The importance of hypogastric artery preservation

“In the days of modern endovascular surgery, treatment should intend to preserve the hypogastric artery and its branches,” Johannes Frederik Schäfers and Alexander Oberhuber (University Hospital Münster, Münster, Germany) tell Vascular News

To preserve or not to preserve

For decades in aortic and iliac surgery, proper treatment of the hypogastric artery with adequate preservation was put in second place. The emergence of the endovascular era did not immediately change this matter.

In fact, there are no means of predicting whether or which complications or consequences occur when hypogastric arteries are not preserved uni- or bilaterally. Today, however, there is robust evidence that maintaining hypogastric artery flow reduces major, potentially lethal, complications during aortic repair. These complications include bowel ischaemia, buttock claudication, erectile dysfunction and spinal cord ischaemia (SCI).1–3 Particularly when other parts of the aorta are treated or planned to be treated, SCI represents the main reason for hypogastric artery aneurysm preservation in contemporary aortic surgery.4

So, there is no question the hypogastric artery should be preserved. The question is whether one or two hypogastric arteries can be preserved.3

Isolated iliac branch device or with EVAR

Treating abdominal aortic aneurysms (AAA) with dilated common iliac landing zones results in flared limbs or in occlusion of the hypogastric artery. Flared iliac limbs are at high risk for late type 1b endoleaks and occlusion of the hypogastric artery can result in the previously mentioned problems.5 There are several studies reporting excellent results of iliac branch devices (PLIANT study) and fewer major problems than open repair.3,6 We suggest iliac branch device implantation in all anatomically suitable patients with ectatic common iliac arteries during endovascular aneurysm repair (EVAR) or in isolated iliac aneurysms with adequate landing zone.

Iliac branch device after EVAR

Failed EVAR with type 1b endoleak or additional hypogastric artery aneurysms may require an iliac branch device in patients with EVAR in place. Since usual crossover access to the iliac branch device is blocked, an axillary or subclavian access route is needed to connect the hypogastric artery to the iliac branch device. This route poses a relevant risk for stroke and nerve injuries. The application of steerable sheaths has enabled the full femoral treatment with an iliac branch device after EVAR.7

See Figure 1.

Iliac branch device for hypogastric artery aneurysm

Initially, iliac branch devices were not intended for treatment of hypogastric artery aneurysms. A serious problem of hypogastric artery aneurysm treatment is that, in major cases of open repair, it results in ligation, and isolated endovascular treatment fails due to lack of proximal landing zone in the hypogastric artery. Occlusion of either the superior or inferior gluteal artery followed by stent graft implantation deep in the other gluteal artery can lead to sufficient exclusion of the hypogastric artery aneurysm using off-the-shelf iliac branch devices (ABRAHAM study).8 See Figure 2

References

1. Dovzhanskiy DI, Bischoff MS, Wilichowski CD, et al. Outcome analysis and risk factors for postoperative colonic ischaemia after aortic surgery. Langenbecks Arch Surg. Nov 2020;405(7):1031–1038. doi:10.1007/s00423-020-01964-2

2. Karch LA, Hodgson KJ, Mattos MA, et al. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg. Oct 2000;32(4):676–83. doi:10.1067/mva.2000.109750

3. D’Oria M, Mendes BC, Bews K, et al. Perioperative outcomes after use of iliac branch devices compared with hypogastric occlusion or open surgery for elective treatment of aortoiliac aneurysms in the NSQIP database. Ann Vasc Surg. Jan 2020;62:35–44. doi:10.1016/j.avsg.2019.04.009

4. Eagleton MJ, Shah S, Petkosevek D, et al. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg. Jan 2014;59(1):89–94. doi:10.1016/j.jvs.2013.07.007

5. Gray D, Shahverdyan R, Reifferscheid V, et al. EVAR with flared iliac limbs has a high risk of late type 1b endoleak. Eur J Vasc Endovasc Surg. Aug 2017;54(2):170–176. doi:10.1016/j.ejvs.2017.05.008

6. Brunkwall JS, Vaquero-Puerta C, Heckenkamp J, et al. Prospective study of the iliac branch device E-liac in patients with common iliac artery aneurysms: 12-month results. Eur J Vasc Endovasc Surg. Dec 2019;58(6):831–838. doi:10.1016/j. ejvs.2019.06.020

7. Oberhuber A, Duran M, Ertas N, et al. Implantation of an iliac branch device after EVAR via a femoral approach using a steerable sheath. J Endovasc Ther. Aug 2015;22(4):610–2. doi:10.1177/1526602815590972

8. Dueppers P, Duran M, Floros N, et al. The Jotec iliac branch device for exclusion of hypogastric artery aneurysms: ABRAHAM study. J Vasc Surg. Sep 2019;70(3):748–755. doi:10.1016/j.jvs.2018.10.124

Johannes Frederik Schäfers is a vascular surgeon at University Hospital Münster in Münster, Germany.

Alexander Oberhuber is a full professor at University Hospital Münster.