Endovascular treatment of a post catheterization pseudoaneurysm: A stitch in time saves nine

External iliac artery (EIA) pseudoaneurysms are a well-known complication after arterial catheterization procedures. Most develop as a result of high femoral puncture. Small asymptomatic pseudoaneurysms are usually of no consequence but large symptomatic pseudoaneurysm carries a significant risk of rupture with serious life-threatening consequences and needs to be treated. We report here a case of EIA pseudoaneurysm in a 60 year old male patient after a cardiac catheterization procedure. CT angiography demonstrated a large pseudoaneurysm arising from the EIA and compressing the urinary bladder. Patient complained of abdominal pain and felt dizzy and required transfusions due to rapidly developing anaemia secondary to blood loss. Conventional angiography revealed free extravasation of contrast from the EIA. Percutaneous intervention through femoral access was performed by deploying a covered stent which effectively sealed off the perforation site with no evidence of contrast extravasation.

Preservation of pelvic perfusion in endovascular aneurysm repair

Endovascular aneurysm repair requires a suitable anatomy for placement of covered stent grafts, which includes a non-aneurysmal distal landing zone within the common iliac arteries. Patients with iliac artery aneurysms, thus, are often not candidates for this minimally invasive repair, as extension of the graft to an appropriate site would cover the internal iliac artery and result in significant symptoms related to poor pelvic perfusion. We present two cases of common iliac artery aneurysms treated by modified endovascular techniques with good results. Select patients with iliac artery aneurysms may be candidates for endovascular repair. These patients should be referred to centers familiar with these techniques.

[Diagnosis and treatment of peripheral arterial aneurysms in lower limbs]

Authors analyzed a five years experience of the diagnosis and treatment of peripheral arterial aneurysms in the Center of vascular surgery of the multidisciplinary military hospital. Authors give the assessment of different diagnostic instrumental methods and demonstrate results of surgical treatment. The possibility and effectiveness of endovascular-traumatic method of surgical correction of this pathology of lower limb arteries are given.

[Analysis of endoleak in short term after endovascular aneurysm repair for abdominal aortic aneurysms]

OBJECTIVE

To observe the occurrence condition of endoleak after endovascular aneurysm repair (EVAR) operation for abdominal aortic aneurysm (AAA), and to analyze the factors of the endoleak.

METHODS

Between July 2005 and June 2013, 210 cases of AAA were treated with EVAR. Of 210 patients, 175 were male and 35 were female, aging 42-89 years (mean, 65.7 years). The patients were all proved to have infrarenal AAA by computed tomography angiography (CTA). The disease duration ranged from 1 week to 2 years (median, 11.3 weeks). The maximum diameter of the aneurysms was 44-72 mm (mean, 57.3 mm). The proximal landing zone was longer than 1.5 cm. CTA was performed routinely at 2 months after operation to detect the endoleak of contrast agent. If endoleak was found, CTA was performed again at 6 months. If obvious endoleak still existed, digital subtraction angiography (DSA) would be performed to clarify the character and the degree of the endoleak, and EVAR should be done if necessary.

RESULTS

Endoleak occurred in 31 cases (14.8%) during operation, including 11 cases of type I endoleak (8 cases of type IA and 3 cases of type IB), 18 cases of type II endoleak, and 2 cases of type III endoleak (type IIIB). The patients were followed up 2-8 months (mean, 3.1 months). At 2 months after operation, contrast agent endoleak was found in the remnant aneurysm cavity of 12 cases (5.7%). At 6 months after eperation, contrast agent endoleak was found in 10 cases (4.8%) by CTA. In 8 patients receiving DSA, there were 4 cases of type I endoleak (3 cases of type IA and 1 case of type IB), 3 cases of type II endoleak, and 1 case of type III (type IIIB) endoleak. In 5 patients having type I and type III endoleak, collateral movement of stent graft was observed in different degree; after increased stent graft was implanted, the endoleak disappeared after 2-4 months. The patients having type II endoleak were not given special treatment, endoleak still existed at 2 months after reexamination of CTA, but the maximum diameter of AAA had no enlargement.

CONCLUSION

The collateral movement of stent graft is a very important factor to cause type I and type III endoleak in the patients of AAA after EVAR, and endoleak can be plugged by EVAR again.

Expansion of an iliac aneurysm after treatment with multilayer stent: an unusual case

A 62 year old man, suffering from arterial hypertension and no other significant comorbidities come to our attention for the presence of an asymptomatic 29 mm left common iliac artery (CIA) aneurysm and bladder cancer. Given the young age of the patient, we opted for endovascular treatment that would allow to maintain the patency of the hypogastric artery. In June 2011, the patient underwent an endovascular exclusion of the left iliac artery aneurysm corrected by multilayer stent placement (Cardiatis 16x120mm) and post-dilatation with 14x40 mm balloon (Medtronic Reliant). At the 3 months follow-up, a CT-angio was made, showing a Type I endoleak with complete perfusion of the aneurismal sac. We analysed the CT-Angio using OsiriX and at the 3D reconstruction a poor adhesion of the stent to the proximal neck was detected. We decided to intervene by implanting two balloon-expendable covered stents (Atrium Adventa; 16x40 mm) The aneurysm sac remained stable for 9 months but at 12 months follow-up the aneurysm presented a diameter of 39mm. Due to the increase of the aneurysm sac, we decided to implant a stent-graft 16-10x95+10-10x80 mm (Medtronic Endurant) with complete exclusion of the aneurysm and internal iliac artery occlusion. At one month follow-up the patient is completed asymptomatic with no endoleak at the Duplex scan and at the CT-Angio.

Technical and outcome considerations of endovascular treatment for internal iliac artery aneurysms

PURPOSE

This study was designed to analyze the outcomes of endovascular treatment for internal iliac artery aneurysm (IIAA) at mid-term follow-up.

METHODS

We retrospectively analyzed 33 patients (28 males, mean age 77.4 years) who underwent endovascular treatment of 35 IIAAs (mean diameter 39.8 mm) from 2002 to 2012. We attempted to completely and selectively embolize all distal branches with permanent embolic materials, followed by proximal controls either by stent-graft placement (type 1) or coil embolization (type 2).

RESULTS

Procedural success rate was 97.1% (n = 34). Complete permanent distal branches embolization was achieved in 27 (79.4%), type 1 in 24 (70.6%), and type 2 in 10 (29.4%) cases. During mean follow-up period of 29.1 months (range, 1.2-92.8), no IIAA-related mortality and stent/stent-graft related complications occurred. Pelvic ischemia occurred and resolved in 8 (25%) patients. Among 32 cases followed by CT, the aneurysm diameter was stable in 18 (56.3%), shrank in 11 (34.4%), and enlarged in 3 (9.4%) cases. In 22 assessed by contrast-enhanced CT, secondary endoleak occurred in 3 (13.6%) cases and 2 required secondary interventions (2/32, 6.3%). Type 1 procedure tends to have better mid-term outcomes. Incomplete permanent distal branches embolization was associated with enlargement and secondary intervention (p = 0.007 and p = 0.042, respectively). The secondary intervention-free rate at 3 years in the complete and incomplete distal embolization group was 100 and 83.3%, respectively (p = 0.128).

CONCLUSIONS

Endovascular treatment for IIAA is feasible and safe. Complete permanent distal branches embolization is important to achieve satisfactory mid-term outcomes.

Decision-making and techniques in hypogastric artery revascularization

The aim of this article was to describe and discuss the currently available endovascular and open surgical techniques to preserve or occlude the hypogastric artery during aortoiliac aneurysm repair and thus support the process of decision-making in hypogastric artery revascularization.

Iliac branched device implantation in tortuous iliac anatomy after previous open ruptured aortic aneurysm repair

The aim of this paper was to present iliac branched device (IBD) implantation in a fit 67-year-old man with tortuous iliac anatomy after previous emergent open abdominal aortic aneurysm (AAA) repair. The patient underwent open treatment for a ruptured abdominal aortic aneurysm in another hospital. The procedure was complicated by extreme blood loss which prevented concommitant treatment of two large iliac aneurysms. Later, the patient underwent stent-grafting of a right common iliac artery aneurysm (CIAA) with coil embolization of the internal iliac artery (IIA). He was then refferred to our institute for treatment of the left CIAA with preservation of the left IIA. An IBD was used to this purpose. The introduction system was inserted over a through-and-through wire, and the bridging stent-graft via a left axillary approach. An Excluder leg was used to mate the IBD with the surgical graft limb. Additional self-expanding stents were needed to keep the limbs of the surgical graft open. One year later the patient is doing well, without buttock claudication, and the aneurysm is well excluded. With challenging anatomy, endovascular repair with an IBD may require additional technical tricks but also back-up materials to achieve success.

[Successful treatment of aneurysm of iliac artery in old patient with widespread atherosclerosis of aorta]

Disclosure of aneurysm of abdominal aorta indicates severity and prevalence of atherosclerotic process which means high probability of combined occlusive affections in other arterial circulations. Authors treated the patient with aneurysm of iliac artery with widespread atherosclerosis of aorta taking into account the abovementioned facts. Right stage surgical tactics assured success.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation

INTRODUCTION

A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability.

METHODS

Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared.

RESULTS

We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002).

CONCLUSIONS

The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).

Endovascular repair of aortoiliac aneurysm with a hybrid technique to preserve pelvic perfusion

Endovascular aneurysm repair (EVAR) has been proven to be an effective and safe technique for abdominal or iliac artery aneurysm. However, for aneurysms extending to both iliac bifurcations, routine EVAR will occlude both internal iliac arteries (IIAs), which may increase the risk for pelvic ischemia. New endovascular techniques have been developed to preserve the pelvic perfusion in EVAR for such situation. This article reports an endovascular repair of an aortoiliac aneurysm with an external iliac artery (EIA) to the IIA endograft to preserve the pelvic perfusion. First, an endograft was advanced into the left IIA under the help of an inflated aortic balloon. Coils were deployed to embolize the distal type-1 endoleak from the tunnel around the endograft. and an aortouniiliac endograft and an iliac extension were deployed below the renal arteries extending to the right EIA. Finally, a right-to-left femoro-femoral artery bypass was constructed. Angiography at completion and computed tomography after 6 months demonstrated patency of all grafts and complete exclusion of the aneurysm without any endoleak. Endovascular repair with an EIA-to-IIA endograft to preserve the pelvic inflow is a feasible and effective technique for aortoiliac aneurysms. Coil embolization might be an option to repair the distal type of endoleak. The balloon assisted U-turn technique may help advance the endovascular device over a sharp-angled vessel bifurcation.

Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review

Spinal cord ischemia is a rare but catastrophic complication after endovascular treatment of infrarenal aortic aneurysm: only 14 cases are reported in the literature. A patient with a 6 cm infrarenal aortic aneurysm extending to both common iliac arteries and high surgical risk was submitted to endovascular repair with exclusion of both hypogastric arteries and surgical revascularization of the right hypogastric artery. The patient presented paraplegia, apallesthesia and superficial hyposensitivity immediately after the procedure. A spinal cord drainage was positioned with little improvement of superficial sensitivity. We undertook a systematic review of the literature on this topic.

Antegrade, covered, self-expanding stent as an iliac extension in a bifurcated endograft: a feasible technical maneuver for challenging aortoiliac aneurysmal anatomy

BACKGROUND

Aneurysmal and occlusive aortoiliac disease can make the process of introducing large delivery catheters for endovascular repair challenging. We describe the case of a patient who could be treated by a bifurcated stent-graft despite having a unilateral external iliac occlusion.

METHODS AND RESULTS

From a brachial access, a covered self-expanding stent was deployed antegradely through the distal gate of the stent-graft into the common iliac artery. This technical choice helped to overcome the problem of an external iliac occlusion, so as to maintain an antegrade flow into the internal iliac and avoid the need for an interfemoral bypass.

CONCLUSION

Auto-expandable covered stent-graft with a thinner shaft can be used through a brachial access as an iliac extension of a bifurcated aortic endograft. However, a longer follow-up duration and more cases are necessary to warrant the safety and the durability of such an "off-label" endovascular material assemblage.