title: Preservation of pelvic circulation with hypogastric artery bypass in endovascular repair of abdominal aortic aneurysm with bilateral iliac artery aneurysms.
abstract: OBJECTIVE
  The endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) with a bilateral common iliac artery aneurysm (CIAA) often requires exclusion of the bilateral hypogastric artery (HA), which can be associated with pelvic ischemic complications such as erectile dysfunction and buttock claudication. This study assessed the effect of HA bypass on improving pelvic circulation.
  
  
  METHODS
  Five patients who underwent endovascular repair with HA bypass for an AAA with bilateral CIAA were evaluated. In all patients, the patency of the inferior mesenteric artery and bilateral HAs arteries was confirmed with preoperative computed tomography (CT) scans and angiography. During EVAR, penile blood flow was monitored with pulse-volume plethysmography measuring the penile brachial pressure index (PBI), and bilateral buttock blood flow was monitored with near-infrared spectroscopy measuring the gluteal tissue oxygenation index (TOI). An aortouni-external iliac artery stent graft with a crossover bypass was performed after embolization of the contralateral HA. HA bypass was performed between the crossover bypass graft and the ipsilateral HA via a retroperitoneal incision.
  
  
  RESULTS
  Unilateral coil embolization of the contralateral side HA trunk slightly decreased blood flow to the contralateral side buttock but did not cause significant changes in penile blood flow. At the completion of EVAR, the levels of both PBI and the contralateral side TOI were significantly lower than the baseline levels. After ipsilateral side HA revascularization with HA bypass, both PBI and bilateral gluteal flow returned almost to the baseline levels. Postoperative angiography and CT scans demonstrated the patency of all HA bypasses and no endoleaks. None of the patients experienced new onset of erectile dysfunction or buttock claudication 1 month after surgery.
  
  
  CONCLUSIONS
  Bilateral HA interruption during EVAR for AAA with bilateral CIAA was associated with significant depletion of both penile and gluteal blood flow. Intraoperative monitoring of PBI and TOI at the bilateral buttocks showed significant improvement of both parameters after HA bypass. HA bypass is an excellent procedure to improve pelvic circulation despite its increased surgical complexity.
authors.affiliation: Division of Vascular Surgery, Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan. unno@hama-med.ac.jp
authors.forename: Naoki
authors.initials: N
authors.lastname: Unno
authors.forename: Kazunori
authors.initials: K
authors.lastname: Inuzuka
authors.forename: Naoto
authors.initials: N
authors.lastname: Yamamoto
authors.forename: Daisuke
authors.initials: D
authors.lastname: Sagara
authors.forename: Minoru
authors.initials: M
authors.lastname: Suzuki
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Konno
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000009:adverse effects; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography; D001158:Arteries / Q000601:surgery; D001783:Blood Flow Velocity; D001794:Blood Pressure; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D002081:Buttocks / Q000098:blood supply; D004621:Embolization, Therapeutic / Q000009:adverse effects; D007172:Erectile Dysfunction / Q000209:etiology; D006801:Humans; D017543:Iliac Aneurysm / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D007383:Intermittent Claudication / Q000209:etiology; D007511:Ischemia / Q000209:etiology / Q000503:physiopathology; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods; D010388:Pelvis / Q000098:blood supply*; D010413:Penis / Q000098:blood supply; D010991:Plethysmography; D012039:Regional Blood Flow; D019265:Spectroscopy, Near-Infrared; D013270:Stomach / Q000098:blood supply*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency