The assessment of pelvic circulation after internal iliac arterial reconstruction: a retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients' ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

The assessment of pelvic circulation after internal iliac arterial reconstruction:—A retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients’ ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

Effects of abdominal aneurysmectomy, aortoiliac bypass grafting and angioplasty on male sexual potency: a prospective study

The preoperative frequency and postoperative status of male sexual potency was studied prospectively in 46 patients who underwent abdominal aortic aneurysmectomy, aortoiliac and aortofemoral bypass grafting, or percutaneous transluminal angioplasty of the iliac artery. The patients with aortic aneurysms were older; approximately half of them were potent. The frequency of impotence was highest in patients who underwent aortoiliac bypass, and correlated well with their low penile to brachial pressure index. Patients who had angioplasty had more localized lesions, a higher penile to brachial pressure index and the lowest rate of impotence. Postoperatively, 13% of the patients regained nocturnal erection and 10% became functionally potent (defined as the ability to achieve penetration). The improvements were similar in bypass and angioplasty patients. No patient experienced deterioration in sexual potency and all showed a markedly improved thigh to brachial pressure index postoperatively. Routine aortoiliofemoral artery angiograms were of limited value in predicting the status and outcome of sexual potency in this series of patients.     

Hypogastric artery embolization in endovascular abdominal aortic aneurysm repair

PURPOSE: Iliac artery anatomy is a central factor in endoluminal abdominal aortic aneurysm therapy. It serves as the conduit for graft deployment and as the region of distal graft seal. Thirty-eight percent of iliac vessels in our patients require special treatment because of aneurysms, tortuosity, or small size. Bilateral hypogastric artery exclusion has been avoided because of concerns of colorectal ischemia, hip/buttock claudication, and impotence. We suggest that elective, staged, bilateral hypogastric embolization can be performed safely with reasonably low morbidity and can expand the anatomic boundaries for stent-graft abdominal aortic aneurysm repair. METHODS: This study was performed as a retrospective chart review of patients requiring hypogastric artery embolization for endovascular repair of abdominal aortic aneurysms between June 1998 and June 2000. Patients with otherwise appropriate anatomy and common iliac artery aneurysms were informed of the option for stent-graft repair with internal iliac artery embolization with its risks of impotence, hip/buttock claudication, and bowel ischemia. Patients underwent unilateral or staged bilateral coil embolizations of their proximal hypogastric arteries with an approximate 1-week interval between procedures. Hospital and office records were reviewed; phone interviews were performed. Follow-up ranged from 1 to 12 months. RESULTS: During a 24-month period, 65 patients underwent endovascular abdominal aortic aneurysm repair; 18 patients (28%) required hypogastric artery embolization. Seven (39%) of these patients underwent bilateral embolization. There were no episodes of clinically evident bowel ischemia. Lactate levels were normal in all measured patients. Postoperative fevers (> 101.0 degrees F) were documented in 10 (56%) of 18 patients. The average white blood cell count was 12.8 x 10(9)/L (range, 8.5-22.9). There were no positive blood culture results. The return to the full preoperative diet occurred in 1 to 3 days. Hip/buttock claudication occurred in approximately 50% of patients with persistent but improved symptoms at 6 months. Eighty-seven percent of patients had preoperative erectile dysfunction. Only two patients noted worsening of erectile function postoperatively. CONCLUSIONS: Preliminary results indicate that bilateral hypogastric artery embolization can be performed, when necessary, with reasonable morbidity in patients undergoing stent-graft abdominal aortic aneurysm repair.     

Erectile function before and after reconstructive arterial surgery in men with occlusive arterial leg disease

Erectile impotence is a well-known complication of vascular surgery in the aorto-iliac area. So far the pathogenesis has not quite been understood, but peroperative damage to the autonomous nerves has been suggested. Ninety-eight men with arterial insufficiency in their legs underwent an additional sexual evaluation including penile blood pressure measurement and cystometric examination. The arterial insufficiency necessitated arterial reconstruction involving aorta or the common iliac arteries in 28 patients. When possible, improvement of the penile blood supply was aimed at during the operation, but no nerve-sparing techniques were employed. The seven potent patients remained potent, while nine patients became potent after the operation. The cases remaining impotent after the operation could all be explained considering the arteriography, the operation and the changes in penile blood pressure. The erectile function is related to the condition of the penile blood supply and it may be possible to reduce the rate of postoperative impotence by considering the penile blood supply when planning the operative strategy.     

Sexual function after aorto-iliac vascular reconstruction. Which is more important, the internal iliac artery or hypogastric nerve?

Sixty patients undergoing surgical reconstruction by classical or modified methods for aorto-iliac vascular disease were studied as to postoperative sexual function. Preoperative impotence was present in approximately half of the patients with abdominal aortic occlusion. Although internal iliac arterial blood flow was regarded as an important factor in sexual function, only a slight correlation was noted between circulatory insufficiency and postoperative sexual dysfunction. Preservation of both trunks or the left trunk of the hypogastric nerve led to a marked decrease in the incidence of ejaculation disturbances. We concluded preservation of the hypogastric nerve was more beneficial than maintenance of internal iliac arterial blood flow.     

Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb-threatening ischemia

Purpose: Although axillobifemoral bypass procedures have a lower mortality rate than aortobifemoral bypass procedures, they are limited by decreased patency, moderate hemodynamic improvement, and the need for general anesthesia. This report describes an alternative approach to bilateral aortoiliac occlusive disease using unilateral endovascular aortofemoral bypass procedures in combination with standard femorofemoral reconstructions.Methods: Seven patients who had bilateral critical ischemia and tissue necrosis in association with severe comorbid medical illnesses underwent implantation of unilateral aortofemoral endovascular grafts, which were inserted into predilated, recanalized iliac arteries. The proximal end of the endovascular graft was fixed to the distal aorta or common iliac artery with a Palmaz stent. The distal end of the graft was suture-anastomosed to the ipsilateral patent outflow vessel, and a femorofemoral bypass procedure was then performed.Results: All endovascular grafts were successfully inserted through five occluded and two diffusely stenotic iliac arteries under either local (1), epidural (5), or general anesthesia (1). The mean thigh pulse volume recording amplitudes increased from 9 ± 3 mm to 30 ± 7 mm and from 6 ± 2 mm to 26 ± 4 mm ipsilateral and contralateral to the aortofemoral graft insertion, respectively. In all cases the symptoms completely resolved. Procedural complications were limited to one local wound hematoma. No graft thromboses occurred during follow-up to 28 months (mean, 17 months).Conclusions: Endovascular iliac grafts in combination with standard femorofemoral bypass grafts may be an effective alternative to axillobifemoral bypass in high-risk patients who have diffuse aortoiliac occlusive disease, particularly when bilateral axillary-subclavian disease is present. (J Vasc Surg 1996;24;984-97.)     

Internal iliac artery revascularization in the treatment of vasculogenic impotence

Five impotent men underwent internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass after preoperative testing suggested a vasculogenic cause for impotence. All patients had abnormal preoperative penile/brachial arterial pressure indices (mean, 0.42 +/- 0.12). Following operation, all patients regained erectile capability and had normal postoperative penile/brachial indices (mean, 0.80 +/- 0.06). One patient developed retrograde ejaculation, emphasizing the need for meticulous nerve-sparing dissection with this operation. Internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass is effective in relieving vasculogenic impotence in properly selected patients.     

Evaluation of profundoplasty in reconstructions of combined aorto-iliac and femoro-popliteal occlusive disease

The results in 135 patients undergoing aorto-iliac and aorto-femoral bypass during 1974-1979 were examined. In most cases, occlusive disease of the iliac arteries was combined with total atherosclerotic occlusion of the superficial femoral arteries and sometimes with additional pathology in the profunda femoris artery. In 18.7%, subsequent vascular procedures became necessary in extremities of patients who had undergone aorto-iliac or aorto-femoral anastomotic procedures without additional profundoplasties. In those cases where the primary reconstruction was combined with profundoplasty the results were very satisfying and subsequent procedures were needed only in 8.8%. The aorta-profunda femoris bypass is now preferred for patients with combined aorto-iliac and femoro-popliteal occlusive disease. Results and technical details are discussed.     

Endovascular preservation of pelvic circulation with external iliac-to-internal iliac artery "cross-stenting" in patients with aorto-iliac aneurysms: a case report and literature review

Endovascular success depends heavily upon anatomical suitability for secure graft placement. Common iliac artery (CIA) aneurysms frequently extend close to the iliac bifurcation, requiring distal fixation in the external iliac artery (EIA), in turn excluding the internal iliac artery (IIA). The preservation of circulation to at least one IIA artery is highly recommended. We report an endovascular technique for complete preservation of the hypogastric arteries of an aorto-iliac aneurysm extending into the iliac bifurcation and hypogastric artery. A left CIA aneurysm involving the iliac bifurcation was excluded with a covered Fluency stent-graft (Bard Inc., New Jersey, USA) deployed from the EIA into the IIA followed by the internal deployment of a Luminex uncovered stent (Bard Inc.) extended into one branch of the hypograstric artery. IVUS evaluation was essential in determining precise aneurysm and sealing zone measurements. Complete preservation of hypogastric circulation was achieved. The placement of the uncovered stent effectively extended the sealing zones without covering either of the hypogastric distal branches and concurrently corrected the Fluency stent kinking due to severe arterial tortuosity. In CIA aneurysms involving the IIA, an uncovered stent can extend the sealing zones, whilst maintaining complete preservation of pelvic circulation and offers support to the covered stent-graft. IVUS seems necessary for precise neck evaluation.     

Surgical Treatment of Unilateral Iliac Artery Occlusive Disease Using a Retroperitoneal Approach

Objective: We evaluated the early and late postoperative outcome of aorto/iliofemoral bypass operations using a retroperitoneal approach.

Methods: From December 1999 until the end of December 2005, unilateral aorto/iliofemoral bypass was performed on 23 patients (3 female, 20 male) for unilateral iliac occlusive disease. The average age was 57 years (range: from 45 to 68 years). Operative indications were claudication in seven patients, rest pain in 14 patients, and non-healing ulcer or gangrene in two patients.

Results: Surgical procedures included aortofemoral bypass in ten patients, iliofemoral bypass in 12 patients and aorto-iliac bypass in one patient. Simultaneous femoropopliteal bypass was performed on seven patients. Mean follow-up period was 2.5 ± 0.31 years. Graft patency was 100% during this period.

Conclusions: A retroperitoneal approach for unilateral iliac obstructive disease is a valuable and well-tolerated alternative to conventional aortobilateral reconstruction in unilateral symptomatic aorto-iliac disease with excellent long-term outcome.     

Aortoiliac Endarterectomy: A Lost Art?

Endarterectomy was first performed on a superficial femoral artery in 1946 by Cid dos Santos and subsequently on the abdominal aorta by Wylie in 1951. During the 1950s and 1960s, aortoiliac endarterectomy (AIE) was the standard procedure for treatment of aortoiliac occlusive disease. When prosthetic graft material became available, aortobifemoral bypass (ABFB) replaced AIE in most cases because occlusive disease commonly affects the external iliac arteries also, which were difficult to endarterectomize. As a result, aorto-common iliac endarterectomy became almost a lost art. However, we believe there is still a place for AIE in selected patients based on a review of our results with the procedure. We reviewed 205 patients who survived 10 years after undergoing operation for aortoiliac occlusive disease by either aorto-common iliac endarterectomy (n = 39) or ABFB (n = 166). Ten-year primary patency was 89.2% for AIE and 78% for ABFB. Graft infection or aneurysmal formation occurred in 5% of ABFB and 0% of AIE cases. Ten male patients who underwent AIE for leg and hip claudication with positive penile/brachial indices of ≤0.6 enjoyed improvement of erectile dysfunction. Twenty of the 39 AIEs were in female smokers with small vessels, localized disease, and elevated triglycerides. Three patients with end-to-side infected ABFB grafts, two with enteric fistula (one ours, two referred), had their grafts removed, followed by AIE with vein patching of their bypass sites. All three patients survived and at 10-year follow-up had patent reconstructed aortofemoral vessels. Since AIE avoids prosthetic material, it is preferable to ABFB in (1) patients whose aortoiliac occlusive disease does not involve the external iliac arteries; (2) male patients with aortoiliac occlusive disease who, in addition to claudication, have erectile dysfunction with penile/brachial indices of ≤0.6 and stenotic internal iliac origins; (3) patients with aortoiliac disease including the external iliac arteries who are not candidates for ABFB because of infection risk or small vessels; (4) patients with localized aortoiliac disease; and (5) patients after removal of an infected ABFB graft (with or without an enteric fistula) that had initially been placed end-to-side for aortoiliac occlusive disease.     

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair

PURPOSE: Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption. METHODS: From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg). RESULTS: There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits. CONCLUSIONS: Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.     

Open surgery of infrarenal aortic aneurysms with iliac involvement: repair should be entirely intra-abdominal

AIM: A review of the literature on the surgical treatment of abdominal aortic aneurysms (AAAs) reveals that aortofemoral bypass (AFB) is used frequently in some centers. The latter series are characterized by higher rates of graft-related complications than in those in which AFB is used less frequently. The aim of our study was to evaluate the relative frequency and outcome of different types of bypass grafts in the surgical treatment of AAAs with iliac involvement, in our center and in others. METHODS: Between 1994 and 2004, 190 AAA patients with involvement of the iliac axes underwent elective repair in our department. Surgery was performed via median transperitoneal access. RESULTS: The AAAs extended to the common iliac artery (CIA) in 90.5% of patients. The remaining 9.5% extended to the external iliac artery (EIA). Aorto bi-iliac grafts were used in 159 cases, straight tube grafts in 13, aorto EIA grafts in 15, and AFBs in 3. Overall 30-day morbidity and mortality rates were 12.1% and 2.6%, respectively. At follow-up (mean: 5.6 years), one distal limb infection of an AFB and 4 CIA/EIA aneurysmal enlargements occurred and were repaired accordingly. Secondary patency and 5-year cumulative survival rate were 100% and 80%, respectively. CONCLUSIONS: In this series of AAAs extending to the iliac axes, AFB was used selectively (1.6%), even when the AAA extended to the EIA. This allowed us to maintain direct vascularization of the hypogastric arteries and eliminate the risk of complications associated with inguinal access. We feel, therefore, that for the repair of aortoiliac aneurysms, AFB is rarely indicated.     

EXternal iliac "steal syndrome"

A case of steal syndrome in the external iliac artery characterized by distinct clinical symptoms and by a reversal of blood flow in the internal iliac artery secondary to the closure of the common iliac artery, has been described. The patient reported marked decrease in sexual activity and impariment of erection in addition to intermittent claudication of the corresponding lower extremity. He was able to achieve and maintain an erection only with absolute rest. The erection disapperaed immediately when he moved his lower extremities. Endarterectomy of the common external and internal iliac arteries along with an aortofemoral bypass, resulted in disapperrance of both claudication and his sexual impotence.     

Closed endarterectomy. Preferred operation for aortoiliac occlusive disease

Closed endarterectomy using the LeVeen plaque cracker was performed on isolated, clamped segments of the unopened aorta, iliac, and femoral arteries. The results of this type of endarterectomy have been analyzed for 111 patients who were followed up from 2 1/2 to nine years. The five-year patency rate was 99%. After nine years, 96.5% of the vessels that underwent surgery remained functionally and radiographically patent. Closed endarterectomy is a substantial improvement over conventional open or half-closed endarterectomy. The closed endarterectomy takes less time, entails little or no blood loss, and is accomplished through a retroperitoneal approach. The aortofemoral bypass graft is inferior to the closed endarterectomy in morbidity, mortality, patency, and alleviation of impotence. Late complications with bypass grafts, using synthetic material, are more numerous and life-threatening.     

Arteriographically determined occlusive disease within the hypogastric-cavernous bed in impotent patients following blunt perineal and pelvic trauma

To determine the presence, location and pattern of arterial occlusive disease within the hypogastric-cavernous arterial bed in impotent men following blunt perineal and pelvic trauma, we reviewed the selective internal pudendal arteriograms of 20 patients with a history of blunt perineal and 7 with blunt pelvic trauma who had immediate development of impotence. Arteriographic studies of 104 other impotent patients also were reviewed and compared. Patients with persistent impotence immediately after blunt pelvic and perineal trauma had significantly different patterns of arteriographically demonstrated occlusive disease within the distal hypogastric-cavernous arterial bed consistent with the site of the traumatic injury. Those who sustained blunt pelvic trauma and complained of immediate impotence revealed arterial occlusive lesions mainly in the internal pudendal, common penile, cavernous and dorsal arteries. The incidence of arterial lesions in the distal internal pudendal or common penile artery was significantly higher (p less than 0.01) in patients with blunt pelvic trauma (92%) than in those with blunt perineal trauma (35%). Patients who sustained blunt perineal trauma and complained of immediate impotence demonstrated a more focal pattern of pathological arterial occlusion primarily in the cavernous and dorsal arteries. The incidence of a solitary arterial lesion in the cavernous artery without proximal disease was significantly higher (p less than 0.05) in patients with blunt perineal trauma (48%) than in those with blunt pelvic trauma (8%). It is hypothesized that blunt trauma without immediate impotence may be a potential risk factor for later development of arterial vasculogenic impotence, and that unrecognized or seemingly innocuous trauma may be a factor in cases of idiopathic impotence. Patients without trauma and with vascular risk factors have a more diffuse pattern of arteriographically demonstrated arterial lesions.     

Repair of abdominal aortic aneurysms in patients with renal, iliac, or distal arterial occlusive disease

Appropriate preoperative vascular assessment of patients presenting with aortic aneurysms and arterial occlusive disease is essential to obtain the optimal results from aneurysm repair. The renal arteries should be evaluated in patients with hypertension or renal dysfunction, and stenosis must be addressed when seen on arteriograms. Hemodynamically significant lesions are candidates for bypass concomitant with aortic replacement. The stump pressure of a patent inferior mesenteric artery should be assessed intraoperatively, and bypass or reimplantation should be performed if colon ischemia might result from internal mesenteric artery ligation. If vasculogenic impotence is suggested by preoperative studies, meticulous nerve-sparing dissection and revascularization of the internal iliac arteries may result in recovery of erectile function in some patients. In all cases of aneurysm repair, the hypogastric circulation must be maintained through either direct revascularization or bypass to major collateral arteries. Iliac occlusive disease may be evaluated with several modalities, including physical examination, noninvasive laboratory testing, arteriography, and the papaverine test, to determine whether critical or subcritical stenoses are present. Aortic bifurcation grafts should be used to construct the distal anastomoses beyond areas of significant disease. The extent of lower-extremity occlusive disease directly affects the long-term patency of aortic replacement, and diligent follow-up is necessary for timely intervention to maintain patency of vascular reconstructions.     

A double bifurcated graft for abdominal aorta and bilateral iliac artery reconstruction

Revascularization of the hypogastric artery often tends to be neglected in aortoiliac reconstructive surgery; however, its incomplete revascularization can result in unfavorable complications such as buttock claudication or necrosis, vascular impotence, and colonic ischemia. Multiple vascular lesions in the abdominal aorta and bilateral iliac arteries were reconstructed using a newly designed double bifurcated graft in five male patients. All five patients demonstrated excellent graft limb patency and postoperative improvement of the ankle-brachial pressure index without any clinical signs of ischemia in regions of the hypogastric artery. Thus, we conclude that an aggressive approach toward hypogastric circulation maintenance is essential in aortoiliac reconstructive surgery. By using this double bifurcated graft, rapid and safe revascularization of the bilateral hypogastric arteries concomitant with the external iliac or femoral arteries can be performed.