, Alevizakos P, Yousefi S et al. Treatment of internal iliac artery
Antoniou GA, Nassef AH, Antoniou SA et al. Endovascular treatment of
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5.
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aneurysms: single-centre experience. ANZ J Surg 2009;79:258-264
isolated internal iliac artery aneurysms. Vascular 2011;19(6):291-300 6.
Brunkwall J, Hauksson H, Bengtsson H et al. Solitary aneurysms of the iliac
arterial system: an estimate of their frequency of occurrence. J Vasc Surg 1989;10:381-384
Dix F.P, Titi M, Al-Khaffaf H. The isolated internal iliac artery aneurysm. A
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7.
review. Eur J Vasc Endovasc Surg 2005; 30:119-129 Kasulke RJ, Clifford A, Nichols WK et al. Isolated atherosclerotic aneurysms
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8.
of the internal iliac arteries: report of two cases and review of the literature. Arch Surg
9.
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1982; 117:73-77
McCready RA, Pairolero PC, Gilmore JC et al. Isolated iliac artery aneurysms.
Surgery 1983;93(5)688-693 10.
Brin B, Busuttil R. Isolated hypogastric artery aneurysms. Arch Surg
1982;117:1329-1333 11.
Perdue GD, Mittenthal MJ, Smith RB et al. Aneurysms of the internal iliac
artery. Surgery 1983; 243-246
ACCEPTED MANUSCRIPT 12.
Uberoi R, Tsetis D, Shrivastava V et al. Standard of practice for the
interventional management of isolated iliac artery aneurysms. Cardiovasc Intervent Radiol 2011;34:3-13 13.
Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex
14.
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aortoiliac aneurysms: Results of midterm follow-up. J Vasc Surg 2013;57:26S-34S
Mehta M, Veith FJ, Darling RC et al. Effects of bilateral hypogastric artery
interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg
15.
Franz RW, Knapp ED. Staged endovascular repair of bilateral internal iliac
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artery aneurysms. Ann Vasc Surg 2009;23:136-138 16.
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2004;40:698-702
Iliopoulos JL, Hermresk AS, Thomas JH et al. Hemodynamics of the
hypogastric arterial circulation. J Vasc Surg 1989;9:637-641 17.
Melki JP, Fichelle JM, Cormier F et al. Embolization of hypogastric artery
18.
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aneurysm: 17 cases. Ann Vasc Surg 2001;15: 312-320
Mori M, Sakamoto I, Morikawa M et al. Transcatheter embolization of
internal iliac artery aneurysms. J Vasc Interv Radiol 1999:10:591-597 Esposito G, Franzone A, Cassese S et al. Endovascular repair for isolated iliac
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19.
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artery aneurysms: case report and review of the current literature. J Cardiovasc Med 2009;10: 861-865 20.
Griado FJ, Wilson EP, Velazquez OC et al. Safety of coil embolization of the
internal iliac artery in endovascular grafting of abdominal aortic aneurysms. J Vasc Surg 2000;32:684-688 21.
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
ACCEPTED MANUSCRIPT 22.
Yano OJ, Morissey N, Einsen L et al. International internal iliac artery
occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001;34:204-211 23.
Cynamon J, Marin ML, Veith FJ et al. Endovascular repair of an internal iliac
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artery aneurysm with use of stented graft and embolization coils. J Vasc Interv Radiol
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1995;6(4):509-511
ACCEPTED MANUSCRIPT
LEGENDS Fig 1: Pre-operative CT.
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Fig 2: Pre-operative digital subtraction angiography
Fig 3: Completion angiography confirming complete exclusion of the aneurysms.
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Fig 4: Computed tomography (CT) 18 months after the procedure
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ACCEPTED MANUSCRIPT
S0890-5096(14)00253-2
DOI:
10.1016/j.avsg.2014.04.010
Reference:
AVSG 2013
To appear in:
Annals of Vascular Surgery
Received Date: 30 October 2013 Revised Date:
10 March 2014
Accepted Date: 1 April 2014
Please cite this article as: Christos K, Dimitrios X, Elias K, Theophanis K, Maria E, Vasilios P, Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms, Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms
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Case report
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Karathanos Christos MD, MSc, PhD, Xanthopoulos Dimitrios MD, PhD, Kaperonis Elias MD PhD, Konstantopoulos Theophanis MD, Exarchou Maria MD, MSc,
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Papavassiliou Vasilios MD, PhD
Department of Vascular Surgery, Sismanoglio, General Hospital of Athens, Athens,
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Greece
Short Title: “Bilateral Hypogastric Artery Aneurysms”
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We declare that this is an original work, there has been no duplicate publication or
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submission of any part of the work. All authors have read and approved the manuscript, and there is no financial arrangement or other relationship that could be construed as a conflict of interest.
ACCEPTED MANUSCRIPT Author for correspondence and reprints request: Christos Karathanos MD, MSc, PhD Department of Vascular Surgery
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Sismanoglio, General Hospital of Athens Sismanogliou 1, 15126 Marousi, Athens, Greece
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Tel: +302132058289, Fax: +302106137326
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EP
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e-mail: [email protected]
ACCEPTED MANUSCRIPT Preservation of Pelvic Circulation in One-Stage Endovascular Repair of Bilateral Hypogastric Artery Aneurysms
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ABSTRACT Bilateral hypogastric artery aneurysms (HAAs) are relatively rare conditions that pose increased management difficulties. We report a case of one-stage
SC
endovascular repair of bilateral HAAs preserving pelvic circulation. A 67-year-old asymptomatic man with bilateral HAAs (4-cm right and 3.9-cm left) was successfully
M AN U
treated with an endovascular approach. The aneurysmal sac of the right hypogastric artery (HA) was embolized first, and two covered stent grafts were deployed into the HA. Coil embolization of the left HAA was then performed followed by the deployment of a covered stent graft to the common and external iliac arteries. Final
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angiography revealed complete exclusion of the aneurysms without endoleaks and with preservation of the pelvic flow. At the 18-month follow-up, the patient remained asymptomatic with good patency of the stent grafts. This case demonstrates an
EP
alternative endovascular approach for the treatment of bilateral HAAs that minimizes
AC C
the risk of ischemic complications by preserving pelvic circulation. Key words: hypogastric artery, internal iliac artery, aneurysm, endovascular repair, one stage, embolization, stent
ACCEPTED MANUSCRIPT INTRODUCTION Hypogastric artery aneurysms (HAAs) are uncommon, representing 0.4% of all intra-abdominal aneurysms.1 Most patients with an HAA are asymptomatic and are incidentally diagnosed. Despite their rarity, HAAs have a high risk of rupture, with
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significant associated mortality rates of up to 50% in emergency operations.2
The natural history of an HAA is continuing enlargement and rupture, and early 2,3
Because of their
SC
repair when the diameter exceeds 3 cm is recommended.
anatomical position deep within the pelvis, open repair is technically challenging and
M AN U
has considerable perioperative morbidity and mortality.2,3 Minimally invasive endovascular repair for aneurysm exclusion might be an alternative treatment.4,5 Bilateral HAAs are even more rare and pose increased management difficulties.
the pelvic circulation.
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CASE REPORT
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We report a successful one-stage endovascular repair of bilateral HAAs, preserving
AC C
A 67-year old asymptomatic male presented with bilateral HAAs detected on a surveillance abdominal ultrasound. The patient had a history of severe hypertension and coronary artery disease. A contrast-enhanced abdominal computed tomography (CT) scan showed a 4-cm maximum diameter right HAA and a 3.9-cm left HAA (Fig 1). Digital subtraction angiography confirmed the CT scan findings (Fig 2). There was a potential proximal landing zone for a stent graft of at least 2-cm within each common iliac artery. The common iliac arteries and the abdominal aorta were of normal diameter.
ACCEPTED MANUSCRIPT The decision was made to treat these aneurysms using an endovascular approach. The procedure was performed under epidural anesthesia in an operating room equipped with mobile C-arm fluoroscopy. The right side was treated first via a left common femoral artery (CFA) surgical approach, and 5000 units of heparin was
RI PT
administered intravenously. An 8-F sheath was introduced, and angiography was performed. Under fluoroscopy, an angled tip of a 0.035 in wire and a 5-F vertebral catheter were introduced to the right HA. The tip of the catheter was placed into the
SC
aneurysm sac, and two embolic coils 8 x 50 mm (0,035” MReye IMWCE 35-5-8-, Cook, Bloomington, IN, USA) were successfully deployed, using the stiff end of a
M AN U
straight guidewire. A balloon expandable covered stent graft 6 x 22 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA) was placed into the HA. A type -Ia endoleak was indentified and a second covered stent, 7 x 22 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA)
was deployed into the HA. The
TE D
confirmatory angiography was then performed and no endoleaks were observed, whereas the HA patency to the distal branches was preserved (Fig 3). The left HAA was treated similarly to the procedure previously described through the ipsilateral
EP
CFA. Three coils, 5 x 30 mm (0.035” MReye, IMWCE 35-3-5- , Cook, Bloomington,
AC C
IN, USA) were used to embolize the aneurysmal HA close to the bifurcation followed by the deployment of an V12 Atrium stent graft 12 x 41 mm (V12 Atrium, Medical Cooperation, Boston, MA, USA) to the common and external iliac arteries. The completion angiography revealed a satisfactory result with complete exclusion of both aneurysms, no endoleaks and preservation of the pelvic flow. The radiation time was 7 min, and the total contrast used was 120 ml. The patient tolerated the procedure well and was discharged with antiplatelet therapy on the third postoperative day.
ACCEPTED MANUSCRIPT At the 18-month follow-up, the patient remained asymptomatic, and a contrastenhanced CT scan revealed decreases in the HAAs sizes and good patency of the stent grafts with preservation of the pelvic flow (Fig 4).
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DISCUSSION Hypogastric artery aneurysms most commonly coexists with aorto-iliac aneurysms. Isolated HAA represents a rare and challenging clinical condition with a
SC
reported incidence of 0.03% in autopsy series.6 Bilateral HAAs are even more rare and are a more complicated clinical entity. Although they are commonly caused by
M AN U
atherosclerosis, other causes include trauma, infection or collagen disorders such as Marfan and Ehlers-Danlos syndromes. They usually appear in the seventh decade with a 6:1 male predominance. The natural history of HAA is not well defined, although aneurysms that are more than 3 cm in diameter, symptomatic or expanding
TE D
by more than 1 cm/year are hypothesized to be associated with a significant risk of rupture.2 There is variability in the literature as the percentage that are thought to be asymptomatic ranges from 29% to 78%.7,
8, 9,10
Although HAAs are normally
EP
asymptomatic, they could cause symptoms from compression to adjacent organs including the ureter, bowel, nerves and iliac veins.2,7 HAAs could also rupture or,
AC C
thrombose, and clots formed within an HAA could embolize.2,7 Open surgical repair of HAAs might involve ligation, excision or
endoanneurysmorrhaphy. Proximal ligation involves limited dissection in the pelvis, which reduces the risk of bleeding; however, the aneurysm might continue to refill by a retrograde flow. Proximal and distal ligation is an effective treatment, with less risk of aneurysm enlargement and more risk of operative blending. Excision of the entire aneurysm is not recommended because of a significant risk of hemorrhage or damage
ACCEPTED MANUSCRIPT to nearby structures.1 Endoanneurysmorrhaphy is only suitable for unilateral HAA because the risk of buttock necrosis in bilateral aneurysms ligation is very high.7 Unilateral HAA ligation
is usually well tolerated. The patency of the inferior
mesenteric artery (IMA) should be evaluated in patients with bilateral HAAs. In cases
RI PT
of proximal IMA occlusion, ligation of the HAAs should be followed by an interposition graft to preserve pelvic circulation.5,7 The deep location of the HAs within the pelvis causes these procedures to be technically difficult, with considerable
SC
morbidity and mortality rates up to 11% in elective cases and 50% in emergency
M AN U
cases.2,7
Endovascular repair of HAA was first described by Perdue in 1983 with elective coil embolization of the aneurysm sac.11 Other endovascular techniques include stent graft deployment along the common and external iliac arteries with or without coil embolization.3,7 Stents could be deployed to the HA to exclude the aneurysm from
complications, in
TE D
circulation. Antoniou et al. reported no differences in the technical success and late the different endovascular procedures.5 Although patients,
EP
especially elderly patients with significant co-morbidities, are likely to benefit from an endovascular approach, there are some limitations. Endovascular treatment could
AC C
not be performed in cases with compression to adjacent organs because, reduction in aneurysm diameter is frequently slow, and surgical decompression is required.7 Other anatomic considerations that might influence endovascular treatment include the following: length of the proximal and distal landing zone <1.5 cm, the length and diameter of the main HA trunk, the concomitant involvement of the CIA and/or abdominal aorta, tortuous iliac anatomy, heavily calcified iliac arteries, external iliac artery occlusion, CIA dissection and a previous abdominal aorta aneurysm open repair complicated by a CIA anastomotic false aneurysm.12,13
ACCEPTED MANUSCRIPT In cases of bilateral HAAs, several procedures have been described. The key objective of all the treatment options is to exclude the aneurysm from circulation and to preserve pelvic circulation. The interruption of blood flow in both HAs is controversial. Bilateral occlusion of HAs might lead to complications including pelvic
RI PT
ischemia, buttock claudication to gluteal necrosis, colonic ischemia and sexual dysfunction.14 Some authors suggest that a staged endovascular coil embolization could reduce the ischemic postoperative complications because of improved collateral
SC
flow across the pelvis in the period between procedures.15 Iliopoulos et al reported that there was no difference in the incidence of buttock claudication following the ipsilateral external iliac artery
M AN U
sequential or one-stage embolization because
branches provide more significant collateral than does the contralateral HA.16 Others procedures preserve at least one HA, and revascularization of the remaining trunk with an external to internal iliac artery bypass is proposed.7 The hypogastric artery
TE D
branched endovascular stent graft or “sandwich technique” described by Lobato are alternative endovascular approaches to preserve pelvic circulation.13
EP
A systematic Medline search was undertaken to identify articles reporting on simultaneous endovascular treatment of bilateral HAAs. Because of the rarity of this
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condition, only four case reports were indentified. In all but one case the aneurysms were successfully excluded from circulation without evidence of an endoleak.5,17,18,19 In a case with left HAA rupture that was treated urgently, residual filling of the aneurysm sac was seen without a need for conversion to open surgery.5 Two patients developed transient buttock claudication symptoms, and the first was treated with a bilateral coil embolization and the other with stent grafts deployment. None of the patients developed an aneurysm related complication during follow-up.
ACCEPTED MANUSCRIPT Although there have been no large series of patients with bilateral HAAs, there are several studies regarding bilateral HAs interruption outcomes in the treatment of complex aortoiliac aneurysms.14,20,21,22 Most of the studies reported that morbidity from interruption of pelvic circulation could be limited. This limitation could be
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achieved by occlusion of the HAs at their origin, avoiding distal branch embolization and preserving the collateral branches of the external iliac and femoral arteries.5,16
In this case, we successfully excluded both HAAs from circulation, maintaining
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the patency of the right HA and the left pelvic collateral circulation. The right HA
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aneurysm sac was embolized first, with coils to decrease the potential for retrograde perfusion, and a stent graft was deployed across the HA to exclude the aneurysm. We selected the coil and cover technique because of the inadequate HAA proximal neck. We embolized the left HAA and covered the orifice of the artery because the aneurysm extended near the bifurcation. With the coil and cover technique, stenting is
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the equivalent of proximal ligation, and coiling is equivalent to distal ligation.7,23 We avoided embolization of the distal branches and no ischemic complications occurred.
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To our knowledge, the exclusion of bilateral HAAs with this technique has not been previously published. To reduce graft related complications and minimize the risk of
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vessel injury, flexible and smaller endografts should be used in patients with suitable anatomy. This case correlates with the previous studies that show that the level of the anatomic occlusion or embolization of the HA and their branches have more significant effects on ischemic complications than the type (embolization or stent graft), and the time (sequential or simultaneous) of the procedure.
14,16,21,22
studies are needed to clarify the safety of bilateral proximal occlusion of HAs.
Larger
ACCEPTED MANUSCRIPT CONCLUSIONS Endovascular treatment of HAAs could safely be performed, even in cases with bilateral involvement. This case demonstrates an alternative endovascular approach
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that minimizes the risk of ischemic complications from the interruption of the pelvic circulation. A larger series with longer follow-up is needed to determine the efficacy
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of this method.
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Conflicts of interest/funding: none.
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ACKNOWLEDGMENT
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LEGENDS Fig 1: Pre-operative CT.
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Fig 2: Pre-operative digital subtraction angiography
Fig 3: Completion angiography confirming complete exclusion of the aneurysms.
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Fig 4: Computed tomography (CT) 18 months after the procedure
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