Late Open Repair of a Massive Common Iliac Artery Aneurysm after Endovascular Failure.

Giant Common Iliac Artery Aneurysms (CIAA) are an uncommon pathology that may present as a late complication after endovascular aortic repair secondary to aneurysmal degeneration with endoleak. We present an unusual case of a patient presenting 9 years after index endovascular CIAA exclusion with a painless abdominal mass found to be a 20+ cm CIAA secondary to type II endoleak from a recanalized coil embolized hypogastric artery. The patient underwent open aneurysmorrhaphy with ligation of the hypogastric artery.

Hypogastric Artery-Colonic Fistula after Coil Embolization of Left Hypogastric Artery Aneurysm.

Coil migration into the colon is an extremely rare complication of aneurysm embolization and only three cases have been reported. Two of these cases were managed with resection of the involved colon and the remaining case was managed with serial imaging. We present a 70-year-old man who developed hematochezia 2 years after coil embolization of a ruptured left hypogastric artery aneurysm. The patient was successfully treated with diverting colostomy and endoscopic closure of the sigmoid colon defect. We present the only case report of the use of advanced endoscopy to treat endovascular coil migration.

The Viabahn balloon expandable stent for endovascular reconstruction of the infrarenal aorta and its bifurcation in cases of severe obstructive disease.

INTRODUCTION: The covered endovascular reconstruction of the aortic bifurcation (CERAB) represents a promising technique for the treatment obstructive lesions involving the aortic bifurcation. The aim of this report is to describe the use of a new generation balloon-expandable stent-graft (Viabahn VBX, W.L. Gore&Associates, AZ, USA), in the CERAB configuration for the treatment of aorto-iliac obstructive lesions involving the infrarenal aorta and bifurcation.Technical note: This technique was adopted in two patients with severe aorto-iliac obstructive lesions. After bilateral iliac recanalization, an 11 mm diameter VBX stent was deployed in the infrarenal aorta; a post-dilatation up to 16 mm with a non-compliant balloon was performed to adapt the proximal edge of the stent to the aortic diameter. Two 8 mm diameter VBX stents were then deployed at the aortic bifurcation in a kissing conformation, overlapping with the previously positioned aortic stent for 15 mm. A post-ballooning with two kissing 12 × 20 mm compliant balloons (Powerflex Pro PTA, Cordis, CA, USA) was performed to adapt the parallel stents to the aortic cuff. A post-operative angio-CT demonstrated optimal conformability of the aortic cuff to the aortic wall, and apposition of the kissing stents to the aortic cuff. CONCLUSIONS: This preliminary experience shows that the VBX stent may allow an effective reconstruction of the aortic bifurcation; the conformability and flaring capability may allow to overcome the diameter mismatch between the aorta and the iliac arteries.

Therapeutic management of isolated internal iliac artery aneurysms.

OBJECTIVE: Isolated internal iliac artery aneurysms (IIIAAs) are rare, life-threatening entities for which the optimal treatment strategy has not been established. This study aimed to evaluate the outcomes of open and endovascular treatment of IIIAAs. METHODS: IIIAA cases between January 2009 and March 2019 at two hospitals were retrospectively reviewed. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed. RESULTS: Forty-two patients (37 men and 5 women) with a mean age of 71 years were included. Twenty-five patients (60%) had a history of hypertension. Twenty-two patients (52%) were asymptomatic, and 16 (38%) presented with abdominal pain (12 with ruptured aneurysms). The 42 included patients had 43 treated IIIAAs. The following surgical techniques were used: surgical resection (n = 6), endovascular coil embolization (n = 12), endovascular stent graft placement across the internal iliac artery origin (n = 8 with 9 aneurysms), and combined coil embolization and stent graft placement (n = 16). The immediate technical success rate was 67%, 67%, and 88% for embolization, stent graft placement, and combined method, respectively. Open surgery was associated with the longest operative time and hospital stay. Overall 30-day mortality was 5% for all patients and 17% for patients with ruptured IIIAAs. Buttock claudication occurred in 7 of 40 patients who survived (18%). The median follow-up time was 56 months. The combined approach was associated with the lowest rates of endoleak (6% vs 25% and 29%) and reintervention (6% vs 17% and 29%) of the three endovascular methods. CONCLUSIONS: Endovascular coil embolization with stent graft placement is a feasible, safe, and effective treatment approach for large IIIAAs without adequate aneurysm necks.

Feasibility and Safety of Sac Embolization Using N-Butyl Cyanoacrylate in Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms or Isolated Iliac Artery Aneurysms.

PURPOSE: To evaluate the feasibility and safety of sac embolization with N-butyl cyanoacrylate (NBCA) in emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA) in comparison to EVAR without sac embolization. MATERIALS AND METHODS: Between February 2012 and December 2019, among 44 consecutive patients with ruptured AAA or IAA, 29 underwent EVAR. Of these, 22 patients (median age 77.5 years; 18 men) had concomitant sac embolization using NBCA; the remaining 7 patients (median age 88 years; 6 men) underwent EVAR without sac embolization and form the control group. The technical success, clinical success (hemodynamic stabilization), procedure-related complications, and mortality were compared between the groups. RESULTS: All EVAR procedures and embolizations were successful. The clinical success rates in the NBCA and control groups were 95% (21/22) and 71% (5/7), respectively (p=0.14). There was no complication related to the procedure. Type II endoleak occurred in 4 of 21 patients (19%) in the NBCA group vs none of the control patients. One patient (5%) died in the NBCA group vs 3 (43%) in the controls (p=0.034). CONCLUSION: Sac embolization using NBCA in emergency EVAR appears to be feasible and safe for ruptured AAA and IAA.

Coil-Covering Caliber-Conforming Stent Grafting: The 4CSG Technique.

Stable coil placement is an imperative when treating arterial pathology at branch points. Coil kick and escape threaten distal organs, particularly as the pack tightens. Before the development of the VBX balloon-expandable stent graft (W.L. Gore, Flagstaff, AZ), vessel caliber change often precluded straightforward stent graft coverage with a single device to secure coils in place. We describe 3 cases using this unique feature of the Gore VBX device to accommodate challenging anatomy. All 3 patients recovered well.

Percutaneous Access of an Expanding Internal Iliac Artery Aneurysm via a Direct Posterior Transgluteal Approach.

BACKGROUND: Internal iliac artery aneurysms (IIAAs) are rare, comprising 0.3% of all aortoiliac aneurysms. Endovascular management is associated with lower morbidity and mortality than open repair. We present a 91-year-old female with a rapidly expanding 8.2-cm IIAA who previously underwent incomplete endovascular treatment, using endovascular aneurysm repair, to exclude the right internal iliac artery (IIA). Transarterial access to the IIAA was not possible secondary to the iliac limb of the endograft over the origin of the IIA. We recommended that the patient undergo embolization and coiling of the IIAA via a direct percutaneous transgluteal approach. METHODS: With the patient in a prone position, under fluoroscopic guidance, a 10-cm long, 18-gauge needle was placed through the gluteus muscle into the right IIAA. Needle location was confirmed by angiography and a 6-French sheath was advanced into the aneurysm. Selective catheterization of the native aorta was accomplished around the occluded limb of the previously placed endograft. Aortography confirmed robust filling of 2 large lumbar arteries with brisk runoff through branches of the IIA. Coil embolization was used to treat both the lumbar arteries causing aortic endoleak, as well as the outflow branches of the IIAA. RESULTS: Completion angiography revealed static flow in the aorta and aneurysm, with minimal flow through the inflow and outflow tracts. At a 1-month follow-up appointment, repeat computed tomography angiography revealed resolution of the endoleak and no blood flow within the aneurysm. There have only been a few case reports utilizing alternative access to an IIAA. Although computed tomography and ultrasound-guided techniques have been described in the literature, a percutaneous, fluoroscopy-guided, transgluteal approach to access the IIAA is a new and unique approach. CONCLUSIONS: In patients who are not candidates for open or standard endovascular repair with a large, inaccessible IIAA, a transgluteal approach to directly access the aneurysm sac may offer a less invasive and successful management strategy.

Percutaneous Embolization of a Saccular Omental Artery Aneurysm.

Omental artery aneurysms are a unique subset of splanchnic artery aneurysms that are associated with intraperitoneal hemorrhage and high mortality rates. Detecting omental artery aneurysms prior to rupture is especially challenging; as such there are limited data surrounding unruptured aneurysms. Various methods of treating ruptured omental artery aneurysms have been previously described including omentectomy and transcatheter arterial embolization. Because of the mortality rate associated with ruptures, elective intervention in unruptured splanchnic artery aneurysms is recommended regardless of their size. This report details the successful embolization of an unruptured omental artery aneurysm utilizing a percutaneous approach.

Streptococcus pneumoniae as a Cause of Mycotic and Infected Aneurysms in Patients without Respiratory Features: Challenging Diagnoses Aided by 16S PCR.

BACKGROUND: Streptococcus pneumoniae is considered a rare cause of mycotic aneurysms. The microbiological diagnosis of mycotic aneurysms can be difficult, and many patients have negative blood culture results. METHODS: We describe a series of four consecutive cases of mycotic aneurysms caused by S. pneumoniae with no respiratory features or extravascular septic foci. In two patients with negative blood culture results, 16S PCR was used for the diagnosis of S. pneumoniae infection. RESULTS: Four men with mycotic aneurysms affecting the aorta, axillary, and popliteal arteries caused by S. pneumoniae presented to our center between 2015 and 2016. All were treated with at least one month of intravenous antibiotics, followed by at least 4 weeks of oral antibiotics. Two were additionally managed using endovascular surgical techniques, and one underwent an open surgical repair. The fourth patient presented with bilateral popliteal aneurysms, one of which ruptured and was managed using surgical ligation and bypass, whereas the other side subsequently ruptured and was repaired endovascularly. Three of the four patients are currently off antibiotics and considered cured, while one died of an unrelated cause. CONCLUSIONS: S. pneumoniae should be considered a potential causative agent of mycotic aneurysms. Diagnosis can be confirmed using 16S PCR, especially in patients where peripheral blood cultures are uninformative.

Overstenting the hypogastric artery during endovascular aneurysm repair with and without prior coil embolization: A comparative analysis from the ENGAGE Registry.

BACKGROUND: Endovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. METHODS: Data from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization-coils or plugs-was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. RESULTS: In 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P = .464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P = .346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P = .080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P = .057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P = .225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. CONCLUSIONS: This study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required.

Psoas abscess after bacille Calmette-Guérin instillations causing iliac artery contained rupture.

Intravesical administration of bacille Calmette-Guérin (BCG) is considered to be the therapy of choice for treating superficial bladder carcinoma. Created from a live attenuated strain of Mycobacterium bovis, BCG is theoretically unable to cause infections. However, both local and systemic complications due to infection are known to arise, including vascular complications. We describe the case of a patient with a history of BCG instillations presenting with an arterial rupture of his left iliac artery due to an abscess in the iliopsoas muscle.

Isolated Spontaneous Dissection of the Iliac Arteries: False Lumen Embolization as an Adjunct to Percutaneous Stent Grafting.

BACKGROUND: Spontaneous dissection of iliac arteries, without involvement of the aorta, is rare. Only few cases of endovascular treatment of this condition are reported in the current literature. METHODS: We report false lumen embolization strategy as an adjunct to stent grafting of the true lumen. RESULTS: A 68-year-old male patient was admitted to our institution with the incidental finding of an isolated iliac dissection with a false lumen aneurysm. He was electively treated with successful segmental iliac stent grafting to cover the primary entry tear in the common iliac artery. Coil embolization of the false lumen was chosen to provide distal seal of the false lumen aneurysm. CONCLUSIONS: As in the treatment of aortic dissections, also in the iliac arteries, false lumen thrombosis should be targeted. To our knowledge, this is the first case of false lumen embolization of an isolated iliac dissection reported in literature. The technique we report was effective and could be easily reproduced.

Multilevel Mycotic Aneurysms Due to Salmonella Infection: Case Report and Review of the Literature.

Infected or mycotic aneurysms (MAs) of the aorta and adjacent arteries are rare and difficult to treat. We report a unique case of a Salmonella serotype enteritidis-induced rapidly expanding aortic and iliac pseudoaneurysm during preoperative workup. Based on the presented case, we postulate that the agressive nature of Salmonella enteritidis MAs should not be underestimated. If postponed intervention is chosen and the patient is managed conservatively with antibiotic therapy to create a window of definitive diagnosis, one should consider close follow-up imaging to observe progression of the pseudoaneurysm. This may prevent the need of acute intervention.

Effectiveness of the conservative therapy for spontaneous isolated iliac artery dissection: Preliminary results.

Purpose To investigate the effectiveness of conservative therapy for spontaneous isolated iliac artery dissection (SIIAD). Methods From February 2006 to May 2016, all patients with SIIAD were included and analyzed. The diagnosis of SIIAD was made based on contrast-enhanced computed tomography. The imaging morphologic characteristics, treatments, and outcomes for each patient were analyzed. Results A total of 11 patients (10 male and 1 female, age 71.1 ± 7.8 years) were included in this study. Of the 11 patients, 8 patients were asymptomatic and the SIIADs were discovered during the course of computed tomography for other diseases, and 3 patients were symptomatic. Initial computed tomography findings: iliac arterial calcification ( n = 7); compression of the true lumen ( n = 6), with stenosis of the true lumen from 25% to 50% ( n = 3) and ≥ 50% ( n = 3); thrombosed false lumen partially ( n = 4), and no thrombosis in false lumen ( n = 7); dissecting aneurysm ( n = 11); entry points ( n = 11); re-entry points ( n = 1); no dissection extended to the internal iliac or common femoral artery. Conservative treatment was performed in six patients, and the remaining five patients need no treatment. During 23.3 ± 14.2 months follow-up, none recurred symptoms and signs of symptomatic SIIAD; partial remodeling of SIIAD was achieved in four patients, and the remaining seven patients with no change of SIIAD. There was no presence of new false lumen enhancement on contrast-enhanced computed tomography during follow-up. Conclusions SIIAD without arterial rupture or lower limb necrosis can be safely treated with conservative therapy.

Giant Ruptured Common Iliac Artery Infected Aneurysm.

INTRODUCTION: Saccular mycotic aorto-iliac aneurysms are extremely rare and when presented with ruptured, they are an important life- threatening condition. METHODS: We present a 52 years old male transferred from another Hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. RESULTS: He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Imagiological study with angioCT revealed a ruptured left common iliac artery saccular aneurysm with 90mm. The patient was instantaneously and successfully submitted to endoaneurismorraphy, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femoro-femoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. CONCLUSION: Long term antibiotics along with aggressive surgical debridement of the infected tissue and vascular revascularization with an extra anatomic bypass remain the most definitive solution while endovascular aneurysm repair may generally constitute a bridge life-saving procedure in mycotic infected aneurysms. Even though surgical approach carries a relative risk of perioperative morbidity it is a feasible and durable solution for extreme situations like the one here described.

Endovascular Aneurysm Repair Treatment of Aortoiliac Aneurysms: Can Iliac Branched Devices Prevent Gluteal Claudication?

PURPOSE: To compare the risk of gluteal claudication after endovascular aneurysm repair (EVAR) of aortoiliac aneurysms by interventional exclusion of the internal iliac artery (IIA) with plugs or coils versus a branch iliac device to maintain pelvic blood supply and to identify risk factors for postoperative gluteal claudication. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected data set included patients with aortoiliac aneurysms treated with EVAR from January 2007 to December 2013 at a tertiary referral vascular unit. Descriptive and procedural data were obtained from a database of prospectively enrolled patients. Medical records of 112 consecutive patients treated with EVAR were scrutinized for graft-related adverse events and pelvic ischemia. The occurrence of gluteal claudication was determined from medical records. RESULTS: Iliac occlusion was performed in 115 limbs, and a branch iliac device was placed in 25 limbs. Gluteal claudication developed in 38% of limbs treated with IIA exclusion but in none of the limbs treated with branch iliac devices (P < .001). Procedure time, fluoroscopy time, and use of iodine contrast material did not differ between the two groups. The incidence of gluteal claudication was higher when coils rather than plugs were used for embolization of the IIA before EVAR (P = .002). CONCLUSIONS: The findings suggest that the use of a branch iliac device significantly reduces the risk of gluteal claudication after EVAR of aortoiliac aneurysm.

Emergency Embolization of a Ruptured Aneurysm of the Internal Iliac Artery by Direct Ultrasound-Guided Puncture: Report of a Case.

We report the emergency embolization of a ruptured aneurysm of the internal iliac artery in a patient at high surgical risk. Admission computed tomography scan showed that the ostium of the aneurysmal internal iliac artery was covered by a covered stent. In this patient, we chose to carry out an embolization of the aneurysm and its efferent arteries by direct puncture of the aneurysmal sac using an antero-external abdominal approach under ultrasound guidance. Short-term results were favorable and we consider that this technique is one of the therapeutic options to discuss in such situation.