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      Endovascular treatment of bilateral isolated aneurysm of the internal iliac artery

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          Abstract

          Isolated aneurysms of the iliac arteries comprise less than 2% of abdominal aneurysms. The internal iliac artery is involved in 10-30% of cases. In most cases patients are asymptomatic, unless rupture occurs. They can be diagnosed by Doppler ultrasonography, magnetic resonance imaging or, preferably, angiotomography. Significant expansion, diameter of 3 cm or greater, and symptomatic cases are indications for surgery. We present the case of a patient with an incidental ultrasonographic finding of bilateral aneurysm of the internal iliac arteries, both with indications for surgery. The patient was successfully treated with endovascular techniques, first repairing the right internal iliac with a branched iliac stent graft, preserving patency, then embolizing the left internal iliac artery. Knowledge of the various different techniques and devices and their limitations is fundamental to adequate planning of endovascular treatment, even in rare cases.

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          Most cited references 28

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          Solitary aneurysms of the iliac arterial system: an estimate of their frequency of occurrence.

          Solitary iliac artery aneurysms are rare, and most reports have been presented as case reports. By combining autopsy records and operating records, a total of 13 cases were found: during a 15-year period (1971 to 1985), 42,010 of the inhabitants of Malmö died (population 230,000) and 35,265 (including 9014 forensic autopsies) underwent autopsy (84%). Solitary iliac artery aneurysms were found in seven (0.03%) of the 26,251 patients who underwent autopsy at the hospital; six of those had been asymptomatic and one was ruptured. Among the 9014 persons who underwent forensic medical autopsy, there were two with ruptured solitary iliac artery aneurysms. Four patients had clinically detected solitary iliac artery aneurysms, three of which were ruptured. All patients underwent surgery, and two of the three patients with ruptured solitary iliac artery aneurysms left the hospital well. The rupture rate of iliac aneurysm among those found at autopsy was one of seven (14%) and among those clinically detected three of four.
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            Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair.

            To assess expansion rate of common iliac artery aneurysms (CIAAs) and define outcomes after open repair (OR) and endovascular repair (EVAR). Clinical data of 438 patients with 715 CIAAs treated between 1986 and 2005 were retrospectively reviewed. Size, presentations, treatments, and outcomes were recorded. Kaplan-Meier method with log-rank tests and chi2 test were used for analysis. Interventions for 715 CIAAs (median, 4 cm; range, 2-13 cm) were done in 512 men (94%) and 26 women (6%); 152 (35%) had unilateral and 286 (65%) had bilateral CIAAs. Group 1 comprised 377 patients (633 CIAAs) with current or previously repaired abdominal aortic aneurysm (AAA). Group 2 comprised 15 patients (24 CIAAs) with associated internal iliac artery aneurysm (IIAA). Group 3 comprised 46 patients (58 isolated CIAAs). Median expansion rate of 104 CIAAs with at least two imaging studies was 0.29 cm/y; hypertension predicted faster expansion (0.32 vs 0.14 cm/y, P = .01). A total of 175 patients (29%) were symptomatic. The CIAA ruptured in 22 patients (5%, median, 6 cm; range, 3.8-8.5 cm), and the associated AAA ruptured in 20 (4%). Six (27%) ilioiliac or iliocaval fistulas developed. Repairs were elective in 396 patients (90%) and emergencies in 42 (10%). OR was performed in 394 patients (90%) and EVAR in 44 (10%). The groups had similar 30-day mortality: 1% for elective, 27% for emergency repairs (P or=3.5 cm seems justified. Although buttock claudication after EVAR remains a concern, results at 3 years support EVAR as a first-line treatment for most anatomically suitable patients who require CIAA repair. Patients with compressive symptoms or those with AVF should preferentially be treated with OR.
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              Natural history and management of iliac aneurysms.

              Fifty-five patients with 72 aneurysms of the iliac vessels were evaluated retrospectively during a 12-year period (1972 to 1985). Atherosclerotic vascular disease was found in all aneurysms. Marked male predominance (5:1) and advanced age (mean 74.6 years) characterized this population group. Two thirds of them harbored multiple aneurysms and isolated aneurysms were found primarily to involve the internal iliac artery (12 of 18 patients). Although symptomatic presentation varied with anatomic location and presence of rupture, most patients were either asymptomatic (45%) or had such nonspecific complaints (11%) that diagnosis was often delayed or erroneous. A mass detected during abdominal, rectal, or vaginal examination was found in 39 patients (70%). Aneurysm size ranged from 2.5 to 18 cm (mean 5.5 cm) for the entire group. Internal iliac aneurysms tended to be larger (7.7 cm) yet demonstrated no increased risk of rupture, which was encountered in 33% of patients. Elective operative management was undertaken in 26 patients with a mortality rate of 11%. When repair had to be performed as an emergency procedure mortality increased to 33%. Aneurysm ligation, resection, or endoaneurysmorrhaphy coupled with graft interposition when necessary did not seem to influence patient survival. Eleven patients treated nonoperatively demonstrated enlargement in three, rupture in one, and progressive ureteral obstruction in one patient. Iliac aneurysms demonstrate expansile growth with eruptive and erosive complications and therefore should be managed aggressively under elective circumstances.
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                Author and article information

                Journal
                J Vasc Bras
                J Vasc Bras
                jvb
                Jornal Vascular Brasileiro
                Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV)
                1677-5449
                1677-7301
                17 April 2019
                2019
                : 18
                Affiliations
                [1 ] originalCirurgia Vascular, Universidade de São Paulo – USP, Ribeirão Preto, SP, Brasil.
                [2 ] originalCirurgia Vascular, Universidade de Franca – UNIFRAN, Franca, SP, Brasil.
                [1 ] originalCirurgia Vascular, Universidade de São Paulo – USP, Ribeirão Preto, SP, Brasil.
                [2 ] originalCirurgia Vascular, Universidade de Franca – UNIFRAN, Franca, SP, Brasil.
                Author notes

                Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

                Correspondence André Luís Foroni Casas Universidade de Franca – UNIFRAN Av. Dr. Armando Sales Oliveira, 201 - Parque Universitário CEP 14404-600 - Franca (SP), Brasil Tel.: +55 (16) 3701-2000 E-mail: vascular@ 123456andrecasas.com

                Author information EEJ - Vascular and endovascular surgeon; Tenured professor, Divisão de Cirurgia Vascular e Endovascular, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). DV - Medical student, Universidade de Franca (UNIFRAN). LSM - Medical student, Universidade de Franca (UNIFRAN). ALFC - Vascular and endovascular surgeon; MSc in Health Promotion; Professor, Disciplina de Cirurgia Vascular, Universidade de Franca (UNIFRAN).

                Author contributions Conception and design: ALFC, DV, LSM Analysis and interpretation: ALFC, EEJ Data collection: ALFC, DV, LSM Writing the article: ALFC, DV, LSM Critical revision of the article: ALFC, EEJ Final approval of the article*: ALFC, DV, LSM, EEJ Statistical analysis: N/A. Overall responsibility: ALFC * All authors have read and approved of the final version of the article submitted to J Vasc Bras.

                Conflito de interesse: Os autores declararam não haver conflitos de interesse que precisam ser informados.

                Correspondência André Luís Foroni Casas Universidade de Franca – UNIFRAN Av. Dr. Armando Sales Oliveira, 201 - Parque Universitário CEP 14404-600 - Franca (SP), Brasil Tel.: (16) 3701-2000 E-mail: vascular@ 123456andrecasas.com

                Informações sobre os autores EEJ - Cirurgião Vascular e Endovascular; Professor Livre Docente, Divisão de Cirurgia Vascular e Endovascular, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). DV and LSM - Discente, Curso de Medicina, Universidade de Franca (UNIFRAN). ALFC - Cirurgião Vascular e Endovascular; Mestre em Promoção da Saúde; Docente, Disciplina de Cirurgia Vascular, Universidade de Franca (UNIFRAN).

                Contribuição dos autores Concepção e desenho do estudo: ALFC, DV, LSM Análise e interpretação dos dados: ALFC, EEJ Coleta de dados: ALFC, DV, LSM Redação do artigo: ALFC, DV, LSM Revisão crítica do texto: ALFC, EEJ Aprovação final do artigo*: ALFC, DV, LSM, EEJ Análise estatística: N/A. Responsabilidade geral pelo estudo: ALFC *Todos os autores leram e aprovaram a versão final submetida do J Vasc Bras.

                Article
                jvbDT20180115_PT 00501
                10.1590/1677-5449.180115
                6629456

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 8, Tables: 0, Equations: 0, References: 25
                Categories
                Therapeutic Challenge

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