In endovascular aneurysm repair cases, when should you consider internal iliac artery embolization when extending a stent into the external iliac artery?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether internal iliac artery (IIA) embolization is necessary for achieving the best clinical outcome in all patients when extension of the stent graft to the external iliac artery is required. Altogether more than 400 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a significant gap in the current literature regarding the subset of patients that may benefit from an IIA embolization during endovascular aneurysm repair (EVAR) as indications have not been clearly defined. There are several situations concerning a small number of patients, that IIA embolization might be beneficial in preventing endoleak not only to the common iliac artery but also to the aortic aneurysmal sac. For the majority of patients requiring extension of the stent graft to the external iliac artery, the current evidence, even retrospective in nature and reporting on small numbers of patients, shows that IIA embolization seems to be associated with worse clinical outcome, mostly raising the risk for new-onset buttock claudication. It seems that not all patients require embolization, as IIA coverage solely by the stent graft was not associated with a significant higher rate of type II endoleak in either study. Furthermore, coil embolization in the largest study so far was associated with higher procedure and fluoroscopy time and amount of contrast media, facts that should not be neglected. However the above-mentioned results should be taken into account with caution, as all studies were retrospective and reported on small number of patients.