Dealing with a large iliac aneurysm containing significant intraluminal thrombus presents unique challenges in open vascular surgery. The presence of thrombus heightens the risk of distal embolization during the procedure. Here is a structured approach to managing this situation, detailing important techniques to optimize patient outcomes and minimize complications.

Procedure Steps
- Dissect the Common Femoral Artery
Begin by isolating the common femoral artery on the side of the iliac aneurysm (i.e., the right femoral artery if the aneurysm is on the right side, or the left if on the left). If bilateral iliac aneurysms are present, dissect both femoral arteries. This step ensures reliable access for control and reduces the risk of complications during the procedure. - Abdominal Aorta Exposure
Open the abdomen and carefully expose the abdominal aorta. Refrain from manipulating the iliac artery to prevent dislodging thrombus and causing distal embolization. Focus on dissecting and isolating the abdominal aorta in preparation for clamping. - Administer Intravenous Heparin
Administer intravenous heparin to ensure anticoagulation, reducing the risk of thromboembolism during the procedure. - Clamp the Aorta and Femoral Arteries
Once the aorta and femoral arteries are exposed, clamp them to secure blood flow control. Avoid clamping the iliac arteries directly, as this might displace thrombus and increase the risk of thromboembolic events. - Open the Aorta and Iliac Aneurysm
Carefully open the aorta and iliac aneurysm. Expect backbleeding from the internal iliac artery, which helps flush out potential emboli and minimizes thromboembolic risks. - Thrombus Removal and Internal Iliac Control
Remove thrombus from within the aneurysm. To control backbleeding and manage the internal iliac artery, use a clamp or intraluminal occlusion (e.g., with a Fogarty or Foley catheter) to temporarily occlude its lumen. This step helps achieve a bloodless field and prevent any thromboembolism into the distal circulation. - Perform External Iliac Artery Embolectomy if Needed
Consider performing an embolectomy of the external iliac artery to clear any residual thrombus that may pose a risk to distal circulation.
Conclusion
Managing large iliac aneurysms with intraluminal thrombus is complex but achievable with precise and careful surgical techniques. Following this methodical approach—dissecting proximally, clamping effectively, and removing thrombus—helps safeguard the patient against thromboembolic events while ensuring optimal repair.