Managing iliac disease

In this video, Drs. Branzan, Modarai, Verzini, Lindsay, and Lee examine the day-to-day challenges of managing iliac aneurysmal disease. They review proximal and distal seal considerations, treatment thresholds, and how their approach has evolved to preserve hypogastric flow when possible. These surgeons also explore the consequences of internal iliac artery occlusion and clarify when embolization remains an appropriate strategy for patients.

Transcript

What challenges are you faced with when treating iliac aneurysms?

Daniela Branzan (00:16)

When you treat this disease, you have to think of both of the proximal and the distal sealing zone. When we think of the internal iliac aneurysm or common iliac aneurysm, when we have to have a good sealing zone there, we have to think both of preserving of the internal iliac artery and both providing the perfect sealing. So it’s not always a very straightforward procedure. So you have to have a good understanding of the anatomy, and you have to plan your endovascular treatment accordingly.

Why is it important to maintain patency to the internal iliac artery?

Bijan Modarai (00:52)

I think we’ve learnt that sacrifice of the internal iliac artery has consequences. Buttock claudication, for example, that ensues from sacrificing an internal iliac artery is not a trivial symptom to have. Sexual dysfunction is also a consequence of internal iliac artery sacrifice. And then finally we know that the internal iliac artery is an important collateral blood supply to the spinal cord. So, if you are using the external iliac artery as the distal seal, it’s imperative that you preserve the internal iliac.

When would you consider embolizing instead of using ZBIS?

Fabio Verzini (01:29)

The clinical reason to occlude one hypogastric is really very small. I mean, just in case in which the hypogastric flow is already impaired, when there is a lot of calcification, in which probably the usage of hypogastric branch device may be in danger of early occlusion. In most of the cases, we found that preserving hypogastric flow is an advantage for the patient quality of life as well as the functional ability of the patient.

What is your treatment algorithm?

Thomas Lindsay (02:12)

Generally, after 3½ to 4 is where I start thinking that if it’s just an iliac aneurysm— 4 is kind of my threshold, for sure, but I start worrying about it at 3½. The ones that I’ve seen rupture tend to be quite a bit bigger. So a lot of it also depends on the size of the aorta. If the patient’s abdominal aorta is relatively small, 3 cm or so, I may wait until those iliac aneurysms get to be 4 centimeters as opposed to doing them at 3½.

How has your treatment of iliac aneurysms changed over the years?

W. Anthony Lee (2:49)

I have always been a very strong proponent of hypogastric preservation. And while variety of endovascular adjunctive procedures have been performed in the past to obtain some type of a distal seal in the setting of concomitant iliac aneurysms— And they include embolization, which will obviously lead to acute hypogastric occlusion, as well as surgical bypasses, namely an external-iliac-to-hypogastric-artery bypass, and other alternative techniques, such as chimney or parallel grafting. However, ever since iliac branch devices have become available, that is obviously the preferred choice.

All physicians were paid consultants of Cook Medical.