1. Management of Iliac Artery Aneurysms

2. Etiology Idiopathic – Remote collagen vascular disease Idiopathic – Remote collagen vascular disease Atherosclerosis, Smoking Atherosclerosis, Smoking Infectious (TB, Syphilis, S. aureus, Salmonella, Klebsiella) Infectious (TB, Syphilis, S. aureus, Salmonella, Klebsiella) Collagen diseases (Marfan’s, Ehlers-Danlos, Cystic Medial Necrosis) Collagen diseases (Marfan’s, Ehlers-Danlos, Cystic Medial Necrosis) Takayasu’s, Kawasaki’s, Bechet’s, etc. Takayasu’s, Kawasaki’s, Bechet’s, etc.

3. Incidence 0.03% lifetime incidence 0.03% lifetime incidence 0.3-1.9% of arterial aneurysms 0.3-1.9% of arterial aneurysms 75-95% present with AAA 75-95% present with AAA 7th-8th decade of life 7th-8th decade of life 8-9:1 male:female ratio 8-9:1 male:female ratio Common Iliac Artery - 70% Common Iliac Artery - 70% Internal Iliac Artery - 20% Internal Iliac Artery - 20% External Iliac Artery - 10% External Iliac Artery - 10% Bilateral Disease – 20-60% Bilateral Disease – 20-60%

4. Complications Rupture Rupture Distal embolization Distal embolization Thrombosis Thrombosis Urologic symptoms secondary to ureteral compression Urologic symptoms secondary to ureteral compression Pain from compression of adjacent nerves and vicera (Rare) Pain from compression of adjacent nerves and vicera (Rare)

5. Complications 106 Patients 106 Patients 59 presented with intact IAA (mean 3.9cm) 59 presented with intact IAA (mean 3.9cm) 10 presented with rupture (mean 7.2cm) 10 presented with rupture (mean 7.2cm) 37 unoperated on (mean 3.2cm) 37 unoperated on (mean 3.2cm) 12 enlarged 12 enlarged 3 ruptured (smallest 3.5cm) 3 ruptured (smallest 3.5cm) Kasirajan V et al. Card Surg. 1998: 6(2), 171-177.

6. Natural History Santilli et al, 2000 (U. of Minnesota) Santilli et al, 2000 (U. of Minnesota) 189 patients in VA system (2 women) with 323 iliac artery aneurysms 189 patients in VA system (2 women) with 323 iliac artery aneurysms 47 patients with isolated IAA 47 patients with isolated IAA Followed with USG or CT at 6 month intervals Followed with USG or CT at 6 month intervals Average f/u: 31.4 months (4.2 studies) Average f/u: 31.4 months (4.2 studies) Survival: 96.3% at 1 year, 88.5% at 2 years, 72.3% at 3 and 4 years Survival: 96.3% at 1 year, 88.5% at 2 years, 72.3% at 3 and 4 years

7. Natural History Average rate of expansion: 0.118 +/- 0.017 cm/year Average rate of expansion: 0.118 +/- 0.017 cm/year No expansion in 37.5% No expansion in 37.5% All IAA between 4 and 4.9cm expanded (All >5cm repaired) All IAA between 4 and 4.9cm expanded (All >5cm repaired) <3cm: 0.05-0.15cm/year <3cm: 0.05-0.15cm/year >3cm: 0.25-0.28cm/year >3cm: 0.25-0.28cm/year

8. Natural History Santelli et al. J Vasc Surg. 2000: 31(1), 114-121

9. Surgical Intervention All series >/= 5 patients between 1961 and 1997 All series >/= 5 patients between 1961 and 1997 367 patients with 500 IIAs 367 patients with 500 IIAs Mean age 68 years Mean age 68 years Symptomatic: 208 (62%) Symptomatic: 208 (62%) Asymptomatic: 123 (38%) Asymptomatic: 123 (38%) Rupture: 108 (29%) Rupture: 108 (29%) Emergent mortality: 40% Emergent mortality: 40% Elective mortality: 7% Elective mortality: 7% Krupski et al, J Vasc Surg. 1998: 28(1)

10. Surgical Intervention Krupski et al, 1998 (U. of Colorado) Krupski et al, 1998 (U. of Colorado) 21 patients (17 men, 4 women) 21 patients (17 men, 4 women) Mean age 69 years (38-87) Mean age 69 years (38-87) 52% unilateral disease, 57% symptomatic 52% unilateral disease, 57% symptomatic Aneurysm >2.5cm (2.5-12cm, mean 5.6 +/- 2cm) Aneurysm >2.5cm (2.5-12cm, mean 5.6 +/- 2cm) Smoking 71%, HTN 67%, CAD 52%, Prior CABG 19% Smoking 71%, HTN 67%, CAD 52%, Prior CABG 19% Mean follow up 5.5 years (2 months - 13 years) Mean follow up 5.5 years (2 months - 13 years)

11. Surgical Intervention Krupski et al. Krupski et al. 19 open repairs, 0 perioperative deaths 19 open repairs, 0 perioperative deaths 17 Elective 17 Elective 1 - Right LE compartment syndrome 1 - Right LE compartment syndrome 2 Emergent 2 Emergent 1 - C. diff requiring colectomy 1 - C. diff requiring colectomy 1 - Multisystem Organ Failure due to rupture/shock 1 - Multisystem Organ Failure due to rupture/shock

12. Surgical Intervention Krupski et al. Krupski et al. 2 Endovascular repairs 2 Endovascular repairs 1 - required femorofemoral bypass due to stent occlusion 1 - required femorofemoral bypass due to stent occlusion 1 - died from rupture 2 years post coiling 1 - died from rupture 2 years post coiling

13. Conclusions Rupture under 3cm very rare Rupture under 3cm very rare High risk of rupture for aneurysms greater than 5cm with a correlation between increasing size and increasing risk of rupture High risk of rupture for aneurysms greater than 5cm with a correlation between increasing size and increasing risk of rupture Many aneurysms remain stable - safe to monitor patients yearly with aneurysms <3cm and every 6 months 3-3.5cm Many aneurysms remain stable - safe to monitor patients yearly with aneurysms <3cm and every 6 months 3-3.5cm Surgical risk for otherwise uncomplicated patients now generally very low Surgical risk for otherwise uncomplicated patients now generally very low Further need for long term comparison of open vs. endovascular repair Further need for long term comparison of open vs. endovascular repair

14. References Santilli SM, Wernsing SE, Lee ES. Expantion rates and outcomes for iliac artery aneurysms. Journal of Vascular Surgery. 2000: 31(1), 114-121. Santilli SM, Wernsing SE, Lee ES. Expantion rates and outcomes for iliac artery aneurysms. Journal of Vascular Surgery. 2000: 31(1), 114-121. Kasirajan V et al. Management of isolated common iliac artery aneurysms. Cardiovascular Surgery. 1998: 6(2), 171-177. Kasirajan V et al. Management of isolated common iliac artery aneurysms. Cardiovascular Surgery. 1998: 6(2), 171-177. Dorigo W et al. The Treatment of Isolated Iliac Artery Aneurysm in Patients with Non- aneurysmal Aorta. European Journal of Vascular and Endovascular Surgery. 2008, doi:10.1016/j.ejvs.2007.11.017. Dorigo W et al. The Treatment of Isolated Iliac Artery Aneurysm in Patients with Non- aneurysmal Aorta. European Journal of Vascular and Endovascular Surgery. 2008, doi:10.1016/j.ejvs.2007.11.017. Krupski WC et al. Contemporary management of isolated iliac aneurysms. Journal of Vascular Surgery. 1998: 28(1). Krupski WC et al. Contemporary management of isolated iliac aneurysms. Journal of Vascular Surgery. 1998: 28(1). Brunkwall J et al. Solitary aneurysms of the iliac artery system: an estimate of their frequency and occurance. Journal of Vascular Surgery. 1989:10, 381-384. Brunkwall J et al. Solitary aneurysms of the iliac artery system: an estimate of their frequency and occurance. Journal of Vascular Surgery. 1989:10, 381-384.