Procedural Complexity and Clinical Outcomes of Contemporary Iliac Branch Device Implantation Versus Internal Iliac Artery Embolization During Endovascular Repair of Aotoiliac Artery Aneurysms

Purpose: We aimed to compare outcomes between contemporary iliac branch device (IBD) implantation, including adjunctive techniques such as the up-and-over approach, and internal iliac artery (IIA) embolization during endovascular aneurysm repair (EVAR) for aortoiliac artery aneurysms (AIAAs), and to assess whether the increased procedural complexity of modern IBD strategies is justified by their safety and functional outcomes. Materials and Methods: We retrospectively reviewed consecutive patients who underwent elective EVAR for AIAAs at a single institution between 2018 and 2024. Ninety-three patients were stratified based on a patient-tailored treatment strategy into Group A (IBD, n=40) and Group B (IIA embolization, n=53). In Group A, 11 patients (27.5%) were treated using the up-and-over technique. Procedural outcomes, limb-based pelvic ischemic symptoms, and midterm durability were compared between groups. Results: Technical success was achieved in all patients in both groups, including all patients treated using the up-and-over technique. No perioperative cardiovascular events occurred in either group. Postoperative acute kidney injury developed in 4 patients (7.5%) in Group B and none in Group A. Fluoroscopy time was significantly longer, and preemptive inferior mesenteric or lumbar artery embolization was more frequent, in Group A, whereas operative time and contrast volume were comparable between the groups. In the limb-based analysis, buttock claudication occurred in 13 of 72 limbs (18.1%) with interrupted IIA flow and in none of 105 limbs with preserved IIA flow (P<0.001). During a mean follow-up of 23.3 months, aneurysm-related mortality (2.5% vs. 3.8%) and type Ib endoleaks requiring reintervention (2.5% vs. 1.9%) occurred at similar rates in Groups A and B, respectively. No type Ic endoleaks or related reinterventions occurred in Group A. Conclusion: Contemporary IBD implantation was associated with acceptable procedural safety and midterm durability, even when complex adjunctive maneuvers such as the up-and-over approach were used. Preservation of IIA flow was associated with a lower incidence of buttock claudication than intentional IIA interruption.