Symptomatic bilateral iliac artery aneurysms: Four cases with four different management strategies and outcomes

Introduction: Iliac artery aneurysms mostly become symptomatic when ruptured or because of local mass effect on surrounding pelvic organs. The challenging part of surgical treatment of aneurysms of the iliac arteries is the involvement of the hypogastric artery which is the most important supply of blood perfusion towards all pelvic organs and buttocks. Ischemic complications can occur postoperatively ranging from buttock claudication to extended pelvic organ ischemia. In addition, infectious and obstructive syndromes caused by iliac artery aneurysms, bring an extra challenge in preserving pelvic circulation. Report: Our report presents four different cases of bilateral iliac artery aneurysms in a (semi-) acute setting because of rupture or symptomatic presentation. Two cases became symptomatic because of direct compression by the aneurysms’ sacs. A third case involves an iliac-enteric fistula. The last case describes a ruptured iliac artery aneurysm. All four cases had a different management strategy regarding open, endovascular or conservative treatment. Our cases report the variable consequences of sacrificing the hypogastric arteries regarding ischemic complications. Discussion: Iliac artery aneurysms are often asymptomatic or misdiagnosed, which leads to rupture or mass effect of the aneurysm sac on surrounding organs. In acute setting there is not always the possibility of sparing the hypogastric artery, nor in open nor in endovascular procedures. An iliac branch device is not always an on the shelf solution and can be an elaborating procedure in patients in hemorrhagic shock. Occlusion of one or two hypogastric arteries can result in buttock claudication, ischemia of pelvic organs, but can also be uncomplicated. This variable behavior of pelvic collateral blood supply makes the treatment of iliac artery aneurysms very challenging. Three of our cases held an additional challenge because of obstruction or infection.