A novel approach to the management of a ruptured Type II endoleak following endovascular repair of an internal iliac artery aneurysm

Abstract

ABSTRACT. Endovascular repair of isolated iliac artery aneurysms is an established safe and effective management option. Type II endoleak is a potential complication, but rarely results in significant morbidity or mortality. We report a case of a patient who presented with a ruptured internal iliac artery aneurysm secondary to a Type II endoleak. To our knowledge this and the following method of managing this have not been previously reported. Established methods of managing endoleaks, such as intravascular transfemoral embolisation and open or laparoscopic ligation, were not possible. Therefore, we resorted to a novel approach to this type of aneurysm and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery. Isolated iliac artery aneurysms (IAAs) are rare, with an incidence rate as low as 0.03% in large autopsy series [1]. These aneurysms represent approximately 2-7% of all intra-abdominal aneurysms [2,3]. Iliac artery dilatation is regarded as aneurismal if it is .25 mm in diameter [4] and repair should be considered for aneurysms greater than 324 cm [3,5]. Over the past decade, endovascular iliac aneurysm repair has been established as a safe and effective alternative to open repair in patients with appropriate anatomy [3,5,6]. A Type II endoleak is one of the complications of endovascular repair and arises due to the persistence of pressurised flow in iliolumbar and sacral arteries. Type II endoleaks are found in up to 20% of cases following endovascular repair [7,8]. Although in most cases Type II endoleaks are considered benign [9], intervention becomes necessary when there is significant expansion of the sac [8] and, subsequently, increased risk of rupture. We report a case of a ruptured IAA secondary to a Type II endoleak and describe a percutaneous technique to embolise the endoleak. To the best of our knowledge, neither has been previously described in relation to an IAA. Case reportAn 84-year-old female presented with a reduced level of consciousness, acute onset abdominal pain and vaginal bleeding for several weeks. Initial assessment revealed that the patient was confused and disorientated, with a Glasgow coma score of 13. The patient was hypotensive (91/49), tachycardic (110) and pyrexial (37.9 u C). Heart sounds were normal, the chest was clear and an abdominal examination revealed tenderness and guarding mostly in the left lower quadrant. Initial investigations revealed haemoglobin (Hb) of 7.7 g dl . Urine dipstick analysis was positive for leukocytes, nitrites, protein and blood. The patient was resuscitated with intravenous (IV) fluids and IV piperacillin and tazobactam was commenced to treat the urinary tract infection. Subsequent urine culture revealed an Enterobacter infection.The patient's medical history included bilateral internal iliac artery aneurysms (IIAAs), chronic renal failure with a left-sided hydronephrosis and ureteric stent in situ, hypertension and ischaemic heart disease. 2 years previously an occlusion of the left IIAA was p...

Direct aneurysm sac catheterization and embolization of an enlarging internal iliac aneurysm using cone-beam CT

“…Other reported approaches for embolization of such partially excluded aneurysms are percutaneous ultrasound-guided access or surgical exposure of the superior gluteal artery. Open ligation is rarely used and only indicated when all other approaches have failed (11).…”

Novel Treatment of an Enlarging Internal Iliac Artery Aneurysm in Association with a Type 2 Endoleak via Percutaneous Embolisation of the Superior Gluteal Artery through a Posterior Approach

“…In such cases, percutaneous direct access of the aneurysm with embolisation of the sac and feeding arteries has shown to be a feasible method of management. This method was first described in 1985 [9] and a variety of methods for accessing the sac have been described since with transperitoneal [1, 3, 10], retroperitoneal [9], transiliac [11], gluteal artery cutdown [12], and posterior [13] approaches reported. Visualisation of the aneurysm is achieved with either CT or duplex ultrasound.…”

“…Consequently, ongoing type II endoleak via retrograde flow through the superior gluteal artery resulted in gradual expansion of the sac. The decision to treat in this instance was based on the increasing size of the aneurysm and the known risk of type II endoleaks causing IIA rupture [13]. …”

“…In this case, the decision was made to approach posteriorly to provide improved access to the vessel of interest and maximise the chances of successful embolisation of the collateral arteries feeding the superior gluteal. Previous case reports using ultrasound guidance [13] or open cutdown [12] approaches have demonstrated that superior gluteal artery access through a posterior approach can be used effectively in the management of IIA disease; however, it has not been previously reported using CT as image guidance. Puncture of the superior gluteal allowed for the straightforward catherisation and embolisation of all 5 supplying collaterals, as well as embolisation of the sac.…”

Ruptured Hypogastric Artery Aneurysms

“…These techniques are not without risk of failure, as recurrent rupture has been reported secondary to recanalization or endotension. [35][36][37] A temporizing measure at proximal exclusion can also be performed via balloon occlusion to allow for either ongoing resuscitation or time to locate appropriate fitting endografts. 38 Flow to the contralateral hypogastric artery should be maintained.…”