PC206 - Surgical Management of a Large Primary External Iliac Vein Aneurysm

Objectives: Iliac vein aneurysms are rare, and the true incidence is unknown. Their etiology is either primary or secondary, and secondary aneurysms are often related to a traumatic arteriovenous fistula. They appear to have a male and left-sided predominance. Due to their rarity the most appropriate surgical management has yet to be elucidated. Here we highlight a case of a large primary external iliac vein aneurysm successfully repaired with interposition graft.

Methods: The patient is a 61-year-old male with a history of hyperlipidemia, BPH, asthma, and congenital dilation of the IVC, who was found to have a right external iliac vein aneurysm discovered incidentally on CT scan during work up for urological complaints. He is an avid biker, non-smoker, without family history of aneurysms, and was asymptomatic regarding his aneurysm. He was not on anticoagulation at the time of vascular surgery consultation. He underwent a venogram with anticipated endovascular intervention. However, the large size of the aneurysm confirmed with IVUS, combined with the fact that it extended into the common femoral vein, precluded a safe distal landing zone for stent placement. The patient was therefore deemed an appropriate candidate for open repair. Through right retroperitoneal exposure the right external iliac vein aneurysm was noted to be 8.5-9cm in greatest diameter (Fig 1). The original plan to use CryoArtery was abandoned, and instead a bifurcated 20x10mm PTFE graft (Gore Medical) was modified to create an end-to-end interposition graft (Fig 2). A micro puncture catheter was placed in the right greater saphenous vein. Heparin was instilled at 500units/hr until post-operative day two. On post-operative day two the catheter was removed, and the patient was started on Xarelto 15mg BID with a plan to transition to 20mg daily. The patient recovered well and was discharged on post-operative day three. He has since been seen in clinic and is recovering well with a patent graft.

Results: The etiology for this patient’s aneurysm is unknown, however could have been related to a genetic predisposition in combination with avid biking as there have been reports of such aneurysms in athletes. Given the rarity of these aneurysms, the true incidence of thromboembolism or rupture is unknown. However, given the large size of the aneurysm in this case, intervention was warranted given that rupture has been reported at smaller sizes.

Conclusions: There is a role for open repair of large iliac vein aneurysms using prosthetic interposition graft in combination with long-term anticoagulation.