Embolization of Large Internal Iliac Artery Pseudoaneurysm through a Retrograde Trans-Superior Gluteal Arterial Access.

The presence of osteal stenosis/occlusion or osteal exclusion by prior interventions poses a challenge to selective catheterization of the internal iliac artery. We describe a case where a retrograde access through the superior gluteal artery (SGA) was used to successfully treat an internal iliac artery pseudoaneurysm (PSA) in a patient when an antegrade catheterization was not feasible due to internal iliac osteal exclusion by an endograft.

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.

Endovascular management of an isolated common iliac artery aneurysm: a case report.

Isolated iliac artery aneurysms are rare, and treatment by conventional surgery gives good results. Endovascular repair of such aneurysms has recently become the preferred form of treatment, provided the appropriate anatomy for endovascular repair exists. We report the case of a 60-year-old man admitted in our department for an aneurysm of the left primitive iliac artery revealed by intermittent claudication and treated by a covered stent after embolization of the hypogastric artery by an Amplatzer Vascular Plug with a good result. This case highlights the importance of preservation of the collaterals of the hypogastric artery when you treat such entity; in order to avoid transient gluteal claudication and sexual dysfunction.

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.

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.

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.

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.

A Meta-analysis of Comparative Outcome and Cost-Effectiveness of Internal Iliac Artery Embolization with Vascular Plug Versus Coil.

PURPOSE: To evaluate the comparative outcome and cost of vascular plugs versus coils for internal iliac artery embolization prior to endovascular aortic aneurysm repair. METHOD: A search was performed for internal iliac artery embolization studies in adult patients from January 2005 to July 2018. Inclusion criteria included embolization of unilateral or bilateral IIAs with either coils or plug(s) prior to endovascular aortic repair. Meta-analysis was performed using a fixed effects model with the inverse variance-weighted average method to determine pooled differences in surgical time, fluoroscopy time, radiation exposure, number of devices used, cost of devices, and post-embolization buttock claudication. Heterogeneity was assessed using the Chi-square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle-Ottawa scale. RESULT: Six studies met inclusion criteria. One hundred and eighty-one patients were included in the study, of which 87 were in the plug group and 94 in the coil group. Vascular plug use led to 35.32 min shorter surgery time (p < 0.001), 15.64 min less fluoroscopy time (p < 0.001), 157,599 mGy/cm2 less radiation (p < 0.001), and 5.88 fewer occlusive devices (p < 0.001) than the use of coils alone. The estimated total cost of occlusion devices was $575.45 USD lower in the plug cohort (p < 0.001). The development of buttock claudication 12 months after EVAR was 11% less likely in the plug cohort but was not statistically significant (p = 0.71). CONCLUSION: The vascular plug appears to be superior to coils in embolization of the internal iliac artery due to shorter surgical time, fluoroscopy time, radiation exposure, and total cost of occlusive devices.

Endovascular Treatment of Persistent Sciatic Artery Aneurysms With Primary Stenting: A Systematic Review of the Literature.

Persistent sciatic artery (PSA) is an embryologic remnant of the internal iliac artery, and when is present, it undergoes aneurysmal degeneration in up to 60% of the cases. Endovascular repair is an increasingly utilized treatment strategy for PSA aneurysms (PSAAs). The objective was to demonstrate the safety and efficacy of the endovascular repair in patients with PSAA and to identify potential risk factors for loss of patency or limb loss. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and eligible studies were identified through search of the PubMed, Scopus, and Cochrane Central databases. Fifteen case reports, comprising 15 patients overall, were included. The median age of the patients was 68 years old (mean age 66 ± 13.4 years) with half of the reported patients being women. Most patients presented with progressive limb claudication, complaining about an enlarging palpable pulsatile buttock mass. The onset of symptoms was sudden in 78% of the reported cases. Additionally, the distal pulses on PSAA side were diminished or absent in 91% of the patients. Acute limb ischemia was the primary diagnosis in 75% of the cases. All patients underwent endovascular repair of the PSAA with a covered stent. Procedural outcomes were favorable in all patients demonstrating no symptoms recurrence, aneurysmal regression, or total obliteration evaluated by angiographic studies (computed tomography angiography [CTA] and angiogram). Periprocedural imaging evaluation was determined either with CTA or duplex ultrasound (DUS). Periprocedural complications included only 1 endoleak with distal dissection. This endoleak was identified after stent deployment and dissection distal to the aneurysm. Mean follow-up (with CTA and/or DUS) was 22 months, with all patients being asymptomatic with no recurrence of symptom. The endovascular treatment of PSAA with covered stent is safe and effective. Persistent sciatic artery aneurysms is associated with high procedural success, low periprocedural compilations, and favorable mid-term follow-up.

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.

Onyx Embolization for Occlusion of the Proximal Internal Iliac Artery During EVAR in Patients with Unsuitable Landing Zones in the Common Iliac Artery.

BACKGROUND: Twenty percent of the patients with AAA have an aneurysm involving the common iliac arteries. Large common iliac diameter can be treated with an iliac branched device or extension of the stent graft to the external iliac artery with occlusion of the ipsilateral internal iliac artery (IIA) to prevent type 2 endoleaks. This study describes and evaluates a embolization technique using Onyx in conjunction with EVAR in aneurysms with poor landing zones in the common iliac arteries. METHODS: Patients with Onyx IIA embolization during EVAR, identified from the hospital operating code database, constitute the study population. Onyx embolization was performed by injection at the IIA origin. Peri- and postoperative complications were collected from the medical records. Thin-sliced CT scan was performed 1 month and 1 year after the procedure. RESULTS: Thirty-six patients with complex iliac anatomy and insufficient landing zones (without sealing possibility for standard stent grafts) were identified out of 243 consecutive EVAR treatments during a 13-year period. In seventeen patients (7%), the IIA was embolized with Onyx. Technical success was obtained in all 17 patients, without adverse event or procedural complication. No complication related to the embolization procedure was noted during follow-up. CONCLUSIONS: During EVAR treatment of patients with aneurysm involving the common iliac artery, Onyx embolization of IIA is a feasible option without need of selective catheterization of the IIA orifice, potentially preserving important branches of the IIA and simplifying emergency procedures.