Outcome after concomitant unilateral embolization of the internal iliac artery and contralateral external-to-internal iliac artery bypass grafting during endovascular aneurysm repair

Objective Despite improvement of devices, endovascular aneurysm repair (EVAR) is still challenging in cases with associated aneurysmal involvement of the iliac arteries. This study examined the safety and efficacy of EVAR with concomitant unilateral embolization of the internal iliac artery (IIA) and contralateral external-to-internal iliac artery bypass grafting, with bilateral endograft limbs extended into the external iliac arteries (EIAs). Methods The study included 22 consecutive patients (mean age, 74 years) who underwent elective endovascular repair of aortoiliac or iliac aneurysms, with concomitant coil embolization of the unilateral IIA and contralateral EIA-to-IIA bypass in the same operative setting. Five patients had a unilateral IIA aneurysm, and eight had bilateral IIA aneurysms. EIA-to-IIA bypass grafting was performed through the retroperitoneal approach. The perioperative and midterm outcome of the procedure was assessed. Results The procedure was successfully performed in all cases. Eleven patients underwent IIA embolization at the main trunk, and the other 11 cases required IIA occlusion at distal branches. There was no perioperative death or severe complication. The mean follow-up period was 15.7 ± 7.8 months, ranging from 2 to 32 months. The bypass remained patent in all cases, and there was no occurrence of graft-related complication. Enlargement of aneurysms or development of type I endoleak was not observed. Persistent mild buttock claudication occurred in two patients (9%) ipsilaterally to the occluded IIA; one patient after IIA occlusion at the main trunk and the other at distal branches. No other pelvic ischemic manifestation was observed. Conclusions EVAR with simultaneous unilateral IIA embolization and contralateral EIA-to-IIA bypass grafting is feasible, with a relatively low risk of complications. It can be a useful treatment option in cases with complex aortoiliac aneurysms, including those with bilateral IIA aneurysms.