Endovascular and Hybrid Revascularization for Concomitant Abdominal Aortic Aneurysm and Iliac Chronic Total Occlusion

Endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysm (AAA) and iliac chronic total occlusion is technically challenging due to difficulties with device delivery, compromised seal zones, and increased risk of complications. Evidence on long-term outcomes in this subgroup remains limited.

A retrospective case series of all patients undergoing EVAR for infrarenal AAA with concomitant iliac artery chronic total occlusion at a tertiary vascular center between January 2009 and December 2024. Demographics, anatomical characteristics, procedural strategies, adjunctive techniques, and outcomes were analyzed. Technical success was defined as successful deployment of the intended endograft configuration-bifurcated following iliac recanalization or aorto-uni-iliac (AUI) with/without femoro-femoral crossover-achieving aneurysm exclusion with patent target vessels, without conversion to open repair or intraoperative death.

Eleven patients (median age 67 years, 91% male) were treated. All patients had unilateral iliac chronic total occlusion; 81.8% had additional contralateral iliac stenotic disease. Four patients (36%) underwent bifurcated EVAR and seven (64%) received an AUI configuration, with femoro-femoral crossover in six. Adjunctive techniques included covered stent placement in all patients, selective re-entry catheter use (9%), and intravascular lithotripsy (9%). Nearly half (45%) were performed percutaneously. Technical success was achieved in all cases with no 30-day mortality. Perioperative complications occurred in two patients, both managed successfully. At median follow-up of 86 months (IQR 66-115), 91% had sustained symptom resolution, graft patency was preserved, and sac regression or stability occurred in 90%. One patient developed late sac expansion from a type Ib endoleak at 11.5 years, successfully treated endovascularly.

EVAR for AAA with iliac chronic total occlusion is feasible and durable when guided by careful case selection, tailored device choice, and use of adjunctive techniques. Long-term outcomes in this series demonstrate high technical success, durability, and favorable AAA sac behavior, supporting its role in anatomically hostile aortoiliac disease. Lifelong surveillance remains essential.