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Endograft Exclusion of Residual Common Iliac Artery Aneurysms

Alex Derom, MD ; Frank Vermassen, MD, PhD; and Karin Ongena, MD

Aneurysm of the residual stump of the common iliac artery (CIA) after aortobifemoral bypass surgery is an uncommon finding.1,2 The usual treatment is either surgical reintervention or coil embolization.3,4 In the present case, endovascular treatment using flexible stent-grafts was selected to exclude the aneurysm.

Case Report

A 73-year-old man presented with symptomatic bilateral aneurysms of residual CIA stumps. He had received a straight interposition graft for a ruptured abdominal aortic aneurysm (AAA) in 1995. In 1996, a right CIA aneurysm was noticed during routine duplex surveillance. Spiral computed tomographic (CT) scanning confirmed the 3.5-cm-diameter aneurysm on the right side and showed the left CIA dilated to 2.0 cm. An albumin-coated aortobifemoral graft was inserted, and the CIAs were ligated bilaterally.

The patient started to complain of worsening claudication a year later. Angiography revealed aneurysms of both CIA stumps (Fig. 1 ). Because the patient was unwilling to undergo a third major operation, we elected to exclude the aneurysms by inserting endografts from the external to the internal iliac artery, thus avoiding retrograde filling of the defects and preserving the internal iliac artery on at least 1 side. However, the >90° angle between the external and internal iliac arteries made stent-graft delivery problematic. After a thorough exploration of all available endoprostheses, the Hemobahn endovascular prosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA) was chosen because of the flexibility afforded by its nitinol stent frame interwoven with ultrathin polytetrafluoroethylene fabric.

Under general anesthesia, the left superficial femoral artery (SFA) was punctured, and a 0.035-inch guidewire was positioned in the internal iliac artery. Five thousand units of heparin were administered. A 13-mm × 10-cm endograft was inserted through a 12-F sheath and positioned from the external to the internal iliac artery. The same procedure was repeated on the right side using an 11-mm × 10-cm Hemobahn device. An intraoperative control angiogram showed exclusion of the aneurysms on both sides. Oral anticoagulation (warfarin) was started on the first postoperative day. Recovery was uneventful, and the patient was discharged on day 4.

Follow-up angiography 2 months later (Fig. 2 ) and CT angiography after 6 and 18 months demonstrated complete exclusion of the aneurysms and confirmed the patency of the endoprostheses bilaterally.

Discussion

Aneurysmal dilatation of a residual CIA stump is uncommon, but rupture has been reported.[4] When both sides are affected, as in our case, the risk of bowel ischemia is considerable.[3,4] Several treatment options are available, but many have drawbacks. Open surgery, for example, can be difficult because of the previous interventions. Ligation of the external iliac artery is insufficient, as further growth and even rupture of the aneurysm can occur through backflow from the internal iliac artery. Ligation of the internal iliac artery may cause buttock claudication.

Coil embolization is a popular endovascular alternative to surgery for iliac artery aneurysms,[5] but this approach was impossible in our patient due to the broad aneurysm necks. Moreover, embolization of both internal and external iliac arteries would also lead to buttock claudication and bowel ischemia.

Covered stents have proven successful in the treatment of various peripheral aneurysms including those in the iliac arteries.[6–8] Complete exclusion relieves pressure in the aneurysm sac, avoiding late rupture, and often results in shrinkage of the aneurysm. In our case, the sharp angle (>90°) between the external and the internal iliac artery could have made stent-graft deployment difficult. However, the flexibility of the Hemobahn device made it possible to negotiate this angle and conclude the procedure successfully.

References

  1. Panayitopoulos YP, Sandison AJP, Reidy JF. et al. Endovascular repair of residual iliac artery aneurysms following surgery for ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 1996;12:482–486.
  2. Plate G, Hollier LH, O' Brien PC. et al. Recurrent aneurysms and late complications following repair of abdominal aortic aneurysms. Arch Surg. 1985;120:590–594.
  3. Minato N, Itoh T, Natsuakil K. et at. Isolated iliac artery aneurysm and its management. Cardiovasc Surg. 1994;2:489–494. [PubMed Citation]
  4. Richardson JW, Greenfield W. Natural history and management of iliac aneurysms. J Vasc Surg. 1988;8:165–171. [PubMed Citation]
  5. Henry M, Amor M, Henry I. et al. Endovascular treatment of internal iliac artery aneurysms. J Endovasc Surg. 1998;5:345–348. [PubMed Citation]
  6. May J, White G, Yu W. et al. Early experience with the Sydney and EVT prostheses for endoluminal treatment of abdominal aortic aneurysms. J Endovasc Surg. 1995;2:240–247.
  7. Krajcer Z, Khonshnevis R, Leachman R. et al. Endoluminal exclusion of an iliac artery aneurysm by Wallstent endoprosthesis and polytetrafluoroethylene vascular graft. Tex Heart Inst J. 1997;24:11–14. [PubMed Citation]
  8. Dorros G, Cohn JM, Jaff MR. Percutaneous endovascular stent-graft repair of iliac artery aneurysms. J Endovasc Surg. 1997;4:370–375. [PubMed Citation]

Figures

Figure 1
Preprocedural arteriogram showing an aneurysm of the residual right common iliac artery stump in a 73-year-old man with an aortobifemoral bypass graft. The left common iliac artery stump was also aneurysmal

Figure 2
Two months after bilateral endograft placement, the common iliac artery aneurysm is excluded and satisfactory flow is maintained in the internal iliac artery. Note the acute angle between the external and internal iliac branches that was negotiated by the Hemobahn device

 

Autor: Alex Derom, MD ; Frank Vermassen, MD, PhD; and Karin Ongena, MD

Fuente: Journal of Endovascular Therapy: Vol. 7, No. 3, pp. 251–254.

Ultima actualizacion: 1 DE AGOSTO DE 2007

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