Nitinol overdose-rescue of acute limb ischemia caused by stenting of the common iliac, external iliac, common femoral, superficial femoral, and popliteal arteries in an actively smoking patient with claudication

Intermittent claudication (IC) from peripheral arterial disease is typically managed with pharmacologic interventions and lifestyle changes. However, despite societal guidelines, initial endovascular interventions are being used more frequently with an increased incidence of complications, resulting in rapid disease progression to critical and acute limb-threatening ischemia (ALI). The present report describes the case of a patient who developed ALI after treatment of IC at another facility, with malpositioned bilateral common iliac stents, continuous stent extension into the popliteal artery, and acute occlusion of the entirety of the right lower extremity vasculature. This case illustrates how extensive endovascular intervention for IC can result in ALI requiring urgent revascularization.

Giant Sac Growth: A Hybrid Approach to Treat a Misdiagnosed Late Type IIIb Endoleak

Introduction

Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak.

Report

An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak.

Discussion

Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.

Delayed Fragmentation and Distal Embolization of Retained Microcatheter Causing Lower Limb Ischemia: Case Report and Review of the Literature

BACKGROUND

Endovascular microcatheter adherence and retention is an uncommon complication during brain arteriovenous malformation (AVM) embolization with glue or ethylene-vinyl alcohol copolymer that has previously reported, although there are sparse reports of symptomatic complications thereafter.

CASE DESCRIPTION

We present a unique complication 6 years after initial embolization of a cerebral AVM. The patient presented with acute lower limb insufficiency with computed tomography angiogram revealing fragmentation of the microcatheter and associated popliteal aneurysm. The patient underwent an emergency grafting and removal of the retained fragment and recovered without deficit postoperatively.

CONCLUSIONS

Fragmentation over retained microcatheters remains a concern that may be worth monitoring in the long term, although there are no recommendations for timing.

Occlusive Shrinkage of Ovation Endograft Presenting as Acute Lower Limb Ischemia: Effective Endovascular Management

The aim of this report is to describe the imaging and successful treatment of an acute shrinkage of the Ovation Abdominal Stent Graft System. The Ovation Prime system utilizes a polymer-filled sealing ring that is cast in situ at the margin of the aneurysm; however, the residual endograft inner volume after ring filling may reduce volume and graft flow. Nevertheless, there are no reports about severe complications using the Ovation Prime system. A 75-year-old male presented to our hospital for acute lower limb ischemia. The patient reported a previous endograft for abdominal aortic aneurysm 1 month previously, which utilized the Ovation device. Computed tomography (CT) angiography demonstrated a critical narrowing of the endograft at the site of the proximal sealing rings. We decided on urgent treatment, delivering a covered stent graft (CP STENT NUMED^™). Intraoperative intravascular ultrasound showed effective compaction of the proximal rings. Nine-month follow-up with CT angiography demonstrated good patency without ring recoil of the endograft. This is the first report of endovascular treatment for an acute and symptomatic shrinkage of proximal rings in the Ovation trivascular endograft. Angiographic and intravascular ultrasound findings showed that covered stenting is effective and that the ring polymer is safely moldable.