Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 71-74

Endovascular Repair of Iliac Artery Aneurysm with Preservation of Internal Iliac Artery: Novel Technique to Re - create Iliac Bifurcation


Department of Vascular Surgery, Endovascular Center, Laurel, MS, USA

Date of Web Publication31-Jul-2015

Correspondence Address:
Dr. Vinay Kumar
Department of Vascular Surgery, Endovascular Center, Laurel, MS
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.161946

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  Abstract 

Internal iliac artery aneurysm occur less frequently. Surgical treatment was standard treatment before endovascular treatment options started. We report use of multiple balloon expandable ePTFE covered stents to treat an iliac artery aneurysm while preserving IIA.

Keywords: Endovascular Repair, iliac artery aneurysms, isolated iliac artery aneurysms


How to cite this article:
Kumar V. Endovascular Repair of Iliac Artery Aneurysm with Preservation of Internal Iliac Artery: Novel Technique to Re - create Iliac Bifurcation. Indian J Vasc Endovasc Surg 2015;2:71-4

How to cite this URL:
Kumar V. Endovascular Repair of Iliac Artery Aneurysm with Preservation of Internal Iliac Artery: Novel Technique to Re - create Iliac Bifurcation. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2021 May 7];2:71-4. Available from: https://www.indjvascsurg.org/text.asp?2015/2/2/71/161946


  Introduction Top


Iliac artery aneurysms are seen in 10-20% patients with abdominal aortic aneurysm (AAA) and often treated during open or endovascular repair of AAA. However, isolated iliac artery aneurysms rarely occur (0.008-0.03%). [1],[2] Aneurysms larger than 3 cm diameter require treatment to prevent rupture. [2],[3] Although, open surgical repair (OSR) is commonly performed, endovascular treatment is becoming popular due to low mortality and morbidity. [3],[4],[5],[6] Aneurysms involving the internal iliac artery (IIA) are difficult to treat due to the unavailability of a bifurcated stent graft. Following case report describe the use of multiple balloon expandable polytetrafluoroethylene (ePTFE) covered stents to treat an iliac artery aneurysm while preserving the IIA.


  Case Report Top


A 78-year-old male was referred for consideration of endovascular repair of a 3.5 cm diameter right iliac artery aneurysm. Patient previously has undergone OSR of a thoraco-abdominal aneurysm 8 years ago and an infra-renal AAA was repaired by open surgery 5 years ago. Since then he was diagnosed with severe oxygen-dependent chronic obstructive pulmonary disease and multi-vessel coronary artery disease with unstable angina. Approximately 7 months ago, he underwent coil embolization of an expanding left IIA aneurysm at an outside hospital. Right iliac artery aneurysm was found to be enlarged by 4 mm during a 6-month follow-up computed tomography scan. He was declined OSR due to high risk for general anesthesia.

Arteriogram performed from the right femoral approach identified aorto-aortic prosthetic graft and 3.5 cm size right iliac artery aneurysm extending across the iliac bifurcation. IAA origin was through the aneurysm sac. IAA also had a 1.5 cm size aneurysm [Figure 1]. Right common iliac artery (RCIA) measured 11 mm in diameter and 8 mm in length.
Figure 1: Angiogram showing isolated right common iliac artery aneurysm

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  Procedure Top


Endovascular repair was performed using local infiltration anesthesia using C-arm image intensifier (GE-OEC 9800, Salt Lake City, Utah). Both femoral arteries were accessed and 7F hemostatic sheaths (Brite Tip, Cordis, Wayne, NJ, USA) were positioned. A 0.035 inch Amplatz Supers Stiff (SS) wire (Boston Scientific, Natick, MA, USA) was placed through the right hemostatic sheath into the aorta. From the left side a 0.035 inch stiff Glidewire (Turomo Interventional System, Japan) was crossed over and advanced in to right IIA and 7F × 45 cm long hemostatic sheath (Brite Tip, Cordis, Wayne, NJ, USA) was advanced and positioned at the origin of right IIA. Measurements were done with the use of pigtail catheter equipped with radio-opaque markers (AngioScale, Endovascular Technologies, Menlo Park, California, USA) [Figure 2]. After adequate heparanization, 8 mm × 59 mm PTFE covered balloon expandable stent (iCAST, Atrium medical, New Hampshire, USA) was advanced from the right side over the Amplatz SS wire and placed across the iliac aneurysm at the origin of RCIA leaving 2 mm of stent into the prosthetic graft. A 2 nd 8 mm × 59 mm iCast stent was advanced through the left femoral sheath and distal end of the stent was positioned into the right internal iliac artery (RIIA) and proximal end was positioned matching with the first stent. After withdrawing the contra-lateral sheath into the left iliac artery, both stents were deployed in the "kissing" fashion by inflation of angioplasty balloons [Figure 3]. Angioplasty was repeated at the overlap in RCIA with the use of semi-compliant angioplasty balloons (Sprinter Semi-compliant, Medtronic, Minneapolis, MN, USA) at high pressure to "crush" the stents against each other, thus occluding potential space between the stents. After advancing the contra-lateral hemostatic sheath into the RIIA, a third iCAST stent (8 mm × 38 mm) was advanced and deployed across the IIA aneurysm. Completion angiogram confirmed the complete exclusion of iliac aneurysms and preserved the patency of IIA [Figure 4]. Puncture sites were closed with 8F puncture site closure device (Angio-seal VIP, St. Jude Medical, St. Paul, Minnesota, USA).
Figure 2: Angiogram showing measurements with the use of pigtail catheter equipped with radio opaque markers

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Figure 3: Both stents were deployed in the "kissing" fashion

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Figure 4: Completion angiogram showing complete exclusion of iliac aneurysms and preserved patency of internal iliac artery

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There were no intra-operative or postoperative complications and the patient was discharged next day with antiplatelet therapy. At 2 years follow-up with computed tomographic angiography; aneurysms continued to remain excluded without any endoleak. IIA remains patent [Figure 5] and [Figure 6].
Figure 5: Two years follow-up angiogram

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Figure 6: Two years follow-up computed tomography angiogram

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  Discussion Top


Internal iliac artery is a major blood supply to the pelvic organs and it is essential to preserve at least one artery during open or endovascular repair of AAA or iliac aneurysms to prevent gluteal, colonic, or pelvic ischemia. [7],[8],[9],[10],[11],[12] Preservation of pelvic blood supply is especially important in patients with previous thoracoabdominal aneurysm repair to maintain adequate spinal cord perfusion and prevent delayed paraplegia. [13] Varieties of open surgical, endovascular or hybrid procedures are described to achieve this goal, but the creation of a bifurcated graft has not been described. [6],[7],[9],[10],[11],[12],[14]

In this particular case left IIA was previously occluded by coil embolization for the repair of IIA aneurysm. [4],[5],[8] During the endovascular repair of RIAA main goal was to exclude the iliac aneurysm with preservation of RIIA flow. Since there is no commercial device available, a bifurcated device was designed with balloon ePTFE covered stents. The bifurcation was created in vivo using the kissing stent technique. Since the OSR of the AAA was performed with a synthetic tube graft, the proximal common iliac artery was available for the proximal landing site for both stents. Bifurcation was recreated by placement of distal ends of stents in external as well internal iliac arteries. At the completion of stent deployment endoleak from the proximal landing zone was a major concern so the stents were crushed against each other with use of semi-compliant balloons which helped obliterate the space between the stents thus achieving successful exclusion without type 1 endoleak. It was also chosen to treat the internal iliac aneurysm with an additional covered stent to prevent future enlargement.

In summary, the case illustrates the repair of a complex iliac artery aneurysm in a high-risk patient, wherein it was necessary to maintain the flow into the IIA. The goal was achieved with the use of multiple PTFE covered, balloon expandable stents placed percutaneously and in vivo creation of a bifurcated stent graft. After extensive Medline search, this appears to be a first successful case of endovascular repair of an isolated iliac artery aneurysm with IIA preservation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Brunkwall J, Hauksson H, Bengtsson H, Bergqvist D, Takolander R, Bergentz SE. Solitary aneurysms of the iliac arterial system: An estimate of their frequency of occurrence. J Vasc Surg 1989;10:381-4.  Back to cited text no. 1
    
2.
Richardson JW, Greenfield LJ. Natural history and management of iliac aneurysms. J Vasc Surg 1988;8:165-71.  Back to cited text no. 2
    
3.
Razavi MK, Dake MD, Semba CP, Nyman UR, Liddell RP. Percutaneous endoluminal placement of stent-grafts for the treatment of isolated iliac artery aneurysms. Radiology 1995;197:801-4.  Back to cited text no. 3
    
4.
Mori M, Sakamoto I, Morikawa M, Kohzaki S, Makino K, Matsunaga N, et al. Transcatheter embolization of internal iliac artery aneurysms. J Vasc Interv Radiol 1999;10:591-7.  Back to cited text no. 4
    
5.
Sakamoto I, Mori M, Nishida A, Fukushima A, Sueyoshi E, Hazama S, et al. Coil embolization of iliac artery aneurysms developing after abdominal aortic aneurysm repair with a conventional bifurcated graft. J Endovasc Ther 2003;10:1075-81.  Back to cited text no. 5
    
6.
van Sambeek MR, van Urk H. Endovascular treatment of isolated iliac artery aneurysms. Eur J Vasc Endovasc Surg 1998;15:91-2.  Back to cited text no. 6
    
7.
McLoughlin RF, Rankin R, McKenzie N. Embolization of iliac artery aneurysms following abdominal aortic aneurysm repair with a bifurcated graft. Clin Radiol 1997;52:680-3.  Back to cited text no. 7
    
8.
Schoder M, Zaunbauer L, Hölzenbein T, Fleischmann D, Cejna M, Kretschmer G, et al. Internal iliac artery embolization before endovascular repair of abdominal aortic aneurysms: Frequency, efficacy, and clinical results. AJR Am J Roentgenol 2001;177:599-605.  Back to cited text no. 8
    
9.
Arko FR, Lee WA, Hill BB, Fogarty TJ, Zarins CK. Hypogastric artery bypass to preserve pelvic circulation: Improved outcome after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004;39:404-8.  Back to cited text no. 9
    
10.
Faries PL, Morrissey N, Burks JA, Gravereaux E, Kerstein MD, Teodorescu VJ, et al. Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001;34:892-9.  Back to cited text no. 10
    
11.
Lin PH, Bush RL, Chaikof EL, Chen C, Conklin B, Terramani TT, et al. A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair. J Vasc Surg 2002;36:500-6.  Back to cited text no. 11
    
12.
Minion DJ, Xenos E, Sorial E, Saha S, Endean ED. The trifurcated endograft technique for hypogastric preservation during endovascular aneurysm repair. J Vasc Surg 2008;47:658-61.  Back to cited text no. 12
    
13.
Cho JS, Rhee RY, Makaroun MS. Delayed paraplegia 10 months after endovascular repair of thoracic aortic aneurysm. J Vasc Surg 2008;47:625-8.  Back to cited text no. 13
    
14.
Nagarajan M, Chandrasekar P, Krishnan E, Muralidharan S. Repair of iliac artery aneurysms by endoluminal grafting: The systematic approach of one institution. Tex Heart Inst J 2000;27:250-2.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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