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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Endovascular Aneurysm Repair (EVAR) For A Complex Aneurysm Involving The Left Common Iliac Artery
Endovascular Aneurysm Repair (EVAR) For A Complex Aneurysm Involving The Left Common Iliac Artery
.Contributed by : Akash K. Shah
.Contributed by : Akash K. Shah
Introduction:
Introduction:
Although the dimensions that define the aneurysm of the iliac artery are dependent on the sex of the patient and the portion of the artery involved, a common iliac artery (CIA) with a diameter ≥1.7 cm in males or ≥1.5 cm in females is considered ectatic. A diameter >2.5 cm is considered aneurysmal (1). Iliac artery aneurysms (IAA) are the second most common aneurysms after abdominal aortic aneurysms (AAA), and most iliac aneurysms are common iliac artery aneurysms (CIAA). Isolated iliac artery aneurysms (IAA) occurring in the absence of AAA are relatively uncommon. They represent only 2% of all intra-abdominal aneurysms. (2) .
Although the dimensions that define the aneurysm of the iliac artery are dependent on the sex of the patient and the portion of the artery involved, a common iliac artery (CIA) with a diameter ≥1.7 cm in males or ≥1.5 cm in females is considered ectatic. A diameter >2.5 cm is considered aneurysmal (1). Iliac artery aneurysms (IAA) are the second most common aneurysms after abdominal aortic aneurysms (AAA), and most iliac aneurysms are common iliac artery aneurysms (CIAA). Isolated iliac artery aneurysms (IAA) occurring in the absence of AAA are relatively uncommon. They represent only 2% of all intra-abdominal aneurysms. (2) .
We present the case of a patient with a large CIAA who was treated with a stent graft. We illustrate the various procedural details including those necessary to prevent short and long-term procedure failures.
We present the case of a patient with a large CIAA who was treated with a stent graft. We illustrate the various procedural details including those necessary to prevent short and long-term procedure failures.
Case presentation:
Case presentation:
A 64 year old man, presented with complaints of gradually progressive lower abdominal and back pain since three years. There was associated pain while walking, climbing stairs and doing any strenuous physical activity. The patient was a known hypertensive on medical management . His BP was 130/90 mmHg. He was not a diabetic.
A 64 year old man, presented with complaints of gradually progressive lower abdominal and back pain since three years. There was associated pain while walking, climbing stairs and doing any strenuous physical activity. The patient was a known hypertensive on medical management . His BP was 130/90 mmHg. He was not a diabetic.
On initial imaging by ultrasonography, there was a large pulsatile mass in the pelvic region showing significant internal vascularity. CECT, revealed a large aneurysmal dilatation of the common iliac artery starting 2 cm after the aortic bifurcation and extending upto its bifurcation into internal and external iliac arteries (Videos 1&2). The aneurysmal sac measured 7.1 cm x 6.4 cm (TR x AP). The diameter of the normal segment of the common iliac artery proximal to the aneurysmal dilatation was 13.6 mm. and the diameter of the normal landing zone in left external iliac artery was 11.4 mm (Video 1, 2).
On initial imaging by ultrasonography, there was a large pulsatile mass in the pelvic region showing significant internal vascularity. CECT, revealed a large aneurysmal dilatation of the common iliac artery starting 2 cm after the aortic bifurcation and extending upto its bifurcation into internal and external iliac arteries (Videos 1&2). The aneurysmal sac measured 7.1 cm x 6.4 cm (TR x AP). The diameter of the normal segment of the common iliac artery proximal to the aneurysmal dilatation was 13.6 mm. and the diameter of the normal landing zone in left external iliac artery was 11.4 mm (Video 1, 2).
VIDEO 1.mp4VIDEO 2.mp4Video 1 (left): CT Aortogram demonstrating aneurysmal dilatation of the left common iliac artery about 2 cm distal to the aortic bifurcation, which involved the entire course of the left common iliac artery till just proximal to its bifurcation
Video 2 (right): Coronal CT demonstrating the tortuous vascular anatomy and the left common iliac artery aneurysm.
Interventional technique
Interventional technique
After thorough discussion with the patient and his relatives about the condition, its potential risks, sequelae & complications were explained to them. They were also counselled about our approach for endovascular management to place a stent graft across the left common iliac artery lesion with its benefits, potential risks and complications. A written informed consent was obtained. . Vascular surgeons were present in the angiography suite for any backup that may be required on the table as well as providing arteriotomy assistance for the introduction of the stent graft system through the left common femoral artery.
After thorough discussion with the patient and his relatives about the condition, its potential risks, sequelae & complications were explained to them. They were also counselled about our approach for endovascular management to place a stent graft across the left common iliac artery lesion with its benefits, potential risks and complications. A written informed consent was obtained. . Vascular surgeons were present in the angiography suite for any backup that may be required on the table as well as providing arteriotomy assistance for the introduction of the stent graft system through the left common femoral artery.
Initially, using a right common femoral arterial access with a 6F sheath, a 5 F pigtail catheter was negotiated proximal to the aortic bifurcation and angiograms were obtained using a pressure injector to determine the vascular anatomy and establish the relations of the common iliac artery aneurysm with the native vessels (i.e. common iliac artery, internal iliac artery & external iliac artery with its branches). (Video 3, 4)
Initially, using a right common femoral arterial access with a 6F sheath, a 5 F pigtail catheter was negotiated proximal to the aortic bifurcation and angiograms were obtained using a pressure injector to determine the vascular anatomy and establish the relations of the common iliac artery aneurysm with the native vessels (i.e. common iliac artery, internal iliac artery & external iliac artery with its branches). (Video 3, 4)
VIDEO 3.mp4VIDEO 4.mp4Video 3 Initial angiogram from proximal to the aortic bifurcation demonstrating common iliac artery aneurysms bilaterally as well as the vascular anatomy.
Video 4:: Selective left common iliac artery angiogram performed using a 4F RDC catheter demonstrating the tortuous vascular anatomy and relations of the aneurysmal sac with the common, internal and external iliac arteries.
The first step was to embolise the left internal iliac artery to prevent the development of endoleak surrounding the stent graft. During planning of the management, it was observed that navigating the tortuous anatomy of the arterial system would be a challenge; hence a 4 F RDC catheter was used to cross the aortic bifurcation from the right side, through which a 2.7 F microcatheter was introduced. A microwire was negotiated across the lesion in order to cannulate the left internal iliac artery (Video 5) for performing embolization using multiple pushable and detachable coils.
The first step was to embolise the left internal iliac artery to prevent the development of endoleak surrounding the stent graft. During planning of the management, it was observed that navigating the tortuous anatomy of the arterial system would be a challenge; hence a 4 F RDC catheter was used to cross the aortic bifurcation from the right side, through which a 2.7 F microcatheter was introduced. A microwire was negotiated across the lesion in order to cannulate the left internal iliac artery (Video 5) for performing embolization using multiple pushable and detachable coils.
VIDEO 5.mp4Video 5: Use of Microcatheter and microwire for negotiating the left common iliac artery into the left internal iliac artery for performing embolization of the internal iliac artery to prevent chances of endoleak.
An angiogram was then obtained to confirm successful cannulation of the left internal iliac artery so as to go forward with performing coil embolization (VIDEO 6).
An angiogram was then obtained to confirm successful cannulation of the left internal iliac artery so as to go forward with performing coil embolization (VIDEO 6).
VIDEO 6.mp4Video 6: Check angiogram performed to confirm successful cannulation of the left internal iliac artery.
Coil embolization of the left internal iliac artery was then performed using multiple pushable and detachable coils (VIDEO 7)
Coil embolization of the left internal iliac artery was then performed using multiple pushable and detachable coils (VIDEO 7)
VIDEO 7.mp4Video 7: Embolization of the left internal iliac artery using multiple coils.
Angiograms were then obtained after deploying pushable and detachable coils into the left internal iliac artery which showed successful embolization of the internal iliac artery. (VIDEO 8).
Angiograms were then obtained after deploying pushable and detachable coils into the left internal iliac artery which showed successful embolization of the internal iliac artery. (VIDEO 8).
VIDEO 8.mp4Video 8: Angiogram obtained post coiling the left IIA showing successful embolization of the artery
After embolization of the left internal iliac artery, CVTS surgeons helped expose the left common femoral artery, superficial femoral artery and the profunda femoris artery and vascular loops along with vascular snuggers were placed at appropriate positions to secure all the three arteries. After adequate exposure of the left common femoral artery, a 6F sheath access was secured into the CFA. A 5F sizing pigtail catheter was then passed over the wire above the aortic bifurcation and angiograms were obtained to determine the length of the lesion in order to choose the stent graft with most suitable dimensions. (Video 9).
After embolization of the left internal iliac artery, CVTS surgeons helped expose the left common femoral artery, superficial femoral artery and the profunda femoris artery and vascular loops along with vascular snuggers were placed at appropriate positions to secure all the three arteries. After adequate exposure of the left common femoral artery, a 6F sheath access was secured into the CFA. A 5F sizing pigtail catheter was then passed over the wire above the aortic bifurcation and angiograms were obtained to determine the length of the lesion in order to choose the stent graft with most suitable dimensions. (Video 9).
VIDEO 9.mp4Video 9: Angiogram obtained through the sizing pigtail catheter which was advanced through the left CFA access to demonstrate the accurate length of the involved segment of the left CIA and to confirm appropriate dimensions of the stent graft to be used for EVAR as well as its accurate positioning. The angiogram also reveals successful coil embolization of the internal iliac artery. (Interestingly, note the delayed reconstitution of the internal iliac artery distally through collaterals with no evidence of retrograde flow).
Based on the angiograms, a decision was then made to use a tapered stent graft which measured 129 mm in length. The diameter of the stent graft at the proximal (common iliac) end was 13 mm and at the distal (external iliac) end was 11 mm. A 4F headhunter catheter along with glide wire was used to reach upto the arch of aorta and then, glidewire was exchanged for an ultra-stiff wire for support.
Based on the angiograms, a decision was then made to use a tapered stent graft which measured 129 mm in length. The diameter of the stent graft at the proximal (common iliac) end was 13 mm and at the distal (external iliac) end was 11 mm. A 4F headhunter catheter along with glide wire was used to reach upto the arch of aorta and then, glidewire was exchanged for an ultra-stiff wire for support.
The 6F sheath was then withdrawn over the stiff wire for allowing introduction of the 22F stent graft deploying system over the stiff wire. Arteriotomy was then performed after securing hemostasis with the help of vascular loops and vascular snuggers and the 22F stent graft deploying system was introduced over the stiff wire from left common femoral arterial approach.
The 6F sheath was then withdrawn over the stiff wire for allowing introduction of the 22F stent graft deploying system over the stiff wire. Arteriotomy was then performed after securing hemostasis with the help of vascular loops and vascular snuggers and the 22F stent graft deploying system was introduced over the stiff wire from left common femoral arterial approach.
Multiple angiograms were then obtained for accurate positioning of the stent graft across the common iliac artery aneurysmal segment with appropriate proximal and distal landing zones. After confirming the correct position of the stent graft in relation to the aneurysmal segment, the stent graft was carefully deployed across the left common iliac artery aneurysm (Video 10)
Multiple angiograms were then obtained for accurate positioning of the stent graft across the common iliac artery aneurysmal segment with appropriate proximal and distal landing zones. After confirming the correct position of the stent graft in relation to the aneurysmal segment, the stent graft was carefully deployed across the left common iliac artery aneurysm (Video 10)
VIDEO 10.mp4Video 10: Deployment of the tapered stentgraft across the involved segment of the left CIA aneurysm after multiple check angiograms to confirm appropriate positioning.
Post deployment of the stent graft across the lesion, a CODA balloon was used to further dilate and expand the deployed stentcgraft to further minimize and avoid chances of development of the endoleak into the aneurysm sac (Video 11)
Post deployment of the stent graft across the lesion, a CODA balloon was used to further dilate and expand the deployed stentcgraft to further minimize and avoid chances of development of the endoleak into the aneurysm sac (Video 11)
VIDEO 11.mp4Video 11: Use of CODA balloon to dilate and further expand the stent graft to minimize chances of retrograde flow into the sac and prevent endoleaks.
Final angiogram was obtained after deployment of the stent graft across the lesion and further dilatation using CODA balloon which demonstrated complete exclusion of the aneurysmal sac from the circulation without any f filling of the aneurysmal sac , There was no endoleak. (Video 12)
Final angiogram was obtained after deployment of the stent graft across the lesion and further dilatation using CODA balloon which demonstrated complete exclusion of the aneurysmal sac from the circulation without any f filling of the aneurysmal sac , There was no endoleak. (Video 12)
VIDEO 12.mp4Video 12: Final angiogram performed after the deployment of the stent graft and dilatation of the stent graft with CODA balloon, showing successful exclusion of the aneurysm from the circulation with no evidence of endoleak.
Discussion:
Discussion:
Like AAAs, IAAs most commonly occur in elderly men. The most common cause of IAA is atherosclerosis. (3) The primary etiology is degenerative; however, isolated iliac artery aneurysms are also caused by other predisposing conditions, including infection, intraoperative injury, dissection, trauma, Marfan syndrome, and other collagen vascular diseases. (4,5)
Like AAAs, IAAs most commonly occur in elderly men. The most common cause of IAA is atherosclerosis. (3) The primary etiology is degenerative; however, isolated iliac artery aneurysms are also caused by other predisposing conditions, including infection, intraoperative injury, dissection, trauma, Marfan syndrome, and other collagen vascular diseases. (4,5)
The natural course of an iliac artery aneurysm (IAA) consists of progressive expansion with eventual rupture. Risk of rupture remains the primary indication for repair. The vast majority of isolated iliac artery aneurysms are asymptomatic and are detected incidentally on imaging studies performed for other indications. Owing to the deep pelvic location of these aneurysms, symptoms including local visceral or venous compression, neuropraxia, or rupture may not occur until the aneurysms reach considerable size. The current consensus is that elective repair should be considered in good risk patients for isolated iliac artery aneurysms greater than 3 to 4 cm in maximal transverse diameter. (6)
The natural course of an iliac artery aneurysm (IAA) consists of progressive expansion with eventual rupture. Risk of rupture remains the primary indication for repair. The vast majority of isolated iliac artery aneurysms are asymptomatic and are detected incidentally on imaging studies performed for other indications. Owing to the deep pelvic location of these aneurysms, symptoms including local visceral or venous compression, neuropraxia, or rupture may not occur until the aneurysms reach considerable size. The current consensus is that elective repair should be considered in good risk patients for isolated iliac artery aneurysms greater than 3 to 4 cm in maximal transverse diameter. (6)
With advances in catheter technology, trans-catheter embolization and endovascular stent-graft placement have become possible alternatives to surgery in the treatment of IAAs. These minimally invasive methods include a variety of therapeutic options, and choosing an appropriate option on the basis of the imaging characteristics of IAAs is essential for achieving excellent long-term results and reducing potential complications (7). Endovascular aneurysm repair (EVAR) is particularly useful for treating iliac artery aneurysms (IAAs) due to its ability to prevent critical complications, such as damage to the neighbouring intrapelvic and genitourinary organs and intrapelvic veins.
With advances in catheter technology, trans-catheter embolization and endovascular stent-graft placement have become possible alternatives to surgery in the treatment of IAAs. These minimally invasive methods include a variety of therapeutic options, and choosing an appropriate option on the basis of the imaging characteristics of IAAs is essential for achieving excellent long-term results and reducing potential complications (7). Endovascular aneurysm repair (EVAR) is particularly useful for treating iliac artery aneurysms (IAAs) due to its ability to prevent critical complications, such as damage to the neighbouring intrapelvic and genitourinary organs and intrapelvic veins.
Postoperative complications of EVAR of common iliac artery aneurysms include type II endoleaks, which are caused by blood flowing into the aneurysm sacs from branching arteries, with the lumbar artery, inferior mesenteric artery, and internal iliac artery (IIA) being the arteries responsible for blood inflow in the case of common iliac artery (CIA) aneurysms [8]. Endoleaks are the main cause of postoperative aneurysm dilatations therefore, concomitant embolization of these arterial branches can be performed as preventive treatment (9). Coil embolization of IIA is a widely utilized and effective method for preventing retrograde flow into CIA aneurysms post EVAR with stentgrafts.
Postoperative complications of EVAR of common iliac artery aneurysms include type II endoleaks, which are caused by blood flowing into the aneurysm sacs from branching arteries, with the lumbar artery, inferior mesenteric artery, and internal iliac artery (IIA) being the arteries responsible for blood inflow in the case of common iliac artery (CIA) aneurysms [8]. Endoleaks are the main cause of postoperative aneurysm dilatations therefore, concomitant embolization of these arterial branches can be performed as preventive treatment (9). Coil embolization of IIA is a widely utilized and effective method for preventing retrograde flow into CIA aneurysms post EVAR with stentgrafts.
Isolated IAAs are defined as aneurysms located only within the iliac artery system without involvement of the aorta. True isolated IAAs without aortic involvement are quite rare. Their prevalence in the general population is estimated at 0.03%, accounting for only 2% of all intra-abdominal aneurysms. The CIA is the most common site for IAAs, followed by the IIA. The external iliac artery (EIA) is seldom affected (10).
Isolated IAAs are defined as aneurysms located only within the iliac artery system without involvement of the aorta. True isolated IAAs without aortic involvement are quite rare. Their prevalence in the general population is estimated at 0.03%, accounting for only 2% of all intra-abdominal aneurysms. The CIA is the most common site for IAAs, followed by the IIA. The external iliac artery (EIA) is seldom affected (10).
Most IAAs are asymptomatic. Consequently, most IAAs are usually discovered incidentally during CT scan or angiography performed for other purposes. However, some patients may present with specific symptoms due to rupture, local compression, thrombosis, or distal embolization. Aneurysm rupture is the most hazardous among the many complications. For aneurysms between 3 to 4 cm in diameter, the risk of rupture is 5% to 9% over 5 years. For aneurysms >4 cm in diameter, the risk of rupture is 10% to 70% over 5 years. Rupture mortality is 25% to 57% (11).
Most IAAs are asymptomatic. Consequently, most IAAs are usually discovered incidentally during CT scan or angiography performed for other purposes. However, some patients may present with specific symptoms due to rupture, local compression, thrombosis, or distal embolization. Aneurysm rupture is the most hazardous among the many complications. For aneurysms between 3 to 4 cm in diameter, the risk of rupture is 5% to 9% over 5 years. For aneurysms >4 cm in diameter, the risk of rupture is 10% to 70% over 5 years. Rupture mortality is 25% to 57% (11).
Like AAAs, IAAs most commonly occur in elderly men. The most common cause of IAA is degenerative (i.e. secondary to atherosclerosis). Other causes include trauma, infection, dissection, excessive athletic effort (eg, bicycle racing), para-anastomotic graft failure, and connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome.
Like AAAs, IAAs most commonly occur in elderly men. The most common cause of IAA is degenerative (i.e. secondary to atherosclerosis). Other causes include trauma, infection, dissection, excessive athletic effort (eg, bicycle racing), para-anastomotic graft failure, and connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome.
Like AAAs, IAAs can mimic neurologic, genito-urologic, and gastrointestinal symptoms due to external compression. In addition, at clinical examination or conventional angiography, IAAs with luminal narrowing secondary to aneurysmal thrombosis may mimic arteriosclerosis obliterans. Hence, it is desirable that iliac artery stenosis be routinely evaluated with CT or magnetic resonance (MR) imaging prior to angioplasty, even if the entity appears to be a simple stenosis. In some studies, IAA is defined as enlargement of the artery to a diameter of more than 1.5 cm. As mentioned earlier, the natural course of an IAA consists of progressive expansion with eventual rupture, and the risk of rupture increases with aneurysm size. A review of the literature reveals that surgical repair should be recommended for isolated IAAs greater than 3.0– 3.5 cm in diameter, since the smallest reported ruptured IAA was 3 cm (12). However, this procedure is associated with mortality rates of 7%–11% for elective surgery and 50% for emergency surgery.
Like AAAs, IAAs can mimic neurologic, genito-urologic, and gastrointestinal symptoms due to external compression. In addition, at clinical examination or conventional angiography, IAAs with luminal narrowing secondary to aneurysmal thrombosis may mimic arteriosclerosis obliterans. Hence, it is desirable that iliac artery stenosis be routinely evaluated with CT or magnetic resonance (MR) imaging prior to angioplasty, even if the entity appears to be a simple stenosis. In some studies, IAA is defined as enlargement of the artery to a diameter of more than 1.5 cm. As mentioned earlier, the natural course of an IAA consists of progressive expansion with eventual rupture, and the risk of rupture increases with aneurysm size. A review of the literature reveals that surgical repair should be recommended for isolated IAAs greater than 3.0– 3.5 cm in diameter, since the smallest reported ruptured IAA was 3 cm (12). However, this procedure is associated with mortality rates of 7%–11% for elective surgery and 50% for emergency surgery.
Ideally, stent-grafts should cover the lesion and at least 1.5–2.0 cm of the normal artery proximal and distal to the lesion. Patients receive long-term anticoagulant therapy (unless contraindicated) after undergoing stent-graft placement.
Ideally, stent-grafts should cover the lesion and at least 1.5–2.0 cm of the normal artery proximal and distal to the lesion. Patients receive long-term anticoagulant therapy (unless contraindicated) after undergoing stent-graft placement.
Over the past decade, endovascular aorto-iliac aneurysm repair has been established as a safe and effective alternative to open repair in patients with appropriate anatomy. Pelvic anatomic and technical considerations that increase the potential for morbidity and mortality during open repair of isolated iliac artery aneurysm make endovascular repair particularly attractive (13).
Over the past decade, endovascular aorto-iliac aneurysm repair has been established as a safe and effective alternative to open repair in patients with appropriate anatomy. Pelvic anatomic and technical considerations that increase the potential for morbidity and mortality during open repair of isolated iliac artery aneurysm make endovascular repair particularly attractive (13).
References:
References:
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