Hypogastric Artery Preservation during Endovascular Aortic Aneurysm Repair: Is It Important?

doi:10.1053/j.semvascsurg.2009.07.012

Seminars in Vascular Surgery

Volume 22, Issue 3, September 2009, Pages 193-200

https://doi.org/10.1053/j.semvascsurg.2009.07.012 Get rights and content

Endovascular repair of aortoiliac artery aneurysm is a safe and effective treatment strategy. Selective hypogastric artery embolization with coils may be necessary to allow the endograft to anchor in the aneurysm-free external iliac artery, thereby eliminating hypogastric endoleak into the aortoiliac aneurysm. Considerable controversy exists regarding the safety of intentional occlusion of the hypogastric artery. Proximal occlusion of a hypogastric artery with embolic coils typically produces little or no clinical symptoms due to well-collateralized pelvic arterial networks. On the other hand, significant complications, such as colonic ischemia, spinal cord paralysis, buttock claudication, or erectile dysfunction are well-recognized adverse events after hypogastric artery embolization. This article examines the natural history of hypogastric artery embolization as well as clinical data regarding the safety and complications following this procedure. Clinical studies regarding risk factors that might contribute to ischemic complication following hypogastric artery embolization are presented. Lastly, treatment strategies to preserve the hypogastric artery thereby obviating the need for hypogastric artery embolization are discussed.

Section snippets

Anatomic Consideration and Clinical Implications of Hypogastric Artery Occlusion in Aortoiliac Aneurysm Repair

The hypogastric arteries provide critical blood flow to the pelvic organs and buttock muscles. These vessels represent a major inflow source of circulation to many gastrointestinal and genitourinary structures, such as the sigmoid colon, rectum, ovary, uterus, and scrotum. Because significant cross-pelvic collateral systems exist between bilateral hypogastric arteries, operative ligation of one hypogastric artery with preservation of the contralateral hypogastric artery is usually

Literature Review of Pelvic Complications Following Hypogastric Artery Embolization

Pelvic ischemic complications as a result of hypogastric occlusion are well-described in the literature, with buttock claudication and colonic ischemia the most common sequelae.1, 2, 4, 6, 7, 9, 11, 12, 16 Additionally, less common complications include spinal cord ischemia, gluteal compartment syndrome, bladder dysfunction, decubitus ulcer, and genital ulceration.1, 2, 4, 6, 7, 9, 11, 12, 16Table 1 lists a summary of 21 published reports regarding hypogastric embolization for endovascular

Pelvic Hemodynamic Alterations of Hypogastric Artery Embolization

The hemodynamic consequence after hypogastric embolization for endovascular aortoiliac artery aneurysm repair was assessed in a prospective clinical study in which 12 patients underwent preoperative and postoperative penile-brachial-index (PBI) and pulse-volume recording assessment.¹² The implication of pelvic flow adaptation following hypogastric artery embolization, as assessed by penile artery blood pressure, was analyzed with occurrence of pelvic ischemic complications.

In this prospective

Risk Factor Analysis of Complications Following Hypogastric Artery Embolization

Several recent studies have analyzed potential risk factors of pelvic ischemic complication following hypogastric artery embolization. Farahmand and colleagues⁷ performed a retrospective analysis of their experience in 96 patients who underwent hypogastric artery embolization. While confirming that endovascular hypogastric artery occlusion is not benign, the authors reported that buttock claudication was observed in 50% of cases. This complication lasted >6 months in 34% of these cases and was

Therapeutic Strategies to Preserve the Hypogastric Artery

Taking all the available literature on hypogastric artery embolization into account, all authors would uniformly agree that pelvic ischemia can be a devastating complication following hypogastric artery embolization. Furthermore, most studies emphasized the high incidence of pelvic ischemia following bilateral hypogastric artery embolization. The importance of maintaining pelvic circulation is critical in preventing pelvic ischemic complications and ensuring patient safety during endovascular

Conclusion

Hypogastric artery embolization during endovascular aortoiliac aneurysm repair is not a benign procedure, as it can lead to numerous pelvic ischemic complications. While buttock claudication and erectile dysfunction are more common examples of pelvic ischemia, other devastating adverse events, such as spinal cord ischemia, can lead to life-long debilitation. Current literature advocates avoidance of bilateral hypogastric artery embolization if possible. The heightened awareness of pelvic