NOTES Difficult Technical Challenges of Open Infrarenal Abdominal Aortic Aneurysm Repair and How to Meet Them

Difficulty Maintaining Pelvic Flow Internal iliac artery blood flow should be maintained if possible. In the Canadian Aneurysm Study, when internal iliac flow was maintained to one or both sides, the incidence of clinically apparent ischemic colitis was 0.3%, but when flow was interrupted bilaterally, ischemic colitis occurred in 2.6%. This observation and the current data from endovascular repairs support the principle that internal iliac artery flow should be maintained to at least one side. If both internal iliac arteries are aneurysmal, it may be very difficult to maintain pelvic flow; however, in other cases, it may be feasible to supply the pelvis using a separate graft from the aortic graft to the internal iliac. If the internal iliac is mildly aneurysmal, it may be feasible to bypass into the vessel and accept the need for careful follow-up and the potential need for endovascular obliteration at a later time.