common iliac artery aneurysm ( cia ) often occurs in conjunction with an abdominal aortic aneurysm ( aaa ) , which extends into one or both of the cias in 20% to 30% of patients . currently , the standard endovascular treatment includes coil embolization of the internal iliac artery ( iia ) , followed by extension of the main bifurcated aaa stent - graft into the external iliac artery ( eia ) , which does not allow preservation of the iia . several reports indicated that complications from intentional occlusion of unilateral or bilateral iias are frequent in the setting of endovascular aortic repair ( evar ) , such as buttock claudication , erectile dysfunction , bowel ischemia , sloughing of the scrotal skin or ischemic injury to the lumbosacral plexus . use of a branched iliac stent - graft is an appealing option , and preliminary data seem promising . however , few cases are reported of bilateral branched graft - stent implantation in iliac artery aneurysms . here we report a case of concomitant bilateral iliac artery aneurysm and aaa treated successfully with branched stent - grafts . a 65-year - old man was admitted for iliac artery aneurysm , detected during coronary angiogram via femoral artery in another hospital . his electrocardiography and echocardiography were within normal range . computed tomographic scan showed significant aneurismal dilatation of both iliac arteries and abdominal aorta ( fig . the size of right and left cia was 3.7 mm  40 mm , 3.7 mm  41 mm in maximal diameter and length , respectively . left and right iia was 36 mm , 15 mm in maximal diameter , respectively . size of aaa was 37 mm but in risk of further dilatation of the aaa and the difficulty of evar after both iliac artery graft stenting , we decided to perform branched iliac bifurcated stenting and evar simultaneously . initially , a custom - made 15-fr delivery right internal iliac branched device ( iibd , seal bifurcated stent graft , s&g biotech , seoul , korea ) was introduced in right femoral artery and oriented under fluoroscopic guidance with the aid of the gold markers . the delivery sheath was withdrawn , and a 0.035-inch guidewire was reintroduced through the branched limb under fluoroscopic guidance from the contralateral femoral artery . after exchange for a stiff guidewire , an 8-fr internal iliac stent - graft ( iisg , seal branched limb extension , s&g biotech , seoul , korea ) was placed in the iia to extend the iibd into proximal iia . the custom - made left iibd was then placed from the ipsilateral femoral artery and iisg from the contralateral femoral artery same as above . the final aortogram showed abdominal and both iliac aneurysms were successfully sealed without any endoleak ( fig . procedure time was 325 minutes and dose of contrast dye was 160 g. the patient was discharged without complications . follow - up computed tomography after 1 month showed patent stent but did not showed right renal artery . however , the patient did not express any discomfort and level of creatinine did not change ( fig . the distal extension of aneurismal disease to iliac branches of the aorta increases the complexity of evar and its consequent morbidity and mortality . unilateral aortoiliac aneurysms are present in 43% , and bilateral cia aneurysms in 11% of patients with intact aaa . in such cases evar requires distal extension of the aortoiliac endograft beyond the ostium of the iia and into the eia , conventionally necessitating the embolization of one or both internal iliac arteries . unilateral iia occlusion could be associated with a risk of complications similar to bilateral iia occlusion , which hypothesizes the use of bilateral iibds . many techniques described for preservation of iia include relocation of the iia origin , iia bypass , bell - bottom grafts , and external - to - internal iliac stent graft with femoro - femoral cross - over . in comparison to these more invasive techniques , the use of internal iliac branch - graft devices offers an appealing endovascular solution . the iibds are recently developed devices that offer the possibility of preserving unilateral flow to the iia during evar in patients with aortoiliac aneurysm . however , complexity of these procedures resulted in prolonged procedural times and increased blood loss in some patients . furthermore , side branches are unlikely to confer significant device fixation and resistance to migration ; therefore , a secure proximal fixation system is of utmost importance . in previous study , suggestive criteria include the presence of aneurismal cia of diameter > 24 mm , the presence of a patent cia lumen of diameter > 18 to 20 mm , an adequate length of eia for distal landing of > 15 to 20 mm , and sufficient length of iia of > 10 mm   to secure the branch device . finally , iia must be up to 11 mm   to receive the iliac branched device ( ibd ) . previous reports showed that the rate of technical success varied between 85% and 100% for modern ibds in current use [ 2,6 - 10 ] . the technical success rate has been shown to improve with time , secondary to the learning curve with ibd deployment and the development of second - generation modular ibds . occluded ibds did not cause aneurysm rupture or sac expansion . in patients whose postoperative ibd occlusion followed initial technical success , 50% manifested symptomatic buttock claudication . factors associated with technical difficulty predisposing to ibd occlusion include a sharp aortic bifurcation , iliac tortuosity or calcification , the presence of intraluminal cia thrombi , severe eia kinking , stenosis of the iia ostium , iia atherosclerosis or iia aneurysm . the type i endoleak occurred at the distal sealing zone of the ibd and was managed with additional stent - graft . type iii endoleak occurred at the junction of the iia limb of the ibd with its main body , which also managed with an interposition of endovascular stent graft . especially , operating time was 101 to 290 minutes , contrast dose was 58 to 108 g in previous studies . we took more time and contrast dye compared to previous reports because this is the first experience of bilateral iibd in korea . the previous report also showed that operating time and contrast dose are different for unilateral or bilateral iibds . however , data are limited , and long - term data such as endoleak incidence , sac size changes , and the potential effect of morphologic change should be further investigated . moreover , patient - tailored graft - stent could be another obstacle to be solved . in conclusion , iibd procedures may be performed with relatively safety . branched devices preserving internal iliac flow do not markedly complicate endograft planning . however , it remains critical to conduct further investigations to evaluate long - term safety and efficacy .
common iliac artery aneurysm ( cia ) often occurs in conjunction with an abdominal aortic aneurysm ( aaa ) , which extends into one or both cias in 20% to 30% of patients . 
 conventional endovascular treatment includes coil embolization of the internal iliac artery ( iia ) , followed by extension of the main bifurcated aaa stent - graft into the external iliac artery . 
 however , complications from intentional occlusion of unilateral or bilateral iias are frequent and sometimes serious . 
 several methods try to preserve the unilateral or bilateral iia . here 
 we report a case of concomitant bilateral cia and aaa successfully treated with bilateral branched iliac stent - grafts .