Editor's Choice – Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

Abstract

WHAT THIS PAPER ADDS The new 2019 guideline of the European Society for Vascular Surgery recommends consideration for elective iliac artery aneurysm (IAA) repair when the iliac diameter exceeds 35 mm. This nationwide study from the Netherlands demonstrates that elective IAA repair is carried out at a median maximum diameter of 43 mm, and ruptured IAA repair at 68 mm. The findings appear to support the recent raise of the threshold diameter for elective IAA repair. Objective: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Methods: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. Results: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38e50) mm and 68 (IQR 58e85) mm, respectively. Mortality was 1.3% (95% CI 0.7e2.4) after eIAA repair and 25.5% (95% CI 18.0e34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, postoperative: 34.0% vs. 13.8%, respectively). Conclusion: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…Although no randomized studies for iliac aneurysm repair size thresholds exist, in large case series and registry reports, rupture of iliac aneurysms at diameters <4 cm is rare. 3,7 Thus, a repair threshold of 3.5 cm seems reasonable to balance procedural risks with rupture risk. Furthermore, to achieve adequate AAA repair, repair of iliac artery ectasia or aneurysms often may be required.…”