title: Embolization of the internal iliac artery before EVAR: is it effective? Is it safe? Which technique should be used?
abstract: OBJECTIVE
  To assess the clinical outcomes of internal iliac artery (IIA) embolization before endovascular aneurysm repair (EVAR).
  
  
  METHODS
  Between 2002 and 2011, 88 patients underwent IIA embolization prior to EVAR. Sixty-five patients underwent unilateral and 23 underwent bilateral IIA embolization. A total of 111 IIAs were embolized: 56 were embolized with coils, 41 with Amplatzer plugs, and 14 with a combination of embolic agents. The outcomes were assessed retrospectively by reviewing medical records and follow-up imaging.
  
  
  RESULTS
  IIA embolization was technically successful in 95.7% of cases. Type 2 endoleak from previously embolized IIAs was seen in 4 cases, and in 1 case this was significant necessitating re-intervention. Buttock claudication was reported in 38% of cases, whereas new onset erectile dysfunction occurred in 10% of cases. No severe ischemic complications, such as spinal cord ischaemia or buttock necrosis, were reported. Analysis comparing unilateral versus bilateral embolization, simultaneous versus sequential embolization, and the type of embolic material used showed no statistical significance.
  
  
  CONCLUSIONS
  IIA embolization is technically successful and effective in preventing significant type 2 endoleak in the majority of cases. It is a relatively safe procedure without major complications, but the incidence of buttock claudication and erectile dysfunction remain relatively high, and patients should be consented appropriately. There is no significant benefit for adopting a particular embolization technique, but there is a tendency towards reduced pelvic ischaemia with proximal embolization. Four cases of type II endoleak occurring after technically successful IIA embolization supports the school of thought that IIA should be embolized prior to coverage and extension of the distal landing zone.
authors.affiliation: Department of Radiology, St. George's Hospital, London, SW17 0QT, UK, drjyc78@gmail.com.
authors.forename: Joo-Young
authors.initials: JY
authors.lastname: Chun
authors.forename: Leto
authors.initials: L
authors.lastname: Mailli
authors.forename: Maaz Ali
authors.initials: MA
authors.lastname: Abbasi
authors.forename: Anna-Maria
authors.initials: AM
authors.lastname: Belli
authors.forename: Michael
authors.initials: M
authors.lastname: Gonsalves
authors.forename: Graham
authors.initials: G
authors.lastname: Munneke
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Ratnam
authors.forename: Ian M
authors.initials: IM
authors.lastname: Loftus
authors.forename: Robert
authors.initials: R
authors.lastname: Morgan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography / Q000379:methods; D015331:Cohort Studies; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic / Q000379:methods*; D057867:Endoleak / Q000209:etiology* / Q000628:therapy; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017543:Iliac Aneurysm / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome