Surgical access of the gluteal artery to embolize a previously excluded, expanding internal iliac artery aneurysm

Retrograde embolization of internal iliac artery aneurysms that enlarged after proximal ligation: A report of 5 patients

The transarterial approach is generally feasible for endovascular treatment of internal iliac artery aneurysms (IIAAs). However, this approach becomes difficult in patients who have undergone exclusion surgery (proximal ligation). We report our experience of performing transcatheter arterial embolization (TAE) using a retrograde approach from the deep femoral artery (DFA) for IIAAs that had enlarged after exclusion surgery. This case series includes 5 male patients (mean age, 57 years; range, 66-81 years) who underwent TAE of IIAAs between March 2015 and March 2024. The procedures were performed at a mean of 47 months (range, 33-108 months) after aortoiliac repair. Preoperative contrast-enhanced computed tomography (CT) or CT during aortography was performed before TAE in all cases to evaluate the development of collateral pathways. TAE was performed via the DFA using a retrograde approach with coils and cyanoacrylate glue in all cases. The procedure was technically successful in all 5 patients (100%). Intra-aneurysmal packing and embolization of the branched vessel was performed in all cases. The follow-up ranged from 6 to 66 months. All patients developed gluteal claudication but no major complications occurred during the follow-up period. No cases of aneurysm dilatation have been recorded to date. In conclusion, retrograde TAE of excluded IIAAs was a feasible and effective treatment in these 5 patients, after evaluating the development of collateral pathways on pretreatment contrast-enhanced CT.

Percutaneous gluteal artery access to embolize false lumen of type B aortic dissection in marfan patient

This case study presents an innovative endovascular approach using percutaneous gluteal artery access for embolizing the false lumen of a type B aortic dissection in a patient with Marfan syndrome. Following multiple complex surgeries, the patient developed an enlarging thoraco-abdominal aneurysm, necessitating an urgent intervention branched endoprosthesis despite persisting false lumen perfusion. Doppler ultrasound-guided percutaneous gluteal access was utilized for spiral-coil embolization of the false lumen. Successful embolization and exclusion of the aneurism, confirmed by follow-up angiography and computed tomography scans, demonstrated the technique's efficacy and safety. This approach underscores the need for innovative solutions addressing complex vascular pathologies in patients with Marfan.

Percutaneous Retrograde Trans-Gluteal Embolization of Type 2 Endoleak Causing Iliac Aneurysm Enlargement after Endovascular Repair: Case Report and Literature Review

Late type II endoleaks (T2ELs) arising from the internal iliac artery (IIA) may present during follow-up after endovascular aortic repair (EVAR) of aortoiliac aneurysm and may warrant embolization if enlargement of the aneurysmal sac is demonstrated. When coverage of the IIA ostium has been made due to extensive iliac disease, access options can be challenging. Different treatment options have been reported over recent years, and a careful selection of the best one must be made based on the characteristics of each case. The present study reports a simple and reproducible sheathless percutaneous superior gluteal artery (SGA) access and provides a discussion based on a review of the existing literature on this topic.

A hybrid approach to previously excluded, expanding internal iliac artery aneurysms

Previously excluded internal iliac artery (IIA) aneurysms can continue to expand and pose a risk of rupture. In this case series, we present three patients with previously excluded, expanding IIA aneurysms after endovascular stent coverage or open surgical ligation of the proximal IIA. We describe a hybrid approach to treat these patients safely and effectively.

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.

Successful endovascular therapy involving direct puncture for spontaneous internal iliac artery aneurysm rupture

Neurofibromatosis type 1 (NF-1) is associated with fatal vascular complications. A 40-year-old woman with NF-1 who had previously undergone left iliac artery ligation and femorofemoral bypass grafting for internal iliac artery (IIA) aneurysm rupture was transported to our hospital for the treatment of a newly developed IIA aneurysm. Although endovascular therapy was difficult owing to the previous surgery, we successfully performed embolization of the aneurysm and its feeding vessels via direct percutaneous puncture under ultrasound guidance. Aneurysm enhancement had completely disappeared at 2 months postoperatively. We have reported a novel approach of direct percutaneous puncture for IIA aneurysm embolization in a patient with NF-1.

Hybrid Treatment of an Enlarging Hypogastric Aneurysm Previously Excluded During Abdominal Aortic Aneurysm Repair

Hypogastric aneurysm is rare, often asymptomatic, but associated with high mortality if it ruptures. Given the deep location of the artery and proximity to critical anatomical structures (i.e., ureter, bladder, and rectum), open surgical repair carries high morbidity and mortality compared with an endovascular approach. We report a simple hybrid approach to repair an enlarging isolated hypogastric aneurysm after a previous aortic aneurysm repair during which the origin of the hypogastric artery was ligated.

Simulation and Training of Needle Puncture Procedure with a Patient-Specific 3D Printed Gluteal Artery Model

The puncture of the gluteal artery (GA) is a rare and difficult procedure. Less experienced clinicians do not always have the opportunity to practice and prepare for it, which creates a need for novel training tools. We aimed to investigate the feasibility of developing a 3D-printed, patient-specific phantom of the GA and its surrounding tissues to determine the extent to which the model can be used as an aid in needle puncture planning, simulation, and training. Computed tomography angiography scans of a patient with an endoleak to an internal iliac artery aneurysm with no intravascular antegrade access were processed. The arterial system, including the superior GA with its division branches, and pelvic area bones were 3D printed. The 3D model was embedded in the buttocks-shaped, patient-specific mold and cast. The manufactured, life-sized phantom was used to simulate the GA puncture procedure and was validated by 13 endovascular specialists. The printed GA was visible in the fluoroscopy, allowing for a needle puncture procedure simulation. The contrast medium was administered, simulating a digital subtraction angiography. Participating doctors suggested that the model could make a significant impact on preprocedural planning and resident training programs. Although the results are promising, we recommend that further studies be used to adjust the design and assess its clinical value.

Inferior gluteal artery surgical access for embolization of large internal iliac artery aneurysm in a hostile abdomen

Introduction

Internal iliac artery aneurysms (IIAA) are a rare entity compared with all aortoiliac aneurysms. Continuous expansion due to retrograde flow from runoff vessels can lead to rupture with devastating results. Exclusion of the aneurysm represents a challenging procedure especially if the access is limited and the patient has a history of reoperations in the pelvic region.

Case

A 78-year-old man with a history of endovascular aortic repair, coverage of internal iliac arteries and right hemicolectomy for adenocarcinoma of ascending colon presented with a rapidly expanding right IIAA (8.8 cm) due to type II endoleak. He successfully treated with coil embolization through inferior gluteal artery surgical access.

Conclusion

Inferior gluteal artery surgical access for embolization of internal iliac aneurysms in patients with hostile abdomen or in cases where antegrade route has already been excluded, is a feasible technique.

Embolization of a Previously Excluded Symptomatic Internal Iliac Aneurysm Through the Iliac Vein

A 69-year-old man was referred urgently for a 58-mm enlarging painful right internal iliac artery (IIA) aneurysm. Since exclusion through proximal IIA coverage and distal IIA branches embolization had been previously performed, aneurysm sac puncture through the iliac vein was decided. The ipsilateral common femoral vein was antegradely punctured, and a 16.5 G Ross modified Colapinto needle from a transjugular intrahepatic access set was used to puncture the sac and fill the aneurysm with coils. Embolization of an IIA aneurysm through the iliac vein may represent an alternative when prior IIA aneurysm exclusion has been performed.

Coil embolization of an excluded internal iliac artery aneurysm with rapid expansion via gluteal artery approach

The aim of the paper is to describe open approach of gluteal arteries for coil embolization of internal iliac artery (IIA) aneurysm. We observed enlargement of the IIA to 5.8 cm at the four-year follow-up evaluation of a 78-year-old man who had undergone surgical abdominal aortic aneurysm repair during which the IIA had been ligated at its origin. Following dissection of the gluteal artery with the patient in the prone position, a catheter was placed inside the aneurysmal sac, and coil embolization was possible to exclude the aneurysm. Postoperative angio-computed tomography showed good coil positioning and no demonstrable blood flow or type 2 endoleak.

Successful Percutaneous Coil Embolization of a Ruptured Internal Iliac Artery Aneurysm Remnant after Abdominal Aortic Aneurysm Repair via the Deep Iliac Circumflex Artery

Here, we describe a case of an 83-year-old man treated with percutaneous IIA coil embolization for an enlarging remnant IIA aneurysm. CT scans revealed a contained rupture and persistent flow in the right IIA with the enlargement. We selected percutaneous embolization via the deep iliac circumflex artery, that was communicating with the superior gluteal artery and the IIA. Coil embolization of the arteries supplying the IIA aneurysm was successfully performed with 12 embolization coils placed in the IIA and its branches. The absence of blood flow and shrinkage of the aneurysm were confirmed by CT three months after embolization.

Transretroperitoneal CT-guided embolization of growing internal iliac artery aneurysm after repair of abdominal aortic aneurysm: a transretroperitoneal approach with intramuscular lidocaine injection technique

This study was designed to evaluate the efficacy and safety of CT-guided embolization of internal iliac artery aneurysm (IIAA) after repair of abdominal aortic aneurysm by transretroperitoneal approach using the lidocaine injection technique to iliacus muscle, making window for safe needle path for three patients for whom CT-guided embolization of IIAA was performed by transretroperitoneal approach with intramuscular lidocaine injection technique. Transretroperitoneal access to the IIAA was successful in all three patients. In all three patients, the IIAA was first embolized using microcoils. The aneurysmal sac was then embolized with glue and coils without complication. With a mean follow-up of 7 months, the volume of the IIAAs remained stable without residual endoleaks. Transretroperitoneal CT-guided embolization of IIAA using intramuscular lidocaine injection technique is effective, safe, and results in good outcome.

Novel Treatment of an Enlarging Internal Iliac Artery Aneurysm in Association with a Type 2 Endoleak via Percutaneous Embolisation of the Superior Gluteal Artery through a Posterior Approach

Internal iliac artery (IIA) aneurysms, while rare, carry a significant risk of mortality if they rupture. Endovascular intervention is now the preferred method of treatment for IIAs; however, due to technical considerations, this is not always feasible. We report a case of a patient who developed an enlarging IIA aneurysm in association with a type 2 endoleak supplied by multiple feeding arteries where conventional endovascular treatment was not possible. A novel method of effectively treating the IIA aneurysm with a posterior approach via image-guided puncture of the superior gluteal artery was employed. Five arteries supplying the superior gluteal from the contralateral internal iliac artery were selectively catheterised and coiled before the aneurysmal sac was embolised. The patient made an uneventful recovery, and follow-up imaging demonstrated resolution of the endoleak and decompression of the aneurysmal sac. This case demonstrates that the posterior approach is a safe and viable method of treating internal iliac artery aneurysm when traditional endovascular approaches are technically possible.

Retrograde hypogastric artery embolization to treat iliac artery aneurysms growing after aortoiliac repair

Transarterial embolization of the feeding internal iliac artery branches via the hypogastric-femoral collateral pathway was feasible in four patients with expanding iliac artery aneurysms and occluded internal iliac artery origins after aortoiliac repair.

Endovascular treatment of isolated internal iliac artery aneurysms

The aim of the paper is to evaluate the outcome of endovascular treatments for isolated internal iliac artery aneurysms. A systematic review of the literature using public domain databases was undertaken. All studies reporting on endovascular treatment of isolated hypogastric artery aneurysms were considered. Experience from our institution was involved in the data analysis. The primary outcome measures were technical success, perioperative, and overall mortality and morbidity. Data were extracted from 30 articles fulfilling the selection criteria, and the study cohort consisted of 55 patients having undergone treatment of 59 internal iliac artery aneurysms. Ten patients (18%) were treated on an urgent or emergency basis for a ruptured aneurysm. Technical success was achieved in 71% of the cases. The most common reason for technical failure was incomplete exclusion of the aneurysm sac. Thirty-day mortality occurred in one patient (2%). The 30-day morbidity rate was 20%, and was mostly associated with insufficiency of the pelvic circulation. One aneurysm-related death occurred during a mean follow-up period of 13 months (range 0.5–56 months). Open surgical intervention for aneurysm-related complications was required in five patients. In conclusion, endovascular treatment of isolated internal iliac artery aneurysms is an effective alternative option, with satisfactory early and mid-term results.