Open Surgical Management of Hypogastric Artery during Aortic Surgery: Ligate or Not Ligate?

Abdominal aortic aneurysm (AAA) is associated with 43% of cases with common iliac artery aneurysms and an extension of prosthetic replacement distal to the iliac bifurcation is needed. The decision about preserving the hypogastric artery (HA) is a source of discussion, in particular when only one HA is interested. The low risk of pelvic ischemia, even if existing, has to be compared with the greater technical difficulty of the vascular reconstruction. The aim of this study is to evaluate retrospectively the perioperative results in patients who underwent ligation or reconstruction of the HA during open surgical procedures for AAA.

Over a period of 11 years (January 2002 to December 2012), 1,487 patients were treated electively for AAA. In 235 cases (15.8%), the aneurysm involved the iliac bifurcation with need to extend distally the prosthetic reconstruction; among them, 63 patients were subjected to HA ligation (26.8%, group 1) and 172 to HA bypass (73.2%, group 2). Indication for ligation was the presence of extended HA aneurysm in 34 cases (54%) and heavy calcification of HA in 29 (46%).

Perioperative mortality and morbidity rates were, respectively, 1.6% (1/63) and 7.9% (5/63) in group 1 and 1.2% (2/172) and 6.4% (11/172) in group 2 (P = 0.902 and 0.689). The incidence of buttock claudication was significantly higher in group 1 (6/63, 9.5% vs. 4/172, 2.3% P = 0.025), while there were no significant differences in other complications of pelvic ischemia. In group 2, higher intraoperative blood loss (754 ± 721 vs. 996 ± 608 mL, P = 0.011), longer operating time (283.2 ± 104.7 vs. 302 ± 109 min, P = 0.053), and longer postoperative length of stay (PLOS) (5.8 ± 2.2 vs. 6.7 ± 3.6 days, P = 0.049) occurred.

HA bypass during open surgery for AAA is a safe procedure. If compared with ligation, it reduces the risk of buttock claudication without increasing perioperative morbidity and mortality. However, the increased complexity of the intervention involves an increase in blood loss, operating time, and PLOS.