Isolated common iliac artery aneurysm with specific anatomical considerations

INTRODUCTION

Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general population involving typically the common iliac artery in 70-90%.

CASE-REPORT

This is the clinical case of an 88 years-old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass.

DISCUSSION

Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

ISOLATED COMMON ILIAC ARTERY ANEURYSM WITH SPECIFIC ANATOMICAL CONSIDERATIONS

INTRODUCTION

Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general popula- tion involving typically the common iliac artery in 70-90%. Literature describes that bilateral common IAA may be present in approximately 50% of the affected patients.

CASE-REPORT

The authors present an 88 years old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an Aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass.

DISCUSSION

Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

Endovascular repair of an ilio-iliac arteriovenous fistula following rupture of common iliac artery aneurysm with an aortic extension cuff in common iliac vein: A case report

RATIONALE

Common iliac artery aneurysm (CIAA) is complicated by ilio-iliac arteriovenous fistulas (IIAVF), which is rare but fatal and require prompt diagnosis and appropriate treatment. As open repair is associated with high morbidity and mortality, endovascular therapy is considered appropriate for treating an IIAVF.

PATIENT CONCERNS

A 76-year-old male patient who developed an IIAVF as a complication of ruptured CIAA, requiring immediate surgical repair presented to the hospital with hemodynamic instability.

DIAGNOSIS

Computed tomography angiography and conventional angiography revealed an IIAVF.

INTERVENTION

Endovascular therapy was selected to reduce the risk of morbidity and mortality. As the angiogram after the first endovascular aneurysm repair with stent-grafting showed contrast medium filling in the aneurysm sac, right common iliac vein, and the inferior vena cava, an aortic extension cuff was inserted into the right common iliac vein to close the orifice on the venous side.

OUTCOMES

The right lower leg edema and discomfort were resolved immediately after the procedure, with the vital signs remaining stable. Computed tomography performed 6 months postoperatively showed patent stent-grafts of the artery and vein, with no evidence of IIAVF and endoleak.

LESSONS

IIAVF following CIAA rupture can be repaired successfully by stenting of the common iliac vein with an aortic extension cuff. For successful endovascular repair, the vein side of the fistula tract should be excluded with a stent-graft to block the backflow into the aneurysm sac.

Epithelioid Angiosarcoma after EVAR. A Case Report

INTRODUCTION

Endovascular aneurysm repair (EVAR) has become a standard in the treatment of aneurysms. However, complications still occur. Endoleaks are the most common. Graft infection diagnosis might be challenging. Even uncommon, we describe a case of epithelioid angiosarcoma after EVAR.

CASE REPORT

A 64-year-old male came to our emergency department with left lumbar and left thigh flexion pain, increasing since a month. Four years before, he had been treated for a left common iliac artery aneurysm extending to the aortic bifurcation by EVAR with a bifurcated unibody aortic (AFX Endologix) endograft. The year before the admission, he was treated twice by percutaneous angioplasty for a symptomatic mural thrombus of the left endograft limb. On admission, CT angiogram showed a recurrence of the aneurysm associated with elevated lab inflammatory markers. FDG-PET-CT showed an abnormal tracer uptake in the endograft limbs and in the left inguinal area. White blood cell scintigraphy did not show any sign of endograft infection. CT angiogram performed 2 months later showed an additional increase of the infrarenal aortic and left common iliac aneurysms. We removed the endograft. Histological analysis showed an epithelioid angiosarcoma. Patient died a few weeks later during chemotherapy.

CONCLUSION

For patients that have undergone EVAR and have subsequently developed morphological changes of the aortic wall and aneurysmal sac, an aortic tumor should be considered. Imaging diagnosis was challenging for this rare case of epithelioid angiosarcoma.

SURGICAL TREATMENT OF A SPONTANEOUS RUPTURE OF A MYCOTIC ANEURYSM

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral 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. 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.

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.

Solitary Iliac Branch Endoprosthesis placement for iliac aneurysms

INTRODUCTION

Isolated iliac artery aneurysms (IAA), accounting for 2-7 percent of all abdominal aneurysms, are nowadays often treated with the use of iliac branched endografts. Although outside of the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an EVAR device, for the treatment of isolated IAA. In this study we aim to describe the outcomes of the use of the Gore IBE device, without support of an infrarenal EVAR device, for the exclusion of isolated IAA.

DESIGN

This study is an international multicenter retrospective cohort analysis.

METHOD

All patients that were treated with a solitary IBE for IAA exclusion from 11-01-2013 up to 31-12-2018 were retrospectively reviewed. The primary outcome was technical success. Secondary outcomes included mortality, intraoperative and postoperative complications, and re-interventions.

RESULTS

In total 18 European and American centers participated, including 51 patients in which 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. There was no 30-day mortality and a 98.1% patency of both the internal and external iliac artery was found at 24-months follow-up. At 24-months follow-up, 81.5% of patients were free of complications and 90% were free of a secondary intervention.

CONCLUSION

Treatment with a solitary IBE is a safe and, at midterm, effective treatment strategy in selected patients with a solitary IAA.

Hematuria in a 3-month-old filly with an internal umbilical abscess and internal iliac artery aneurysm

A 3-month-old foal with a history of acute hematuria was evaluated. Hydronephrosis and hydroureter were visualized upon renal ultrasonography of the left kidney. Cystoscopy identified a blood clot occluding the left ureter. Computed tomography (CT) revealed a large retroperitoneal abscess at the level of the aortic bifurcation and a left internal iliac aneurysm. Due to the severity of the lesions and the poor prognosis, the filly was euthanized and the clinical findings were confirmed by post-mortem examination. This report emphasizes the value of obtaining a precise diagnosis via CT in order to avoid unviable treatment approaches when confronted with this unusual secondary complication of omphaloarteritis. Key clinical message: Umbilical complications are routinely diagnosed in equine neonatal medicine, and commonly lead to septicemia, physitis, and septic arthritis; severe internal umbilical abscessation, and subsequent vascular and urinary disorders are uncommon sequelae.

Cross-over Deployment of a Tapered Stent Graft to Repair a Ruptured Isolated Internal Iliac Aneurysm

We report the case of a 72-year-old man who presented with a left ruptured internal iliac aneurysm (IIA). A percutaneous cross-over approach was used to coil-embolize the 3 distal branches of the IIA. A tapered endograft limb was then delivered via the right common femoral artery using a femorofemoral through-and-through cross-over approach. The widest part of the graft was deployed in the common iliac artery and the smallest in the external iliac artery. This percutaneous endovascular technique opens up new perspectives in emergency care for ruptured internal iliac artery aneurysms.

[Endoprosthetic repair of iliac artery aneurysm with a branch of the Anaconda stent graft]

An iliac artery aneurysm is characterized by arterial lumen dilatation which is more than 1.5 times greater than the normal diameter of the artery. In clinical practice, this pathology is rarely encountered, being associated with arterial hypertension and smoking, and more often observed in men. Its natural course inevitably leads to aneurysmal rupture. Treatment is only operative. Is admissible to use both open and endovascular techniques, with preference given to endovascular interventions using special linear endografts. Presented herein are two clinical case reports concerning endoprosthetic repair of an iliac artery aneurysm with a branch of the bifurcated stent graft Terumo Aortic Anaconda. The operative interventions had no complications in either peri- or postoperative periods. Our experience shows that endoprosthetic repair of an isolated aneurysm of the common iliac artery with a branch of the bifurcated stent graft Terumo Aortic Anaconda combines safety and efficacy and may be used by a wide range of vascular and roentgenoendovascular surgeons.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES

This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients.

METHODS

This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping.

RESULTS

From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter.

CONCLUSIONS

The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Coexistence of isolated internal iliac artery aneurysm with uterine cervical carcinoma

Isolated internal iliac artery aneurysms are rarely described in the available literature. The paper presents a case of a 70-year-old female with idiopathic thrombocytopenia, squamous cell cervical carcinoma, and saccular aneurysm of the left internal iliac artery, detected in magnetic resonance. The review of aneurysm of the common, external and internal iliac arteries is added.

Progressing left-side sciatica revealing a common iliac artery mycotic aneurysm in an elderly patient: A CARE-compliant case report

RATIONALE

Sciatica is usually caused by lumbar spine disease; the incidence of sciatica from extra-spinal causes is noted to be only about 0.09%.

PATIENT CONCERNS

We report a case of a 92-year-old man who came to the neurologist outpatient department due to left buttock pain and numbness that radiated to the left lower leg in the recent 6 months and progressed rapidly over 10 days.

DIAGNOSIS

We arranged magnetic resonance imaging for lumbar nerve lesion. Magnetic resonance imaging showed a common iliac artery mycotic aneurysm, at about 6.3 cm in diameter, which compressed the psoas muscle, nerve plexus, and vein.

INTERVENTIONS

We used a left-side iliac bifurcation stent graft of 12 mm in diameter for aneurysm repair. An internal iliac artery with a stent graft of 10 mm x 5 cm. An abdomen aortic aneurysm stent was inserted, 1 cm beneath the right renal artery from the right side femoral artery.

OUTCOMES

After endovascular repair and 4 weeks of antibiotic treatment, he could walk again, and no sciatica was noted. We repeated computed tomography 5 months after the operation and noted that the size of the iliac artery aneurysm decreased without stent graft migration or extravasation. Our patient recovered from sciatic and left leg weakness; above all, he could walk again.

LESSONS

We suggest practitioners check for common iliac artery aneurysms in the diagnosis of symptoms mimicking spinal cord origin sciatica, especially in elder patients.

Iliac Arteries Dissection with a Rapid Dilatation as Debut of Fibromuscular Dysplasia

We report a case of a 38-year-old male diagnosed with fibromuscular dysplasia (FMD) and a dissection of both common iliac arteries without aortic involvement. It was revealed after an inguinal hematoma and a pelvic pain, which are not the typical FMD presentation. Surgical treatment was performed after a rapid iliac growth in the first month control computed tomography angiography. Although the clinical course of this entity is relatively benign, rupture of the common iliac artery has also been described.

Treatment Results of Endovascular Aneurysm Repair Using the Parallel Stent-Graft Double D Technique for Distal Saccular Abdominal Aortic Aneurysms and Common Iliac Aneurysms

BACKGROUND

Endovascular aneurysm repair (EVAR) using a bifurcated stent graft may involve technical challenges when aortic disease (aneurysm or dissection) consists of a length <70 mm between the inferior renal artery and aortic bifurcation or narrow aortic bifurcation that is common in asymmetric distal abdominal aortic aneurysms (AAAs) or iliac artery aneurysms (IAAs). We use EVAR with the double D technique (DDT-EVAR) for such cases, which involves straight type of stent grafts with same diameter in left and right that are deployed parallel to an aortic cuff that has been previously placed. In addition, DDT-EVAR can preserve the inferior mesenteric artery (IMA) for IAA.

METHODS

DDT-EVAR was performed for 21 of 910 (2%) cases from April 2007 to April 2019 at our institution. The median patient age was 74 years (range, 52-85). Nineteen patients (90%) were men. Six patients (all saccular; 1 rupture) had AAAs, 12 had IAAs, and 3 had chronic type B aortic dissociation (TBAD) for re-entry closure. AAA and IAA had diameters of 45 mm (range, 34-71) and 34 mm (range, 25-58), respectively. An aortic cuff was used for 19 (90%) cases. Endurant II (Medtronic, Santa Rosa, CA) was used for 12 cases. The Excluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) was used for 7 cases. Endurant II was used for 20 cases, and the VBX (W.L. Gore & Associates, Inc) was used for 1 case as stent-graft limbs.

RESULTS

The procedural success rate was 100%. The median operative time was 146 min (range, 88-324). IMA planned for preservation was successful for all 12 cases. Type I and type III endoleaks were not observed. With TBAD, flow to the false lumen decreased or disappeared, and no complications during the hospital stay were associated with the procedure. For 2 patients whose procedure involved Endurant II stent-graft limb, limb occlusions were observed postoperatively, and reintervention was required. No other patients required additional treatment at a median follow-up of 18 months (range, 4-50).

CONCLUSIONS

DDT-EVAR is a safe and straightforward technique for the treatment of distal AAA, common iliac artery aneurysm, and TBAD. It may help preserve the IMA and internal iliac artery, even when it is impossible to preserve them with a bifurcated stent graft.

The Triple Wire Technique for Delivery of Endovascular Components in Difficult Anatomy

We describe a novel endovascular technique in which three 0.014″ guidewires are placed in parallel through a 0.035″ lumen catheter, in order to create a stiff platform to allow for delivery of 0.035″ profile devices through challenging anatomy. Three illustrative cases are presented: a difficult aortic bifurcation during lower extremity intervention, a tortuous internal iliac artery during placement of an iliac branch device, and salvage of a renal artery after inadvertent coverage during proximal cuff deployment for type 1a endoleak. We also quantify the relative stiffness of the triple 0.014″ wire configuration, using several well-known 0.035″ wires for comparison. The "triple wire technique" is an effective method for tracking endovascular devices through difficult tortuous anatomy, and can be used in a variety of clinical settings. The technique is especially useful when a traditional, stiff 0.035″ wire will not track without "kicking out." Each 0.014″ wire is reasonably soft and traverses the tortuous vessel easily, but when the 3 wires are used together as a rail it provides a stiff enough platform for delivery.

[Common iliac artery aneurysm urological manifestations]

BACKGROUND

An iliac artery aneurysm is a permanent and focal dilation of the artery that measures more than 50% of the normal diameter of the vessel. Isolated iliac artery aneurysms are infrequent, mostly as an association with an abdominal aortic aneurysm. The objective of this article is mainly to focus on urological symptoms as the manifestations of iliac artery aneurysm, to propitiate an early diagnosis.

CLINICAL CASE

In this article, we present a clinical case of a patient with generalized weakness, an episode of lipothymia and pain in the renal fossa, finding three aneurysms in the computed tomography, located in the right common iliac artery, the left internal iliac artery and the left external iliac artery. Later, the patient presents urological complications, after an obstruction of the right ureter, and therefore, a right hydronephrosis and loss of renal parenchyma function. Given this, urgent surgery is performed with satisfactory results.

CONCLUSIONS

The diagnosis of an iliac aneurism represents a challenge since most patients are asymptomatic. As main manifestation, urinary compression symptoms represented a fundamental part of diagnostic suspicion, which coincides with other similar cases reported in the literature.

Prevalence of abdominal aortic aneurysm and associated lower extremity artery aneurysm in men hospitalized for suspected or known cardiopulmonary disease

BACKGROUND

AAA is a disease affecting predominantly male patients ≥65 years and its dreaded complications such as rupture led to population-based screening programs as preventive measure. Nonetheless, the supposed prevalence may have been overestimated, so that targeted screening of high risk populations may be more effective. This study was performed to evaluate the prevalence of abdominal aortic aneurysm (AAA) of an inpatient high-risk cohort and to estimate the co-prevalence of lower extremity arterial aneurysms.

METHODS

Participants: 566 male inpatients, ≥ 65 years of age, hospitalized for suspected or known cardiopulmonary disease. Primary and secondary outcome measures: Maximal infrarenal aortic diameters using abdominal ultrasound (leading edge to leading edge method). Upon detection of an AAA (diameter ≥ 30 mm), the lower extremity arteries were examined with regard to associated aneurysms.

RESULTS

In 40 of 566 patients (7.1%) AAAs were detectable. Fourteen patients (2.5%) had a first diagnosis of AAA, none of which was large (> 55 mm), the remaining 26 patients were either already diagnosed (14 patients, 2.5%) or previously repaired (12 patients, 2.1%). The three most common main diagnoses at discharge were acute coronary syndrome (43.3%), congestive heart failure (32.2%), and chronic obstructive pulmonary disease (12%). The cohort showed a distinct cardiovascular risk profile comprising arterial hypertension (82.9%), diabetes mellitus (44.4%), and a history of smoking (57.6%). In multivariate analysis, three-vessel coronary artery disease (Odds ratio (OR): 4.5, 95% confidence interval (CI): 2.3-8.9, p <  0.0001) and history of smoking (OR: 3.7, CI: 1.6-8.6, p <  0.01) were positively associated with AAA, while diabetes mellitus (OR: 0.5, CI: 0.2-0.9, p = 0.0295) showed a negative association with AAA. Among the subjects with AAA, we found two large iliac and two large popliteal aneurysms.

CONCLUSION

Ultrasound screening in male inpatients, hospitalized for suspected or known cardiopulmonary disease, revealed a high AAA prevalence in comparison to the present epidemiological screening programs. There was a moderate proportion of newly-screen detected AAA and additional screening of the lower extremity arteries yielded some associated aneurysms with indication for possible intervention.

Comparison of Perioperative Outcomes of Patients with Iliac Aneurysms Treated by Open Surgery or Endovascular Repair with Iliac Branch Endoprosthesis

BACKGROUND

Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE.

METHODS

The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions.

RESULTS

Sixty-seven patients (96% male) were treated with OS (n = 25, mean age 68 ± 8 years) or IBE (n = 42, mean age 73 ± 8 years; P = 0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P = 0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5 ± 3.4 vs. 1.7 ± 1.4 days for IBE, P < 0.0001 and ICU LOS 3.3 ± 2.1 vs. 0.1 ± 0.4 days, P < 0.0001). Estimated blood loss was higher for patients undergoing OS (4,732 ± 2,540 mL) compared to patients treated with IBE (263 ± 451 mL, P < 0.0001), resulting in higher RBC transfusion requirements (1.5 ± 2.4 vs. 0.2 ± 0.8 units, P = 0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P = 0.09).

CONCLUSIONS

Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.

Urinary retention revealing a large common iliac artery aneurysm

Isolated aneurysms of the common iliac artery are rare, affecting less than 0.01% of the general adult population. Most of these aneurysms are asymptomatic and are discovered as an incidental finding. We describe an elderly patient presented with a urinary retention, which the investigations had led to the diagnosis of a large left common iliac artery aneurysm.