The Unfinished Battle:Management of Bilateral Common and Internal Iliac Artery Aneurysms,High Risk Penetrating AorticUlcers at the Celiac Axis in a Patient Presenting 10 years after Open Aortic Repair

Vascular Division, Dr. Homobono B. Calleja Heart and Vascular Institute,St. Luke’s Medical Center – Quezon City

Presenters:

Wisdom Ang MD, Jonathan Moses Jadloc MD, Donna Aurea Maderazo MD, Patrick Vera Cruz MD

Training Officer:

Neva Jean Reloj MD

ABSTRACT

Introduction:

Management of complex aortoiliac disease requires a thorough assessment of vascular pathology, the technical expertise of the treating team, the patient’s clinical status, and family preferences. We report a case of an elderly female presenting with high-risk penetrating aortic ulcers at the celiac axis, bilateral common and internal iliac artery aneurysms, and an aneurysmal proximal abdominal aorta, detected a decade after open abdominal aortic aneurysm repair.

Clinical Presentation

A 74-year-old female presented for a routine check-up. She was initially asymptomatic, but on review of systems, however, she reported a throbbing sensation in the anal area during defecation. She is known hypertensive, dyslipidemic, non-diabetic, and had previously undergone open surgical repair of an infrarenal abdominal aortic aneurysm 10 years prior.

On physical examination, her point of maximal impulse was displaced to the left anterior axillary line. An infraumbilical midline scar was noted, with an audible abdominal bruit over the hypogastric and bilateral lower quadrant areas. Ankle-brachial indices were within normal limits.

Diagnostics

A computed tomography aortogram revealed an atherosclerotic abdominal aorta with a proximal

aneurysmal dilatation measuring 3.4 cm. Two penetrating aortic ulcers (PAUs) were identified just above the celiac trunk. A patent aorto-bi-iliac bypass graft was visualized, with bilateral common iliac artery(CIA) and internal iliac artery (IIA) aneurysms. The right and left CIA aneurysms measured 2.7 × 3.1 cm and 4.2 × 4.0 cm, respectively; while the right and left IIA aneurysms measured 7.6 × 7.4 × 6.2 cm and 5.8 × 5.4 × 5.6 cm, respectively.

Figure 1. Bilateral common and internal iliac artery aneurysms seen in the coronal view (figure 1A) and in 3D rendered view (figure 1B) of the CT aortogram. The first PAU measured 1.0 cm in depth and 1.4 cm in width, with a corresponding aortic diameter of 4.2 cm. The second PAU measured 1.3 cm in depth and 2.9 cm in width, with a 3.6 cm total aortic diameter.

Figure 2. Sagittal view of the CT aortogram showing PAUs seen in the proximal segment of the abdominal aorta which are 0.7 cm apart from each other and are in close proximity with the celiac and SMA (Figure 2A). Cross-sectional view showing the first PAU (figure 2B) and second PAU (figure 2C).

Duplex ultrasonography confirmed distal anastomosis of the bypass graft to both external iliac arteries, with antegrade flow directed towards the distal external iliac arteries. Notably, there was appreciable retrograde flow from the proximal external iliac arteries into the dilated common and internal iliac arteries.

Management

The patient underwent endovascular repair of the bilateral iliac artery aneurysms. A Talent endoluminal occluder was deployed at the right proximal external iliac artery, just distal to the origin of the internal iliac artery. This was followed by the deployment of an Endurant II stent graft system extending from the right aortoiliac graft limb to the external iliac artery. The same procedure was performed on the contralateral side.

The proximal abdominal aortic aneurysm and penetrating aortic ulcers were managed conservatively with oral medications, including atorvastatin, ezetimibe, carvedilol, aspirin, and telmisartan, along with regular imaging surveillance.

Postoperative duplex ultrasonography revealed completely thrombosed iliac artery aneurysms. However, there was severe stenosis in the right aortoiliac graft limb, with a corresponding decrease in anklebrachial indices bilaterally. Despite this, the patient was discharged in good condition, without claudication or recurrence of the throbbing anal sensation. Follow-up imaging at two months demonstrated blood flow into the previously thrombosed left internal iliac artery aneurysm which was assumed to be a Type 2 endoleak. This persisted at 6 months with a decrease in size noted. She was then advised to continue optimal medical treatment and have follow-up imaging done every 6 months for the next 2 years. The patient’s ankle-brachial indices had normalized during this time.

Learning points

• Internal iliac artery aneurysms are uncommon, with an incidence of 0.15% to 3%.

• Endovascular therapy is the preferred treatment for iliac artery aneurysms, offering lower

perioperative risks and shorter hospital stays than open surgery.

• Endoleaks are the most frequent cause of secondary interventions after endovascular iliac

aneurysm repair.

• With type 2 endoleak physiology complication and a <10 mm growing sac aneurysm at 6 months

follow-up, patients are advised follow up imaging every 6 months for 2 years.

• Complex aortic disorders involving the major visceral arteries (e.g. at the celiac origin) are often

not suitable for standard endovascular techniques.

• Asymptomatic penetrating aortic ulcers (PAUs) may be safely managed conservatively without

prophylactic intervention.

• Shared decision-making between the medical team, patient, and family improves patient

understanding, adherence, and outcomes.

• Strict compliance with medical therapy, imaging surveillance, and follow-up is essential after

both endovascular and surgical interventions