title: A longitudinal view of improved management strategies and outcomes after iatrogenic iliac artery rupture during endovascular aneurysm repair.
abstract: BACKGROUND
  Intraoperative rupture of the iliac artery is a serious complication of endovascular aneurysm repair (EVAR), the outcomes of which have changed with increasing experience and improved endovascular tools over the past 2 decades. Over the past 15 years, the incidence and management of iliac rupture has changed as devices have improved and experience has grown. This study reviews our longitudinal experience with this complication.
  
  
  METHODS
  All cases of iliac artery rupture during EVAR from 1997 through 2011 were reviewed for presentation, treatment strategies, and outcomes.
  
  
  RESULTS
  Iliac artery rupture complicated 20 (3%) of 707 EVARs performed. Sixteen (80%) common and four (20%) external iliac arteries were ruptured. Hypotension (systolic blood pressure: <90 mm Hg) was present in 11 (55%) cases. Five open bypasses were performed (25%), whereas 15 were repaired using an endovascular approach (75%). All open repairs (100%) were associated with postoperative morbidity (one wound infection, four multiorgan system failure), whereas three of the 15 patients (23%) repaired endovascularly experienced postoperative morbidity (cerebrovascular accident, myocardial infarction, line infection). There were no intraoperative deaths. There were four (20%) early deaths in the intensive care unit (<3 days postoperatively), all of which were associated with resection of bilateral hypogastric arteries and were due to complications of pelvic ischemia and/or multiorgan system failure.
  
  
  CONCLUSIONS
  Iliac artery rupture remains relatively uncommon but can carry a high morbidity and mortality. As device technology, imaging quality for preoperative planning, and experience level have improved, iliac rupture has become less common, and outcomes in the setting of iliac rupture have significantly improved. Endoluminal management has evolved as the primary treatment strategy. Resection of both hypogastric arteries is associated with mortality from pelvic ischemia, a likely indicator of systemic disease.
authors.affiliation: Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX 77030, USA.
authors.forename: Cassidy
authors.initials: C
authors.lastname: Duran
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Naoum
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Smolock
authors.forename: Charudatta S
authors.initials: CS
authors.lastname: Bavare
authors.forename: Mitul S
authors.initials: MS
authors.lastname: Patel
authors.forename: Javier E
authors.initials: JE
authors.lastname: Anaya-Ayala
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007049:Iatrogenic Disease; D007083:Iliac Artery / Q000293:injuries* / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D012421:Rupture; D013997:Time Factors; D016896:Treatment Outcome; D057772:Vascular System Injuries / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*