Preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery

Abstract

Bilateral absence of the common iliac artery is an extremely rare congenital vascular malformation in which the distal aorta divides directly into two external iliac arteries and two internal iliac arteries. In the case of the presence of this vascular malformation in association with an aortic aneurysm, preservation of the internal iliac artery flow during endovascular aortic repair represents a technical challenge. We have reported a case in which the bilateral absence of the common iliac artery associated with an infrarenal abdominal aortic aneurysm was successfully treated by endovascular aortic repair using commercially available iliac branched devices to maintain pelvic perfusion.

Keywords: Abdominal aortic aneurysm; Bilateral absence of common iliac artery; EVAR; Iliac branched devices; Novel iliac artery bifurcation.

Fig 1

Preoperative three-dimensional reconstruction (A) and axial computed tomography imaging (B) of the fusosaccular infrarenal abdominal aortic aneurysm (AAA) associated with bilateral absence of the common iliac artery (CIA). Note the termination of the distal aorta into four branches: two external iliac arteries (EIAs) and two internal iliac arteries (IIAs). The AAA was ∼52 mm in the largest diameter with a nonangulated cylindrical proximal neck.

Fig 2

Digital subtraction angiography during endovascular aortic aneurysm repair (EVAR). A, Embolization of the right internal iliac artery (IIA) with a vascular plug. B, Catheterization of the side branch of the E-liac (JOTEC) iliac branched device (IBD) and deployment of a balloon-expandable covered stent to bridge the side branch to the left IIA. C, Completion angiogram showing complete exclusion of the abdominal aortic aneurysm (AAA) and the absence of endoleaks.

Fig 3

A, Postoperative three-dimensional reconstruction showing complete exclusion of the abdominal aortic aneurysm (AAA) with a type II endoleak from the lumbar arteries (curved arrow) and patency of the left internal iliac artery (IIA). Note the vascular plug in the right IIA (arrowhead). B, Axial computed tomography scan showing the type II endoleak (arrow) from the lumbar arteries.

Fig 4

A, Diagram showing the iliac branched device (IBD) with the shortest proximal length (53 mm), which includes a 27-mm segment for the main body limb overlap and a 26-mm segment for the internal iliac limb. B, Diagram showing the main body graft with the shortest possible main trunk length (85 mm). C, Imaging study showing the length (115 mm) from the lower renal artery to the orifice of the right external iliac artery (EIA).