Isolated internal iliac artery aneurysm resection and reconstruction: operative planning and technical considerations

Isolated iliac artery aneurysms are rare but dangerous aneurysms associated with a high incidence of rupture (between 14 and 70%). Rupture is frequently associated with an exceedingly high mortality primarily because of the elusive nature of the presenting symptoms and the resulting major delays in treatment. Accordingly these aneurysms are best managed aggressively. Although emerging endovascular techniques show promise surgical resection and reconstruction remains the gold standard for definitive management and has withstood the test of time with excellent durable and unparalleled results. That said, from an operative perspective these aneurysms are technically demanding and remain one of the more formidable technical challenges in vascular surgery. To highlight the key elements involved in a successful repair we present a right internal iliac artery aneurysm with an associated contralateral common iliac artery occlusion, review the necessary preoperative planning and the available surgical treatment options, and detail the technical steps leading to a successful reconstruction. Careful operative planning is critical. Inadequate preoperative studies, inadequate preoperative decision making, and a poorly formulated operative strategy can lead to catastrophic results. Some of the most feared complications include pelvic venous injury with resulting massive hemorrhage and postoperative pelvic ischemia (with resulting rectal and/or spinal cord ischemia) which occurs as a result of inadequate contralateral collateral pelvic blood flow when the internal iliac artery is not reimplanted. Accordingly the preoperative workup must include a careful analysis of the adequacy of the contralateral pelvic blood flow to supply collateral flow in the event that the internal iliac is not reimplanted. In the presence of compromised contralateral internal iliac perfusion, resection and reconstruction or an alternative form of pelvic revascularization is mandatory. Excellent and unencumbered exposure is mandatory for a safe and successful repair. The retroperitoneal approach as illustrated in this case is strongly recommended. Although it is challenging excellent results can be achieved by resection of the aneurysm and reconstruction.