Complex Common and Internal Iliac or Aortoiliac Aneurysms and Current Approach: Individualised Open-Endovascular or Combined Procedures

Table 2

Surgical repair strategies of aortoiliac and isolated iliac aneurismal disease for fit and high risk patients.

(a)

Concomitant iliac aneurysm with abdominal aortic aneurysms
Disease patterns		Suggested surgical approach
		Low risk patient		High risk patient
	AAA and; unilateral; CIAA		Aortoiliac bypass with; reimplantation of IIA to EIA; or jump-graft		Sufficient CIA DLZ: EVAR; Insufficient CIA DLZ: EVAR with unilateral flare cuff or; EVAR with unilateral BBT or IBD
	AAA and; bilateral; CIAA		Aortoiliac bypass with; reimplantation of one or both; IIAs to EIA or jump-graft		Sufficient CIA DLZ: EVAR; Insufficient CIA DLZ: EVAR with bilateral BBT or EVAR with bilateral IBD or; Aortouniliac graft with embolization of IIA, and reverse-U stent with FFBP
	AAA and; unilateral CIAA; Unilateral IIAA		Aortoiliac bypass with reimplantation of; IIA to EIA or jump-graft		EVAR with aneurismal IIA embolization with unilateral graft extension to the EIA or; EVAR with unilateral IBD if aneurismal IIA DLZ is sufficient or; aortouniliac with unilateral reverse-U stent with FFBP
	AAA and; bilateral CIAA and; unilateral IIAA		Aortoiliac bypass with reimplantation of; one or both IIAs to EIA or jump-grafts		EVAR with bilateral IBDs if aneurysmatic IIA DLZ is sufficient; Sufficient CIA DLZ: EVAR with one leg in IIA and FFBP; Insufficient CIA DLZ: Embolization of aneurismal IIAA, aortouniliac graft, contralateral reveres-U stent and FFBP; (reverse-U stent is preferred in aneurysmatic CIA)
	AAA; Occluded CIA; Contralateral CIAA; Unilateral IIAA		Aortoiliac bypass with reimplantation of; IIAs to EIA or graft reimplantation		Aortouniliac and FFBP
	AAA and; occluded IIA and CIA; Contralateral CIAA and IIAA		Aortoiliac/femoral bypass with; reimplantation of IIA to EIA or; jumb-graft		Aortouniiliac and chimney barrel from unilateral IIA to EIA (if sufficient EIA diameter); and FFBP, otherwise obligatory IIA reimplantation to the EIA
	AAA and bil.; CIAA and bilateral; IIAA		Aortoiliac bypass with; IIA reimplantation		EVAR and bilateral IBD if IIA is sufficient or; aortouniliac, reverse-U stent and FFBP
	AAA and; unil. CIAA and; contralateral IIAA		Aortoiliac bypass with bilateral; IIA reimplantation		Sufficient CIA DLZ: EVAR with BBT and EVAR distal leg to aneurismal IIA if DLZ sufficient and FFBP; Insufficient CIA DLZ: Aortouniliac, IIA embolization, reverse-U stent, and FFBP
	AAA and; unil. CIAA and; bilateral IIAA		Aortoiliac bypass with bilateral; IIA reimplantation		Sufficient CIA DLZ: EVAR and uniilateral IBD if aneurismal IIA sufficient for deployment and; contrallateral IIA embolization or aortouniiliac, EIA to IIA endograft (reverse-U stent), IIA embolization and FFBP; Insufficient CIA DLZ: combined (aortouniliac, reverse-U stent, IIA embolization, and FFBP)

(i) In this table we consider that there is enough proximal subrenal aortic landing zone. In juxtarenal or thoracoabdominal aneurysms we consider the use of fenestrated stents or hybrid surgical interventions.
(ii) The possibility for combined endovascular and IIA to EIA implantation or jump graft through retroperitoneal access may be applied in all cases of aortoiliac aneurismal disease.

(b)

Isolated iliac aneurysms
Disease patterns		Suggested surgical approach
		Low risk patient	High risk patient
	Unilateral CIAA	Aortoiliac bypass and IIA reimplantation or; jumb-graft		Sufficient CIA PLZ and DLZ: CIA stent-graft; Insufficient CIA DLZ: BBT; Insufficient CIA DLZ only: IBD device or BBT
	Unilateral CIIA and; unilateral IIAA	Aortoiliac bypass and IIA reimplantation; (jumb-graft)		Sufficient CIA PLZ and DLZ: Unilateral CIA-EIA stent-grafting with ipsilateral IIAA embolization; Sufficient CIA PLZ: IBD if IIA DLZ is sufficient; Insufficient CIA PLZ: reverse-U stent graft, aortouniliac (if aortic diameter is favorable), IIAA embolization and FFBP
	Bilateral CIIA and; unilateral IIAA	Aortoiliac bypass with bilateral; IIA reimplantation (unilateral jumb-graft)		Sufficient CIA PLZ: Bilateral IBD if IIA DLZ sufficient; Insufficient CIA PLZ: chimney-double barrel technique with IIAA embolization or; embolization of aneurismal IIA and aortouniliac graft (if aortic diameter is favorable),; reverse-U stent and FFBP
	Bilateral CIIA and; bilateral IIAA	Aortoiliac bypass with bilateral; IIA reimplantation (bilateral jumb-grafts)		Sufficient CIA PLZ: unilateral (with unilateral IIAA embolization) or bilateral IBDs if distal IIA/IIAs are suitable for deployment; Insufficient CIA PLZ: unilateral IIAA embolization, aortouniliac graft (if aortic diameter is favorable), reverse-U stent, and FFBP. In case of lack of IIA DLZ then open IIA jumb-graft to EIA is obligatory
	Unilateral CIAA and; unilateral IIAA	Aortoiliac bypass with bilateral; IIA reimplantation (unilateral jumb-graft)		Sufficient CIA PLZ: unilateral IBD and reverse-U stent if IIA DLZ is sufficient with FFBP (ideal solution that may be simplified with right IIA embolization); Insufficient CIA PLZ: reverse-U stent with aortouniliac (if aortic diameter is favorable),; IIA embolization and FFBP
	Unilateral CIAA and; bilateral IIAA	Aortoiliac bypass with bilateral; IIA reimplantation (bilateral jumb-graft)		Sufficient CIA PLZ: unilateral IBD if IIA DLZ is suitable and EIA to IIA graft if DLZ is sufficient with FFBP; Insufficient PLZ: reverse-U stent with aortouniliac (if aortic diameter is favorable), IIA embolization and FFBP; In case of lack of IIA DLZ then open IIA jumb-graft to EIA is obligatory

(i) External Iliac artery aneurysm patterns are not reported in this table because of their extremely low frequency.
(ii) FFBP = Femoral-femoral bypass, BBT = Bell Bottom Technique, IBD = branched iliac device, DLZ = distal landing zone, PLZ = proximal landing zone.
CIA = common iliac artery, EIA = external iliac artery, IIA = internal iliac artery.