Published online Mar 28, 2016. doi: 10.4329/wjr.v8.i3.275
Peer-review started: August 11, 2015
First decision: October 16, 2015
Revised: October 23, 2015
Accepted: December 29, 2015
Article in press: January 4, 2016
Published online: March 28, 2016
Approximately 20%-40% of patients with abdominal aortic aneurysms can have unilateral or bilateral iliac artery aneurysms and/or ectasia. This influences and compromises the distal sealing zone during endovascular aneurysm repair. There are a few endovascular techniques that are used to treat these types of aneurysms, including intentional occlusion/over-stenting of the internal iliac artery on one or both sides, the “bell-bottom” technique, and the more recent method of using an iliac branch stent graft. In some cases, other options include the “snorkel and sandwich” technique and hybrid interventions. Pelvic ischemia, represented as buttock claudication, has been reported in 16%-55% of cases; this is followed by impotence, which has been described in 10%-17% of cases following internal iliac artery occlusion. The bell-bottom technique can be used for a common iliac artery up to 24 mm in diameter given that the largest diameter of the stent graft is 28 mm. There is a paucity of data and evidence regarding the “snorkel and sandwich” technique, which can be used in a few clinical scenarios. The hybrid intervention is comprised of a surgical operation, and is not purely endovascular. The newest branch stent graft technology enables preservation of the anterograde flow of important side branches. Technical success with the newest technique ranges from 85%-96.3%, and in some small series, technical success is 100%. Buttock claudication was reported in up to 4% of patients treated with a branch stent graft at 5-year follow-up. Mid- and short-term follow-up results showed branch patency of up to 88% during the 5-6-year period. Furthermore, branch graft occlusion is a potential complication, and it has been described to occur in 1.2%-11% of cases. Iliac branch stent graft placement represents a further development in endovascular medicine, and it has a high technical success rate without serious complications.
Core tip: There are a few endovascular techniques that have been used to treat aortoiliac artery aneurysms in cases where the distal landing zone is challenging; these include intentional occlusion/over-stenting of the internal iliac artery on one or both sides to create a distal landing zone in the external iliac artery, the “bell-bottom” technique, the “snorkel and sandwich” technique, and the more recent treatment of using an iliac branch stent graft. This review describes the pros and cons of these different endovascular techniques, while paying particular attention to the latest developments in branch stent graft technology.