We prospectively enrolled all men patients admitted to our Department of Vascular Surgery to undergo elective EVAR from September 2021 to November 2021.

Indication to EVAR was AAA diameter of >5.5 cm in man and >5 cm in woman, or if the aneurysm was rapidly increasing (>0.5 cm in 6 months or >1cm in 12 months). All patients treated in an urgent or emergent setting and all patients treated for other conditions than AAA (such as dissection and iliac aneurysm) were excluded. Patients evaluated for EVAR with a CT without contrast were also excluded from the enrollment.

Patients' demographics were prospectively compiled in a dedicated database with preset variables. Hypertension, CAD, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), renal disease (chronic renal insufficiency defined by serum creatinine level >1.2 mg/dl), smoking history (any current or past regular use of tobacco), congestive heart failure (CHF), history of cerebrovascular events (stroke and/or transient ischemic attacks), history of cancer (any current or past incidence if malignancy), atrial fibrillation (AF), and dyslipidemia were taken in account as comorbidities.

Drugs assumption was also evaluated, with a major attention relatively to their eventual impact on sexual function.

The study followed the Declaration of Helsinki on medical protocol. Patient informed consent for data collection was obtained, and the local institutional review board was informed of the descriptive, non-experimental nature of the study.

At the time of the admission, the International Index of Erectile Function-5 (IIEF-5) (6, 7) was submitted to all patients. The questionnaire is made by five questions; each IIEF-5 item is scored on a five-point ordinal scale where lower values represent poorer sexual function. Thus, a response of 0 for a question was considered the least functional, whereas a response of five was considered the most functional. The possible scores for the IIEF-5 range from 5–25 (one question has scores of 1–5), and a score above 22 was considered as normal erectile function, and at or below this cutoff was considered as ED. According to this scale, ED is classified into four categories based on IIEF-5 scores: severe (5–7), moderate (8–11), mild-to-moderate (12–16), mild (17–21), and no ED (22–25). Table 1 reports the IIEF-5 questions and answers. Trained physicians interviewed each of the men in an individual room with a total guarantee of confidentiality.

Moreover, we investigated whether the patient had ever discussed about sexual issue with their healthcare provider or with any other medical specialists.

Preoperative imaging was routinely performed with an angio-CT (GE Healthcare, discovery 750 hd) scan of the abdominal aorta and iliac district of 1.25 mm slice thickness.

The CT exam was performed using a standardized protocol (recin int 0.625, 140 kvp, automated modulated mA 250–650, breath hold, contrast medium infusion of 4 m/s via an antecubital vein 18 g access).

According to reporting standards, the evaluation of anatomic and morphologic characteristics was performed in order to plan the EVAR procedure (8).

Two operators independently reviewed the pelvic arterial tree of all patients without having information about IIEF-5 responses. A post-processing images analysis such as 3-D volume rendering, center-lumen line, and multi-planar reconstruction was performed in order to have a precise view of the hypogastric artery divisions (Figures 1A–C). Stenosis was evaluated using both CT images to have a morphological preliminary view and CT-Angio images using dedicated post-processing software in order to have the most correct arterial view and flow impairment. Stenosis percentages were calculated dividing residual lumen vs. native artery diameter (outer/outer layer).

An innovative score of pelvic arterial disease associated to AAA was defined. For this purpose, the iliac district was analyzed and divided it in four zones: (1) the inflow zone that corresponds to common iliac artery; (2) hypogastric zone I that includes the trunk of the hypogastric artery till its bifurcation in anterior and posterior division; (3) hypogastric zone II that includes the anterior division till the origin of the internal pudendal artery; (4) hypogastric zone III, the more distal, that includes the whole internal pudenda artery. The steno-occlusive disease was staged in four different groups: complete patency, <50, 50–79, and >80% stenosis. A score, ranging from 0 to 3 was associated to each lesion, where 0 was complete patency and 3 was >80% stenosis. The disease was considered diffuse if two or more zones had a score ≥1 per side.

The evaluation was repeated for both right and left arterial district. The outlined score ranges from 0 to 24 points. A dedicated “MAPPING AND SCORING SHEET” was designed in order to simplify the analysis (Figure 2).

According to this score, pelvic arterial tree disease is classified into 3 categories: severe (>12), moderate (4–11), and no significant disease (<3).

Arterial pelvic tree anatomy was also studied in order to detect anatomical variations according to Yamaki classification for both right and left hypogastric arteries (Groups A–D) (9).

Inter- and intra-observer variability was determined in all 25 CT scans.

Continuous data were shown as mean values ± SD. Categorical variables were expressed as fractions. Analysis of variance was used for independent tests to compare groups on continuous variables after demonstrating a normal distribution of the data.

IIEF-5 answers were graphically highlighted using a radar graph reporting the percentage of patients' answers (for the first question: very low, low, moderate, high, and very high; for questions no 2-3-5: almost/never/never, a few times, sometimes, most times, almost always/always; and for question no 4: extremely difficult, very difficult, difficult, slightly difficult, and not difficult).

Inter- and intra-observer variability was assessed using the Cohen's kappa test of concordance. A k value of 0.61–0.80 and 0.81–1.0 indicated good agreement and excellent agreement, respectively.

Correlation coefficients providing information about the strength and direction of a relationship between two continuous variables was calculated by the Pearson linear regression analysis. All statistical analyses were performed with GraphPad Prism 9.0 (GraphPad Software Inc., San Diego, Calif) and StatPlus Build 7.1.1 (AnalysisSoft Inc., Walnut, Calif).

A total of 31 patients underwent EVAR during the period study. Six of them were excluded to lack of Angio CT (3/6) and the rest due to the lack of consent. Median age was 74 ± 5.3 years. Baseline population characteristics were listed in Table 2. Particular attentions were dedicated to pharmacological anamnesis. In 3 cases both beta- and alpha blockers were used, in only two cases antidepressant therapy was chronically used. None of these patients have the history of prostatic interventions. AAA maximum diameter was 56 ± 6.3 mm. All patients underwent EVAR in elective setting using dedicated endografts.

Only 2 patients (8%) declared to have discussed sexual issues with a physician in the past.

All patients completed the IIEF-5 questionnaire. IIEF-5 average score was 14.8 ± 7.1. Eight cases (32%) had severe ED (IIEF-5 score 5–7); one case (4%) had moderate ED (IIEF-5 score 8–11); 4 patients (16%) had mild-to-moderate ED (IIEF-5 score 12–16); 6 patients (24%) had mild ED (IIEF-5 score 17–21), and only 6 (24%) patients had no ED (score > 22). Detailed outcomes were highlighted in Figure 3.

Before starting the population analysis, two operators (GdD and EP) trained with 10 CT angiography evaluations of previous patients not included in this study, in order to identify the pelvic tree vascularization patterns.

Then, all CT angiography exams were independently reviewed by the two operators without knowing the IIEF-5 score of each patient enrolled.

The inter-observer variability was very good for the identification of the pelvic steno-occlusive disease at any of the 4 zones: overall evaluation k = 0.9; zone I k = 0.99; zone II k = 092; zone III k = 0.85; and zone 4 k = 0.91.

The intra-observer agreement, evaluated by asking each observer to assess the images twice with a 7-day interval, was excellent (k = 0.95).

Meantime to fill a single patient sheet was 9 ± 3 min.

Table 3 summarizes the “MAPPING AND SCORING SHEET” detailed results.

According to our innovative score of pelvic arterial disease, the average score was 7.9 ± 4.5.

Pelvic disease was considered severe-moderate in 20 cases (80%) and not significant in 20% (5 cases).

The most pathological segment appeared to be zone II (mean score 1.52), the inflow zone corresponding to common iliac artery was the lesser pathologic (mean score 0.18). Figure 4 shows an example of significant pelvic arterial disease.

The steno-occlusive disease was localized in 16% (8/50) and diffuse in 80% (40/50). In one patient both left and right iliac district was not characterized by atherosclerotic disease.

Anatomical study of the internal iliac artery district according to the Yamaki classification revealed that most hypogastric branching types were Group A (34/50, 68%), followed by Group B (9/50, 18%), and Group C (7/50, 14%).

The IIEF-5 score and the anatomical score were analyzed to estimate any correlation between the severity of the anatomic disease and the severity of ED.

The data were examined using linear regression analysis (Figure 5). The analysis confirmed the hypothesis that a more diseased pelvic arterial tree was correlated to a more severe ED. The linear regression line was defined by the equation “Y = −1.350^* × + 25.59” (slope CI: −1.7 to −1.0, p < 0.0001).

The main limitation of our investigation was the small patient population, not allowing for adjustment for possible confounders such as age, diabetes mellitus, medication, active smoking, and psychiatric disorders. A clear limitation is when only patient self-reporting data are taken into consideration in the absence of objective measures. Although we recognize that our analyses are only partially based on patient self-reporting data, anatomical data from angio-CT provided objective measures of vascular anatomy and penile blood flow, potential surrogate variables for sexual performance. Still ED may be classified as psychological, organic (vasculogenic, neurogenic, or endocrinologic), or drug-induced, and our investigation was not designed to evaluate the risk factors in the AAA population. So, we recognize that some biases may have influenced our results and analyses.