Internal iliac artery preservation strategies in the endovascular treatment of aortoiliac aneurysms.

INTRODUCTION: Common iliac aneurysms are present in up to 40% of abdominal aortic aneurysms and frequently impair distal landing zones for endovascular aneurysm repair. Several techniques have been developed in order to overcome these issues, with different applications and conflicting results. Although long-term outcomes of hypogastric exclusion are favorable, the risks of pelvic ischemia and morbidity rates are high. We aim to review current hypogastric preservation strategies used in the endovascular treatment of aortoiliac aneurysms.

EVIDENCE ACQUISITION: A thorough non-systematic review of the literature was conducted using PubMed/Medline. Forty-five articles were included, according to their scientific relevance and relation with the subject.

EVIDENCE SYNTHESIS: The bell-bottom technique can be used in common iliac arteries with up to 24mm of diameter. Although apparently effective in the short-term, long-term durability is questionable with reported type 1b endoleak rates varying from 3,4-7,8% and high re-intervention rates reported. Iliac branches have better long-term outcomes, with 90,4% patency rates and 91,8% freedom from re-intervention at 10 years' follow-up. Nonetheless, its widespread application is limited by complex anatomies and increased costs. Finally, parallel-graft techniques are an effective option for hostile anatomies unsuitable for other techniques. Endoleak due to gutter development remains the biggest limitation for its long-term durability and solid evidence regarding its application is still lacking.

CONCLUSIONS: When determining the appropriate hypogastric preservation strategy, several factors should be considered. Anatomic criteria, life-expectancy as well as physical and sexual activity are the most important criteria. Procedure complexity and cost should also be accounted for.