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1
Department of Angiography and Interventional Radiology, AKH-University
Clinics, Währinger
Gürtel 18-20, A-1090 Vienna, Austria.
2
Department of Surgery, Barmherzige Schwestern, Stumpergasse 6, A-1060 Vienna,
Austria.
3
Department of Vascular Surgery, AKH-University Clinics, A-1090 Vienna,
Austria.
4
Ludwig Bolzmann Institute of Vascular Medicine, A-1090 Vienna, Austria.
Received November 15, 2000;
accepted after revision March 8, 2001.
Address correspondence to M. Schoder.
Abstract
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MATERIALS AND METHODS. Of 343 patients examined for stent-graft repair, 147 were suitable for endovascular treatment. Fifty-five patients underwent preprocedural embolization of the internal iliac artery either unilaterally (46 patients) or bilaterally (nine patients). Successful embolization was assessed angiographically and with helical CT follow-up examinations. Colonic ischemia was ruled out clinically or colonoscopically. Buttock claudication, and sexual dysfunction in men, were evaluated through a questionnaire.
RESULTS. Embolization of the internal iliac artery increased by 16% the percentage of patients for whom endovascular repair was suitable. After successful embolization in all patients, routine CT follow-up examinations after a mean time of 16.7 months showed no evidence of endoleaks related to retrograde perfusion via embolized internal iliac arteries. Nevertheless, in all patients who had undergone embolization, a primary endoleak was detected in 43.4% at the first postoperative CT examination. None of our patients had evidence of colonic ischemia. Clinical follow-up data of 46 patients were available. Of these patients, mild to severe new onset buttock claudication was found in 13 (36.1%) of 36 patients with unilateral, and in eight (80%) of 10 patients with bilateral, internal iliac artery embolization (p = 0.03). Five (25%) of 20 men had an erectile dysfunction after the procedure.
CONCLUSION. Embolization of the internal iliac artery is a safe and efficient procedure that increases the applicability for endovascular repair of aortoiliac aneurysms. However, buttock claudication and erectile dysfunction are a drawback in a substantial number of patients.
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Since the first description of abdominal aortic aneurysm treatment with stent-grafts by Parodi et al. [5] in 1991, endovascular repair with a variety of straight and bifurcated grafts has been the subject of worldwide clinical investigations [4, 6,7,8,9,10,11,12]. Commercially available bifurcated stent-grafts necessitate a proximal aortic neck longer than 15 mm with a vessel diameter 2 mm less than the available stentgraft diameter for anchoring. The common iliac artery diameter should be 2 mm less than the stent-graft limb available for safe placement of the distal part of the stent-graft. In cases of short, ectatic, or aneurysmal common iliac arteries, extension of the aortic stent-graft into the external iliac artery is mandatory to ensure safe limb positioning and a friction seal. It has been proposed that internal iliac artery coil embolization should be performed to prevent retrograde blood flow and potential endoleaks [11, 13,14,15,16,17]. However, buttock claudication and sexual dysfunction appear to be dominant clinical symptoms after occlusion of internal iliac arteries [18,19,20].
The aim of this study was to assess the frequency of preprocedural internal iliac artery embolization before aortic stent-graft implantation and its efficacy in the prevention of endoleaks caused by retrograde perfusion of the internal iliac artery, and to evaluate the incidence of postprocedural buttock claudication and sexual dysfunction.
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The diameters of the common iliac arteries were measured in the axial CT planes perpendicular to the course of the artery. The length of the common iliac artery was determined on the diagnostic angiograms by means of a calibrated catheter. The status of the nonembolized internal iliac artery was reviewed retrospectively and was rated as normal (<50% stenosis), moderate stenosis (50-75%), severe stenosis (76-99%), or occluded.
The EUROSTAR classification system (Fig. 1A,1B,1C,1D,1E), which is a modified classification derived from Allenberg and Schumacher [21], was used to classify the aneurysms as type A to type E aneurysms.
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A total of 147 patients were suitable for endovascular repair. The comorbid conditions of the patients and the types of abdominal aneurysms present are listed in Table 1. In 20 patients, the anatomy of the aneurysm allowed the implantation of a tube-graft. Six patients were examined for an aortoiliac unilateral graft and 121 patients for a bifurcated graft. Initially straight and bifurcated self-expanding endoprostheses composed of a nitinol frame covered with woven polyester fabric were available (Mialhe Stentor, MinTec, Freeport, Bahamas; and Vanguard, Boston Scientific, Oakland, NJ). The devices were commercially available with a diameter of the stent-graft body up to 26 mm and a diameter of 10 or 12 mm for the iliac limbs. Later in the study, a bifurcated self-expanding graft with a diameter of the iliac limb of up to 14.5 mm was available (Prograft; W. L. Gore, Palo Alto, CA). The aortoiliac unilateral stent-graft was a custom-made self-expanding endoprosthesis consisting of a nitinol framework covered with Dacron (Talent; World Medical Manufacturing, Sunrise, FL). Of these 147 patients, 92 were suitable for stent-graft treatment without embolization of the internal iliac artery. A total of 55 patients (six women, 49 men; age range, 57-87 years; mean age, 71.2 years) underwent preprocedural internal iliac artery embolization. Patients were selected for preprocedural embolization on the basis of the morphology and anatomy of the common iliac arteries. For safe anchoring of the distal graft, the common iliac diameter should be 2 mm less than the stent-graft limb available, as described before. To prevent retraction of the stent-graft limb into the aneurysmal vessel, a concordant diameter of the common iliac artery and the graft limb by a length of 20 mm should be achieved. The status of the superior mesenteric artery origin was an additional consideration in all patients examined for internal iliac artery embolization. None of our patients had a stenosis of the superior mesenteric artery origin greater than 30%. The status of the inferior mesenteric artery was not considered in the selection for internal iliac artery embolization.
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Of 46 patients with unilateral embolization, the aneurysms were type B in 10 patients, type C in 11, type D in 19, and type E in six patients. Of the 10 patients with a type B aneurysm, three had an anatomic length of the common iliac artery of less than 20 mm, six had a diameter (14-16 mm) greater than that of the stent-graft limb available, and one patient had an internal iliac artery aneurysm. In all patients with type C aneurysms, the nonaneurysmal distal diameter was greater than that of the stent-graft limb available, and a concomitant internal iliac artery aneurysm was found in one patient. The diameters of the common iliac arteries on the embolized side ranged from 14 to 60 mm (mean, 21.7 mm).
Bilateral embolization was performed in two patients with type D and in seven patients with type E aneurysms. In the two patients with type D aneurysms, the nondiseased distal part of the contralateral common iliac artery was less than 15 mm in length and was therefore unsuitable for safe limb positioning. The diameters of the aneurysmal common iliac arteries ranged from 18 to 55 mm (mean, 31 mm).
In our patient cohort, internal iliac artery aneurysms requiring treatment were found in five patients. One of these patients had an aortic type B aneurysm, one patient had type C, one had type D, and two patients had an aortic type E aneurysm.
All our patients presented with an increased risk for standard surgical repair. Twenty-eight patients were class III and 27 patients were class IV of the American Society of Anesthesiologists classification [22].
The protocol of this study was approved by our institutional review board. All patients undergoing endovascular repair gave their written informed consent to the experimental nature of the procedure and to all necessary preprocedural interventions.
Embolization Procedure
A total of 64 internal iliac artery embolizations were performed in 55
patients. Forty-six patients required embolization of one artery, and nine
patients required embolization of both internal iliac arteries. In patients
with bilateral embolization of internal iliac artery, an interval of 2-4 weeks
between the procedures was maintained to enable the formation of collateral
vessels. Stent-graft implantation was performed 2-4 weeks after unilateral, or
the second procedure of bilateral, embolization of the internal iliac artery.
The right internal iliac artery was embolized in 45 patients, and the left
internal iliac artery, in 19 patients. Selective catheterization of the
internal iliac artery was performed after puncture of the ipsilateral
(n = 53) or contralateral (n = 11) common femoral artery. In
cases of a regular internal iliac artery, a 5- or 6-French
Sidewinder-Simmons-I catheter (Cordis-Johnson & Johnson, Roden, The
Netherlands) or a 5-French cobra catheter (Cordis-Johnson & Johnson) was
positioned in the main trunk of the internal iliac artery. Gianturco coils
(Cook, Bloomington, IN) were placed either above or at the bifurcation of the
internal iliac artery. At the time of this study, no particular attention was
paid to placement of the coils above or within the bifurcation of the iliac
branches. In the five patients with an aneurysm of the internal iliac artery,
the branches of the internal iliac artery were catheterized selectively using
a 3-French Tracker-18 catheter (Target Therapeutics, Boston Scientific,
Fremont, CA) with a coaxial technique, and embolization was accomplished with
complex helical platinum-fiber coils (Target Therapeutics, Boston Scientific).
Coils were placed in the main trunk or in the branches of the internal iliac
artery until adequate compactness was achieved. For embolization of a regular
internal iliac artery, several coils (6-21), with diameters of 4-10 mm and
lengths of 4-8 cm, were used. The diameters of the platinum coils were 3-6 mm,
with lengths of 3-6 cm. The endpoint of embolization was determined as a
minimal remnant or the absence of antegrade flow in the internal iliac
artery.
Technical success of internal iliac artery embolization was established angiographically immediately before stent-graft implantation. All postoperative CT studies (n = 143) and all 12-month CT follow-up examinations (n = 111) were evaluated for the presence of endoleaks or perfusion of an embolized internal iliac artery. In addition, in patients with internal iliac artery embolization, all follow-up CT studies performed at 3 months (n = 48), 6 months (n = 41), 12 months (n = 35), 24 months (n = 19), and 36 months (n = 8) were evaluated for mid- and long-term successful occlusion of the embolized internal iliac artery (mean follow-up, 16.7 months).
Clinical Evaluation
All patients were examined clinically for the occurrence of mucous or
bloody stool. Patients with bilateral embolization were examined
colonoscopically 3 days after the second embolization to exclude colonic
ischemia. Signs and symptoms of new onset buttock claudication were
investigated retrospectively by reviewing medical records and with a
questionnaire and a structured interview. The mean follow-up period of
symptomatic patients was 19.2 months (range, 4-42 months) after the procedure.
Questions focused on signs of weakness, pain, or cramps in the gluteal muscle
or thigh. Walking distances on even ground were categorized as less than 100,
100-250, and more than 250 m. Walking distances uphill were categorized as
less than 50, 50-250, and more than 500 m. The ability to walk up stairs was
categorized into two groups: one to 20 steps until onset of symptoms, and
21-50 steps until onset of symptoms. Men were questioned about their erectile
function before and after internal iliac artery embolization.
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Angiography immediately before stent-graft implantation showed complete occlusion in all embolized internal iliac arteries. The overall 30-day mortality rate was 2.0% (three patients). Death was caused by myocardial infarction in two patients and by multiorgan failure in one patient. Patients available for the first postoperative CT follow-up were 53 patients with internal iliac artery embolization and 90 patients without embolization (two patients had a conversion) before stent-graft repair (Table 2). A primary endoleak (other than related to the embolized internal iliac artery) was detected in 23 (43.4%) of 53 patients with embolizations and in 25 (27.8%) of 90 patients without embolizations. All stent-graft—related endoleaks were treated successfully by placing an additional graft. In seven patients, cessation of the type II endoleak (reperfusion of the aneurysm via side branches) was achieved by embolization of the inferior mesenteric or the lumbar artery. At all follow-up CT examinations of patients who had undergone embolization, no evidence was seen of retrograde perfusion of the internal iliac artery. Despite streak artifacts arising from the level of coils in transverse CT sections, the perfusion status of the internal iliac artery could be assessed in all patients above and below such artifacts. The frequency and location of endoleaks (unrelated to internal iliac artery embolization) in the first postprocedural CT follow-up and at 12 months after stent-graft placement are given in Tables 2 and 3, respectively.
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Clinical Results
Colonic ischemia.—None of the patients had mucous diarrhea
or bloody stool suggestive of ischemic colitis. No colonoscopic evidence of
colonic ischemia was found in any of the nine patients with bilateral internal
iliac artery embolization.
Buttock claudication.—For evaluation of buttock claudication, 46 patients (43 patients with a bifurcation, and three patients with an aortoiliac unilateral stent-graft) were available (Table 4).
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One patient (with unilateral embolization) was lost to follow-up, and eight patients were deceased (seven patients with unilateral and one with bilateral embolization). Death was not related to stent-graft implantation or to the preprocedural embolization. One of the patients with unilateral embolization had an unintentional overlay of the nonembolized internal iliac artery orifice by the stent-graft, and a second patient had a primary occlusion of the contralateral internal iliac artery. Therefore, these two patients were recategorized to the bilateral iliac artery occluded group.
Unilateral iliac artery embolization.—Twenty-three (64%) of 36 patients with unilateral embolization of the internal iliac artery were clinically asymptomatic. Of these 23 patients, coils were placed above (n = 12) or in the bifurcation or the branches (n = 11) of the internal iliac artery. All patients except two with a severe stenosis had normal status of the contralateral internal iliac artery.
Thirteen (36%) of 36 patients with unilateral iliac artery embolization were symptomatic. Four patients (11%) had no symptoms of pain, but all four complained about weakness in their gluteal region or thigh on the side of embolized internal iliac artery. Symptoms appeared after walking a distance of less than 250 m on even ground, after walking upward from 50 to 250 m, or after going up fewer than 20 steps. Of these four patients, one noted improvement of his symptoms (no weakness walking on even ground) at the 18-month follow-up. The remaining three patients still had symptoms at their latest follow-up appointment (mean, 9.5 months; range, 4-12 months). All these patients had coils placed at the bifurcation or within the branches, and the contralateral internal iliac artery was normal in all instances.
Nine patients (25%) with unilateral occlusion had moderate to severe new onset buttock claudication on the embolized side. Pain occurred after walking a distance of less than 100 m on even ground in five patients. Four patients had pain after walking a distance of less than 250 m on even ground. All patients had symptoms after walking upward less than 50 m and after going up five to 30 steps (mean, 14 steps). Three of these patients had coils placed above the bifurcation, and six patients had coils placed at the bifurcation or in the branches of the internal iliac artery. All had a normal contralateral internal iliac artery. In three of nine patients, the claudication was self-limited up to 6 months. One patient reported a substantial improvement of symptoms but remaining mild symptoms of claudication after walking upward more than 500 m at the 24-month followup. Six patients (17%) had pain or cramps in their gluteal muscles or thigh for longer than 6 months (range, 7-42 months; mean, 24.5 months).
In all patients who underwent unilateral embolization, we found a greater proportion of postembolization buttock claudication when coils were placed in the iliac bifurcation (10/21) than when the coils were placed above the bifurcation (3/15). This difference was not statistically significant (p = 0.09, chi-square test).
Bilateral iliac artery embolization.—Of 10 patients with bilateral embolization of the internal iliac artery, two patients (20%) had no symptoms of buttock claudication. One patient reported unilateral weakness in his gluteal region as a mild symptom of buttock claudication after walking more than 1000 m on even ground or after going up more than 20 steps. Symptoms resolved at the 6-month follow-up. Seven (70%) of the 10 patients had bilateral and nearly symmetric moderate to severe buttock claudication. Pain occurred after walking a distance of less than 100 m on even ground in four patients, and after less than 250 m in three patients. All patients had pain after walking upward for less than 50 m and after going up five to 20 steps (mean, 11 steps). One patient had moderate pain or cramps for less than 6 months, and six patients (60%) reported pain or cramps for longer than 6 months (range, 6-31 months; mean, 20.5 months).
Overall, the proportion of patients with buttock claudication was significantly greater in patients with bilateral internal iliac artery embolization (8/10) than in patients with unilateral internal iliac artery embolization (13/36) (p = 0.03, Fisher's exact test).
Sexual function.—Of the 49 men, 33 answered our question about sexual function. Thirteen men (39%) had sexual dysfunction before embolization. Twenty men (15 with unilateral and five with bilateral embolization) had normal erectile function before the stent-graft repair and preprocedural embolization. Of the 15 patients with unilateral embolization, four (27%) reported erectile dysfunction, and two patients noted a reduced erection. All patients with impaired erectile function had a nondiseased contralateral internal iliac artery. In the group with bilateral iliac artery occlusion, only one (20%) of five patients reported erectile dysfunction.
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In 55 of 343 patients examined for endovascular stent-graft repair, embolization of the internal iliac artery (46 unilateral, nine bilateral) was necessary to allow safe positioning of the distal graft. Therefore, the applicability of endovascular abdominal aortic aneurysm repair could be increased from 27% (92/343) without internal iliac artery embolization to 43% (147/343) after internal iliac artery embolization.
Concordant with other authors [18, 20], we believe that embolization of the internal iliac artery is mandatory to prevent retrograde blood flow and a potential endoleak after extension of the aortic stent-graft into the external iliac artery. Preprocedural coil embolization of the internal iliac artery has also been reported as necessary before graft repair of isolated common iliac artery aneurysms [14, 15, 17,18,19,20].
Embolization was technically successful in all our patients with no major complications. In our study, 34 (53%) of 64 embolized internal iliac arteries had a continued antegrade flow at the completion of embolization. Nevertheless, all patients had a complete obstruction of antegrade flow at the time of stent-graft implantation. Follow-up CT (postoperatively at 3, 6, 12, 24, and 36 months) showed no endoleak caused by retrograde perfusion of the embolized internal iliac artery. Nevertheless, a primary endoleak was detected at the first postoperative CT examination in 23 (43.4%) of 53 patients with embolization. Our data indicate that type II endoleaks occur more often in patients treated with internal iliac artery embolization than in patients without embolization. Although this might be explained by a greater number of or wider lumbar or inferior mesenteric arteries, or even by chance, we cannot exclude the possibility that internal iliac artery embolization increases flow in the lumbar and inferior mesenteric arteries.
Cynamon et al. [20] reported persistent flow at the completion of internal iliac artery embolization in 13 (41%) of 32 patients and an early retrograde endoleak through the coils in one patient, with cessation at the 1-month follow-up. This finding confirms that a complete obstruction during embolization is probably not necessary when coils are adequately packed in the internal iliac artery [20].
To date, the largest series (43 patients) with intentional occlusion of one internal iliac artery, in which clinical follow-up occurred in 32 patients, was reported by Cynamon et al. [20]. The authors reported new-onset buttock claudication in 13 (41%) of 32 patients. Focusing on the location of the coils in the internal iliac artery, they found symptoms in 12 (55%) of 22 patients in whom the coils were placed at or distal to the bifurcation of the internal iliac artery. If coils were placed above the bifurcation of the internal iliac artery, as was done in 10 patients, in only one patient (10%) was buttock claudication reported. We also found a greater proportion of postembolization claudicants when coils were placed in (10/21) versus above (3/15) the internal iliac artery bifurcation. Despite the fact that our result did not reach the level of statistical significance, our findings support those of Cynamon et al., suggesting that the frequency of claudication is reduced if coils are placed above, rather than in, the bifurcation of the iliac branches. In the study by Lee et al. [19], the degree of chronic occlusive disease of the contralateral internal iliac artery did not predict the occurrence of buttock claudication. Our results are in accord with this study. None of our patients who developed buttock claudication after unilateral embolization had contralateral internal iliac artery stenosis. Conversely, the two patients who had contralateral internal artery stenosis were asymptomatic after internal iliac artery embolization. This might be explained by the data of Iliopoulos et al. [27] who found that branches arising from lumbar or inferior mesenteric arteries as well as from the ipsilateral external and femoral arteries provide a more significant pathway than cross-pelvic circulation.
However, if both internal iliac arteries are embolized before stent-graft implantation, the proportion of postembolization claudication (8/10) is significantly increased compared with patients who undergo unilateral embolization only (13/36). A similar trend toward increased likelihood of symptoms in bilateral occluded internal iliac arteries is also reported by Razavi et al. [18]. Therefore, bilateral embolization of the internal iliac artery in older patients with known atherosclerotic disease and presumably inadequate development of collateral pathways must be considered carefully.
With respect to the duration of symptoms, we found symptoms of moderate to severe buttock claudication in 16 (35%) of 46 patients with embolization of the internal iliac artery. Contrary to Razavi et al. [18], who found resolution of symptoms in nearly all their patients at a mean interval of 14 months, we found that 11 (69%) of 16 of our patients had no significant resolution of buttock claudication at a mean follow-up of 22.5 months. Symptoms of buttock claudication disappeared in four patients in less than 6 months, and symptoms improved in one patient at the 24-month follow-up.
In contrast to others [2, 6, 14] who reported colonic or pelvic ischemia in patients with unilateral occlusion of the internal iliac artery, we found that none of our patients with unilateral or bilateral embolization had clinical symptoms or colonoscopic evidence of colonic ischemia. Some authors have suggested that intentional occlusion of the internal iliac artery should be reserved only for patients with a fully patent contralateral internal iliac artery [6, 13, 16]. In our experience with bilaterally occluded internal iliac arteries, a superior mesenteric artery that is free of disease may provide sufficient colonic perfusion via mesenteric collaterals.
In the two recent reports [18, 19] dealing with embolization of the internal iliac artery before endovascular aneurysm repair, erectile dysfunction was noticed in 4% and 12% of men, respectively. After surgical reconstruction of the aortoiliac segment, sexual dysfunction can occur as a result of nerve or vascular disturbance, resulting in ejaculatory and erectile dysfunction [28]. Depalma [29] and Thetter et al. [30] stated that unilateral occlusion of the internal iliac artery is tolerated without erectile dysfunction in otherwise intact arterial vessels. Stelzner and Stark [31] found unimpaired erectile function in patients with otherwise disease-free arterial systems after bilateral in situ ligature of the internal iliac artery. However, the incidence of buttock claudication and sexual dysfunction after surgical repair of aortic aneurysms, concomitant with exclusions of internal iliac aneurysms, has been reported as 1-15% and as 10-39%, respectively [32,33,34,35]. In our patient group, of 20 patients with normal sexual function before occlusion of the internal iliac artery, five (25%) experienced sexual dysfunction, and two patients reported a reduced erection. The reason for hypoperfusion of the genital regions could also be attributed to additional arteriosclerosis and therefore insufficient collateral pelvic cross-flow and blood flow of the mesenteric and common femoral arteries.
Our study has several limitations. The assessment of clinical symptoms was conducted as a retrospective interview and questionnaire. We did not obtain objective measurements such as treadmill test results. However, we believe that the subjective information provided by the patients reflects their experience reasonably well.
In conclusion, embolization of the internal iliac artery is a technically safe and effective procedure to prevent retrograde blood flow and potential endoleaks from the internal iliac artery after stent-graft repair of aortoiliac aneurysms. However, buttock claudication and erectile dysfunction are a major drawback, particularly in patients with bilateral internal iliac artery embolization. Therefore, our current strategy is, first, to try to obviate embolization and preserve pelvic circulation by using new stent-graft devices with iliac limb diameters up to 24 mm. Second, if embolization of internal iliac arteries is necessary before stent-graft treatment, preference is given to proximal embolization of the internal iliac artery to minimize the risk of buttock claudication. Third, bilateral embolization should be reserved for patients with comorbidities that carry a high risk for open surgical repair of aortoiliac aneurysms.
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