Hypogastric Artery Management During Open and Endovascular Aortoiliac Repair
While iliac artery aneurysms (IAAs) are frequently associated with abdominal aortic aneurysms (AAAs) [1, 2], isolated IAAs are rare, with a frequency between 0.5% and 2% of all arterial aneurysms [3] and an incidence among general population of about 0.03
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Hypogastric Artery Management During Open and Endovascular Aortoiliac Repair Aaron Fargion, Carlo Pratesi, Fabrizio Masciello, Walter Dorigo, and Giovanni Pratesi
8.1
Demographic, Pathogenesis, and Natural History
While iliac artery aneurysms (IAAs) are frequently associated with abdominal aortic aneurysms (AAAs) [1, 2], isolated IAAs are rare, with a frequency between 0.5% and 2% of all arterial aneurysms [3] and an incidence among general population of about 0.03% [4]. IAAs are defined as an increase in iliac artery diameter of at least 100% [2]; and considering that a normal common iliac artery has an approximate diameter of 1.2 cm, 2.5 cm is considered the threshold limit for the definition of IAAs [5]. As far as general demographic data are concerned, IAAs are more frequent in men, with a 5:1 ratio with women, and in patients aged 70 or older [2]. More than 70% of IAAs involve the common iliac artery (CIA), between 20 and 25% involve the hypogastric artery (HA), and isolated external iliac artery (EIA) aneurysms are quite rare, probably due to its different embryogenesis [6]. Frequently an aneurysmatic lesion is detected in more than one iliac artery, and it is bilateral in almost one third of the patients (Fig. 8.1).
It has been suggested that IAAs share the same multifactorial pathogenetic pathway promoting the development of AAAs. More than 90% of the lesions has an atherosclerotic cause; among other causes, collagenopathies (Marfan’s syndrome, Ehlers-Danlos’ syndrome) and inflammatory arterial diseases (Takayasu’s disease, Behçet’s disease, and polyarteritis nodosa) have to be considered. Infective aneurysms are quite rare and often anecdotally reported. As AAAs, their natural history contemplates a constant lesion growth, progressively increasing risk of aneurysmal rupture. In the largest published study reporting the fate of untreated IAAs, Santilli
A. Fargion · C. Pratesi (*) · F. Masciello · W. Dorigo Department of Vascular Surgery, University of Florence, Florence, Italy e-mail: [email protected] G. Pratesi Department of Vascular Surgery, University of Rome Tor Vergata, Rome, Italy © Springer Nature Switzerland AG 2019 Y. Tshomba et al. (eds.), Visceral Vessels and Aortic Repair, https://doi.org/10.1007/978-3-319-94761-7_8
Fig. 8.1 MIP reconstruction of bilateral internal iliac aneurysms 91
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et al. [7] followed over 300 people with iliac aneurysms of 3 cm ranging between 14 and 70% and that perioperative risk in elective and urgent conditions varies from 3–5% [3] to 30%, current guidelines recommend this threshold as an indication for surgical repair [9, 10]. However, a recent survey involving more than 500 members of the Vascular Societies of Great Britain and Ireland showed that most physicians would wait until an IAA reached 4 cm in diameter before considering intervention [11]. Obviously, in the presence of symptoms and/ or of lesions with a 5.5 cm diameter, a prompt or urgent intervention is required.
8.2
Clinical and Instrumental Diagnosis
8.2.1 Clinic
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