Complex retrograde transarterial access and embolization of a giant internal iliac artery aneurysm after occlusion failure of Micro vascular plug (MVP) embolization and preceding EVAR in the distal ectatic Aorta and bilateral iliac artery aneurysms

Abstract

The therapy of pelvic aneurysms is minimally invasive through interventional radiology using various devices and embolic agents: 
 1. By using a covered stent/prosthesis to maintain antegrade flow when a landing zone, i.e., a
 vascular segment angiographically present into which the stent can be placed to bridge the neck of the aneurysm, thereby interrupting aneurysm perfusion. 
 2. Through complete embolization of the aneurysm using embolic agents/coils. 
 3. As performed in our case, by covering the aneurysm (Img 14 A-C) with a covered stent /prosthesis, following prior embolization of the branching vessels using macroembolic agents. In cases where there is insufficient occlusion of the aneurysm with residual perfusion, secondary em- bolization becomes considerably more complex due to the occlusion of the anatomically antegrade access and the altered hemodynamics around the aneurysm causing retrograde collateralization. Through detailed analysis of CT angiography, even in static CT, retrograde circulation could be iden- tified, allowing for a minimally invasive secondary approach to the aneurysm without the need for general anesthesia and/or surgery. By completely eliminating the aneurysm, the risk of rupture in the elderly patient was minimally invasively eliminated. The treatment of this patient exemplifies the possibilities that embolization with a wide array of embolic agents and catheters offers in a hemo- dynamically very complex situation.