A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair

Purpose: Hypogastric artery embolization (HAE) is often performed in endovascular aortoiliac aneurysm repair to prevent potential endoleak, and this can be associated with pelvic ischemic sequelae. This prospective study was performed to evaluate the clinical outcome of HAE in patients who underwent endovascular aortoiliac aneurysm repair. Methods: During a 15-month period, 12 patients who underwent either unilateral or bilateral HAE for endovascular aortoiliac aneurysm repair were prospectively evaluated. All patients underwent preoperative and postoperative penile pressure measurement and pulse-volume recording evaluation. Angiographic features relating to pelvic collaterals and clinical outcomes relating to pelvic ischemia were evaluated. Results: Unilateral HAE was performed in eight patients (67%), and bilateral HAE was performed in four patients (33%). Mean reductions in penile brachial index (PBI) after unilateral and bilateral HAE were 13 ± 6% (not significant) and 39 ± 14% (P < .05), respectively. Erectile dysfunction occurred in three patients for unilateral HAE (38%) and in two patients for bilateral HAE (50%), with an overall PBI reduction of 36 ± 12% (P < .01). No significant change in thigh brachial or ankle brachial index occurred after HAE. Hip and buttock claudication occurred in four patients for unilateral HAE (50%) and in two patients for bilateral HAE (50%), with an overall PBI reduction of 18 ± 9% (P < .05). Other associated pelvic ischemic complications after bilateral HAE included one scrotal skin sloughing (25%) that occurred 3 days after aortic endografting and one sacral decubitus (25%) that occurred 4 months after aortic endografting. With analysis of angiographic collateral patterns, diseased profunda femoral artery (PFA; >50% stenosis) was noted in four patients, all in whom post-HAE pelvic ischemic symptoms developed (P < .05). In contrast, only four of the remaining eight patients with normal or mild PFA disease had pelvic ischemic sequelae after HAE. Conclusion: Erectile dysfunction after HAE correlates with significant reduction in PBI. Severe pelvic ischemic symptoms are more likely to occur after bilateral HAE, which should be avoided if possible. Moreover, patients with diseased PFA are at risk of development of pelvic ischemia after HAE. Our data suggest a potential role of concomitant profundapalsty at the time of aortic endografting to improve pelvic collateral flow and reduce pelvic ischemia in this subset of patients with HAE.