Coiling versus preservation of internal iliac artery in EVAR of aortoiliac aneurysm.

Aortoiliac aneurysms, particularly those involving the common iliac artery, present a unique technical challenge during endovascular aneurysm repair (EVAR). As the disease often extends to the iliac bifurcation, the internal iliac artery (IIA) may require coverage or occlusion to achieve adequate sealing and fixation of endografts. The clinical decision between preserving or sacrificing the IIA has significant implications on postoperative morbidity, particularly with regard to pelvic ischemia. Internal iliac artery preservation techniques—including use of branched iliac stent-grafts, surgical bypass (such as external-to-internal iliac artery bypass), or use of the "bell-bottom" technique—aim to maintain perfusion to the pelvic organs, gluteal muscles, and spinal cord. These strategies have been associated with reduced risks of ischemic complications, including buttock claudication, erectile dysfunction, and colonic or spinal cord ischemia. However, they are technically demanding, require advanced devices and skills, and may not be feasible in all anatomical scenarios. On the other hand, internal iliac artery coiling or embolization is often used to prevent type II endoleak and to facilitate graft landing in the external iliac artery. While it is a more straightforward and accessible technique, unilateral or especially bilateral IIA embolization has been associated with a significantly increased incidence of pelvic ischemic complications. These may include buttock pain, impaired sexual function, and rare but severe outcomes such as colon ischemia or paraplegia.