Internal Iliac Artery Aneurysm Research Articles

Clinical experience with a shape memory polymer peripheral vascular embolisation plug: a case series

BackgroundShape memory polymers are materials that are manufactured in a certain shape, can be stored in a temporary deformed shape, and then return to – or remember – their original shape upon exposure to external stimuli such as temperature and moisture. This property lends itself to application in endovascular medical devices. Peripheral vasculature embolisation devices incorporating this novel technology have become commercially available and this case series, where the data were collected as part of a post market registry, outlines initial clinical experience with these novel devices.ResultsEight cases are described in this series. The disease state/conditions for which embolisation was indicated were right common iliac artery aneurysms (n = 3), a type II endoleak into the thoracic aorta following thoracic endovascular aneurysm repair (n = 1), a left inferior gluteal artery aneurysm (n = 1), left internal iliac artery aneurysms (n = 2), and a case of splenomegaly, where splenectomy was planned after the embolisation procedure (n = 1). Target arteries were 5–10 mm in diameter. In each case, at least one IMPEDE Embolization Plug (IMP-Device) of an appropriate diameter was used. All procedures were technically successful and target vessel thrombosis was achieved in all cases. Follow-up imaging available during the 45–90-day data collection timeframe showed sustained vessel occlusion. This case series includes examples of situations commonly encountered when embolising the peripheral vasculature, namely, the use of one or multiple devices in a single vessel and in combination with the use of other embolic devices (e.g., microcoils, gelatin sponge, and PVA particles) in the same case. There were no adverse events related to the specific use of the device.ConclusionsThis small series illustrates the safety and efficacy of this novel sponge-based embolic device for the embolisation of small and medium sized arteries and further experience will demonstrate the utility of the shape memory polymer devices.

Limb ischemia after coil migration used for a hypogastric aneurysm embolization

Hypogastric artery aneurysms are an uncommon entity. When the diameter achieves > 30-35 mm, they should be treated. Endovascular repair may be considered as first line therapy. One therapeutic option for internal iliac artery aneurysm exclusion is its embolization with or without covering the ostium with a covered stent. They may be some complications when it is not, as a distal coil migration that may produce ischemic symptoms. We are presenting a 73-years-old male admitted to hospital with an acute right lower limb ischemia caused by a coil migration. He recently underwent a right hypogastric artery aneurysm endovascular treatment by coil embolization without covering the hypogastric ostium with a covered stent. The patient underwent an emergency surgery to remove the coil by a transfemoral surgical approach with posterior thrombectomy of the secondary thrombus. Actually, he remains asymptomatic and with right posterior tibial pulse. Covered stent placement at the common iliac artery and external iliac artery could be the best option to avoid the risk of aneurysm rupture caused by endotension and the risk of distal coil migration.

Atypical presentation of melorheostosis with soft tissues involvement: a case report

BackgroundMelorheostosis is a skeletal disorder giving rise to a dripping wax appearance. The exact cause is still unclear, and the diagnosis is always challenging due to its wide differential diagnoses. Soft tissue involvement of melorheostosis has been reported in previous literatures but it is a rare phenomenon.Case presentationA 10-year-old child with melorheostosis presented with hematuria. Ultrasonography (USG) identified a cystic lesion in the right hemipelvis adjacent to the urinary bladder which was initially regarded as an ovarian cyst. Computed tomography (CT) confirmed the cystic lesion as a fusiform right internal iliac artery aneurysm, as well as multiple right retroperitoneal and right lower limb capillary hemangiomas with uterine involvement. Hence, the final diagnosis was atypical melorheostosis with vascular malformations. The patient was managed conservatively with Sirolimus therapy for the vascular anomalies.ConclusionAlbeit the rare involvement of soft tissues, careful search for vascular malformation is recommended in melorheostosis.

A Case of Chronic Right Hip Pain Revealing an Insidious, Incidental Eight-Centimeter Internal Aneurysm Among Multiple Diffuse Aneurysms

The prevalence of internal iliac artery aneurysms (IIAA) is very low. Existing data on IIAA are scarce and mainly based on case reports and small retrospective series. We present the case of a 55-year-old African American man with a past medical history of HIV, hypertension, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), coronary artery disease, polysubstance abuse, schizophrenia, depression, and bipolar disorder who presented to the emergency department with dyspnea on exertion. He was admitted for COPD exacerbation. He reported concerns of ambulatory chronic right hip pain, for which he underwent a CT, which revealed the presence of a partially visible right IIAA. A CT of his abdomen/pelvis revealed multiple aneurysms, including a partially thrombosed 8-cm fusiform right IIAA. Due to the presence of multiple aneurysms, the vascular surgery team was consulted, and elective repair was recommended. IIAA should be considered in the differential diagnosis of patients with significant smoking history and hip pain and acted upon immediately.

Ruptured internal iliac artery aneurysm masquerading as an inguinal hernia

Internal iliac artery aneurysms are rare, representing less than 2% of all aneurysms. Nonetheless, the mortality is high at up to 60% when ruptured. Ruptured internal iliac artery aneurysms commonly present with overt abdominal pain and systemic instability. They can also present with symptoms of pelvic organ dysfunction, such as urinary retention or obstipation. This report describes the first case of a ruptured internal iliac artery (IIA) aneurysm masquerading as a reducible inguinal hernia. It was diagnosed on a Computed Tomography scan, which showed a large contained ruptured right IIA aneurysm with extension of haemorrhage through the hernia sac. He underwent an endovascular procedure to exclude the aneurysm that was uncomplicated, and he had an uneventful recovery. It highlights the importance of considering IIA aneurysms as differentials for abdominal masses, groin lumps or vague symptoms of pelvic organ dysfunction. Thorough exploration of the history and careful examination will help flag these diagnoses in our clinical assessment.

Lower limb pain and swelling: is it sciatica, DVT, or else?

Background: Only 1% of all aortoiliac aneurysms could be presented with isolated internal iliac artery aneurysms with an incidence of 0.1% in the general population. Patients are mostly asymptomatic, yet they can present with clinical presentations related to aneurysm size and adjacent anatomical structures. Case Presentation: We report the case of a 76-year-old male patient with ruptured isolated internal iliac artery aneurysm presenting as ecchymosis and severe thigh pain with redness and discoloration. The patient was known hypertensive, diabetic type 2, and had end-stage renal disease but was not on regular hemodialysis. The patient's vital signs and systemic and abdominal examination were unremarkable, further laboratory tests were also normal. There was no sign of surrounding cellulitis and all the peripheral pulses were intact and normal. Because of unclear diagnosis and repeated visits to the emergency department, the patient was admitted for further investigation to rule out malignancy. CT abdomen was conducted and it revealed a ruptured internal iliac artery aneurysm with an extension into the gluteal region. Conclusion: Early diagnosis of isolated internal iliac artery aneurysm is difficult, as it is more easily detected when it is expanded or ruptured, which significantly increases morbidity and mortality rates and determines poor prognosis. Therefore, there are diagnostic as well therapeutic challenges. Surgical ligation is known as the most common management approach; however, the endovascular approach has shown promising outcomes, even in cases of a ruptured aneurysms.

Racial Differences in Isolated Aortic, Concomitant Aortoiliac, and Isolated Iliac Aneurysms: This is a Retrospective Observational Study.

Our aim was to describe the racial and ethnic differences in presentation, baseline and operative characteristics, and outcomes after aortoiliac aneurysm repair. Previous studies have demonstrated racial and ethnic differences in prevalence of abdominal aortic aneurysms and showed more complex iliac anatomy in Asian patients. We identified all White, Black, Asian, and Hispanic patients undergoing aortoiliac aneurysm repair in the VQI from 2003 to 2019. We compared baseline comorbidities, operative characteristics, and perioperative outcomes by race and ethnicity. In our 60,435 patient cohort, Black patients, followed by Asian patients, were most likely to undergo repair for aortoiliac (W:23%, B:38%, A:31%, H:22%, P < 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P < 0.001), and White and Hispanic patients were most likely to undergo isolated aortic aneurysm repair (W:76%, B:59%, A:68%, H:76%, P < 0.001). Black patients were more likely to undergo symptomatic repair and underwent rupture repair at a smaller aortic diameter. The iliac aneurysm diameter was largest in Black and Asian patients. Asian patients were most likely to have aortic neck angulation above 60 degree, graft oversizing above 20%, and completion endoleaks. Also, Asian patients were more likely to have a hypogastric artery aneurysm and to undergo hypogastric coiling. Asian and Black patients were more likely to undergo repair for aortoiliac and isolated iliac aneurysms compared to White and Hispanic patients who were more likely to undergo repair for isolated aortic aneurysms. Moreover, there were significant racial differences in the demographics and anatomic characteristics that could be used to inform operative approach and device development.

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis.

The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes. We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model. Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I2 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I2 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I2 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I2 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I2 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I2 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I2 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I2 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I2 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I2 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I2 0%, P = .622). IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication.

A Case of Internal Iliac Artery Aneurysm Embolization: Catheter Set AVP Deployment Enables Internal Coil Packing Easy

A Case of Internal Iliac Artery Aneurysm Embolization: Catheter Set AVP Deployment Enables Internal Coil Packing Easy

Direct transarterial embolization via the deep circumflex iliac artery for a type II endoleak using a novel Onyx™ mixture

Internal iliac artery aneurysms (IIAA) can be associated with abdominal aortic aneurysms. We describe a technique of successful transarterial embolization using a mixture of Onyx™ formulations in a 72-year-old with previous open and endovascular aneurysm repairs of his abdominal aorta and a residual large left IIAA causing a Type II endoleak. We demonstrate that utilization of the deep circumflex iliac artery is a safe and viable alternate route to treating IIAA when direct access is not achievable.

Bell-bottom technique in iliac branch era: mid-term single stent graft performance

BackgroundEndovascular abdominal aortic aneurysm repair (EVAR) is considered the primary option for abdominal aortic aneurysm but the management of concomitant wide or aneurysmal iliac arteries (CIAs) is still controversial.MethodsWe retrospectively evaluated mid-term results of patients receiving standard EVAR combined with bell-bottom technique (BBT) using Medtronic Endurant endograft between January 2009 and December 2018. Patients were followed up by CT scan performed 1 month after the procedure and by duplex ultrasound annually (with or without contrast medium) followed by CT scan in case of evolution.ResultsSeventy-one patients (67 males; mean age of 77,1 years) with abdominal aortic aneurysm and wide or aneurysmal common iliac artery (distal landing zone diameter up to 25 mm and length more than 20 mm) were treated with standard EVAR and BBT (107 limbs) using Endurant stent graft. The median aortic diameter was 56,1 mm (31.0-85.0). Technical success was obtained in 100%. Mean procedural time was of 100.1 min. No 30 days’ mortality, renal failure or limb ischaemia occurred. The median follow-up was of 36.56 months (1–136). 5-year aneurysm related mortality was not found. At 5 years, the number of all-cause deaths was seven. The freedom from secondary intervention was 91.6% at 5 years. Three patients (4.4%) were treated for iliac related complications at 5 years: internal iliac artery aneurysm, iliac obstruction, type 1b endoleak, all successfully treated by endovascular technique.ConclusionsAccording with this study BBT using Endurant stent graft is effective and safe with good mid-term results, with low rate of iliac related complications and no aneurysm related mortality.

The Effect of Manufacturer's Instructions for Use Compliance on Cook ZBIS Iliac-Branched Endograft Long-Term Outcomes

Current guidelines indicate iliac-branched endografts (IBDs) as the ideal means to preserve pelvic perfusion during endovascular aortic repair. Because patient vascular anatomy represents the main limitation to extensive use of these devices, off-label application may be considered to expand the number of patients being treated. The aim of this study is to evaluate long-term outcomes obtained using the Cook ZBIS endograft in the treatment of aortoiliac aneurysms as per or outside manufacturer's instruction for use (IFU). Data from all patients who underwent IBD implant in a single center were reviewed. Study population was divided into two subgroups: Group I treated as per manufacturer's IFU and group II treated outside IFU. During the study period (2008-2018), 119 patients were treated with 130 IBDs. Eighty-six patients were treated as per IFU (group I) and 44 outside IFU (group II). Overall technical success was 99.2%. Mean follow-up was of 63.5±38.3months for group I and 58.3±35.9months for group II (P=0.45). Freedom from reintervention at ten years was 79.8% in group I and 69.6% in group II (P=0.29). Freedom from IBD-related reintervention rate was 98.7% and 95.3% in groups I and II, respectively (P=0.240). Iliac-branched module thrombosis occurred significantly more in patients treated outside IFU with 4 cases in group I (4.7%) and 10 cases in group II (22.7%), (P=0.005). Cox regression analysis identified hypogastric artery aneurysm as the only independent predictor for both IBD thrombosis and hypogastric artery occlusion during follow-up. When used by an experienced team, Cook IBDs are safe and effective in the treatment of aortoiliac aneurysms both inside and outside IFU. Anyway a lower target hypogastric patency rate should be expected when treating patients with hypogastric aneurysms.

Transgluteal Coil Embolization of Internal Iliac Artery Aneurysm

Inflow occlusion of internal iliac artery aneurysm without occlusion of the outflow vessels can lead to continued aneurysm expansion and possible rupture because of retrograde flow. Surgical exploration could be challenging, with significant morbidity. Percutaneous options for embolization are also limited owing to lack of antegrade access into the aneurysm sac. We describe a percutaneous transgluteal approach to the internal iliac artery aneurysm for coil embolization. An 80-year-old man underwent endovascular repair of right iliac artery aneurysm. The patient also had an internal iliac artery aneurysm that could not be repaired with an iliac branch graft for technical reasons. After repair, the patient continued to show evidence of endoleak into the internal iliac artery aneurysm because of continued blood flow. Antegrade arterial access into the aneurysm was unsuccessful. The decision was made to perform transgluteal coil embolization of internal iliac artery aneurysm. The patient was placed on the angiography table in lateral position with left side down. We prepared the right buttock with the right knee bent to facilitate ultrasound-guided access into inferior gluteal artery. We accessed the right inferior gluteal artery using ultrasound guidance. Micropuncture wire dilator and sheath were then placed. After that, we were able to place a 035 angled Glidewire (Terumo Interventional Systems, Somerset, NJ) into the artery to obtain secure access. Subsequently we placed a 0.38 glide catheter into the artery. A microcatheter was then telescoped through the glide catheter into the aneurysm cavity. We were able to cannulate the branches coming off the internal iliac artery aneurysm and to coil embolize arterial branches going into the aneurysm. The aneurysm cavity itself was then packed with coils as well. Inferior gluteal artery leading to the internal iliac artery aneurysm was also coil embolized to stop any flow from going into the aneurysm. The procedure was completed without any complications. Follow-up scan showed no evidence of endoleak. The aneurysm size has remained stable subsequently after follow-up in 1 year. Coil embolization of the internal iliac artery by a percutaneous, transgluteal approach is effective and safe when standard antegrade transarterial access is not an option.

Comparison of Endovascular Repair Outcome for Common and Internal Iliac Artery Aneurysms

Endovascular repair for iliac artery aneurysm is standard because of favorable outcome. The aim of this study was to evaluate the difference of outcome between common iliac artery aneurysm (CIAA) and internal iliac artery aneurysm (IIAA).

Treatment Management in a Patient with Giant Ruptured Internal Iliac Artery Aneurysm

Treatment Management in a Patient with Giant Ruptured Internal Iliac Artery Aneurysm

Therapeutic management of isolated internal iliac artery aneurysms

ObjectiveIsolated internal iliac artery aneurysms (IIIAAs) are rare, life-threatening entities for which the optimal treatment strategy has not been established. This study aimed to evaluate the outcomes of open and endovascular treatment of IIIAAs. MethodsIIIAA cases between January 2009 and March 2019 at two hospitals were retrospectively reviewed. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed. ResultsForty-two patients (37 men and 5 women) with a mean age of 71 years were included. Twenty-five patients (60%) had a history of hypertension. Twenty-two patients (52%) were asymptomatic, and 16 (38%) presented with abdominal pain (12 with ruptured aneurysms). The 42 included patients had 43 treated IIIAAs. The following surgical techniques were used: surgical resection (n = 6), endovascular coil embolization (n = 12), endovascular stent graft placement across the internal iliac artery origin (n = 8 with 9 aneurysms), and combined coil embolization and stent graft placement (n = 16). The immediate technical success rate was 67%, 67%, and 88% for embolization, stent graft placement, and combined method, respectively. Open surgery was associated with the longest operative time and hospital stay. Overall 30-day mortality was 5% for all patients and 17% for patients with ruptured IIIAAs. Buttock claudication occurred in 7 of 40 patients who survived (18%). The median follow-up time was 56 months. The combined approach was associated with the lowest rates of endoleak (6% vs 25% and 29%) and reintervention (6% vs 17% and 29%) of the three endovascular methods. ConclusionsEndovascular coil embolization with stent graft placement is a feasible, safe, and effective treatment approach for large IIIAAs without adequate aneurysm necks.

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.

A Case of AKI Exposes Underlying Danger

Abstract A 66-year-old male with Acute Kidney Injury (AKI) after cardiac catheterization is discovered to have other comorbidities such as vascular disease, ectopic kidney, and hydronephrosis of the ectopic kidney due to a common iliac artery aneurysm. Discovery of the new comorbidities created a therapeutic challenge which concluded successfully. Keywords AKI; Cholesterol emboli; Ectopic kidney; Internal iliac artery aneurysm

A Case of a Giant Internal Iliac Artery Aneurysm due to Endotension

A Case of a Giant Internal Iliac Artery Aneurysm due to Endotension

Mid-term Results of Iliac Branched Endografting with Self-expandable Bridging Stents-grafts

Introduction: Iliac artery aneurysms may pose therapeutic challenges when considering an endovascular approach. The ideal treatment scenario involves preservation of both internal and external iliac arteries while ensuring an adequate fixation of the endograft. To this purpose iliac branched devices (IBDs) have been developed with several reports demonstrating good technical results and short-term durability. Distal landing in the internal iliac artery may take place with a balloon-expandable or a self-expandable bridging stent-graft (BSG). Our aim was to report mid-term results of patients treated with IBDs in combination with a self-expandable BSG. Methods: We analyzed a prospectively maintained database including all patients with iliac artery aneurysms that underwent IBD implantation within the period January 2004 - January 2014 in a vascular institution experienced in endovascular techniques. Results: A total of 72 patients (66 male, mean age 71 ± 8.1 years) were treated with 89 IBDs in the aforementioned period. In 67 cases (75.3%) treatment was carried out due to a common iliac artery aneurysm, in 5 cases (5.6%) due to an internal iliac artery aneurysm and in 17 cases (19.1%) due to a combination of both. Technical success was achieved in 85 cases (95.5%). In 81 cases self-expandable BSGs were used for the internal iliac artery. Additional endolining of the BSG with a self-expandable stent was carried out in 41/81 (50.6%) cases. In-hospital mortality was 2 patients (2.8%) and perioperative morbidity 6 patients (8.4%). Mean follow-up (FU) was 46.3 ± 15.5 months. An in-stent stenosis of the internal iliac BSG was detected in 3 (3.7%) and an occlusion in another 3 (3.7%) IBDs during FU. Endoleaks were detected in 6 (7.4%) cases, (Type Ib n=4; Type II n=2). Reinterventions were carried out in 8 (9.8%) cases due to a stenosis or endoleak. Buttock claudication occurred in 3 patients. Conclusion: Implantation of IBDs for iliac artery aneurysms is associated with low perioperative mortality and morbidity. Mid-term results demonstrate a high patency rate and a low rate of endoleaks and reinterventions for IBDs in combination with self-expandable BSGs for the internal iliac artery. Disclosure: Piotr Kasprzak is a consultant for Cook Inc., W.L. Gore & Associates, Bard, Maquet, Medtronic, and Vascutek.