Foreign Body Granuloma After Embolization of Internal Iliac Artery Aneurysm Using N-Butyl-2-Cyanoacrylate: A Case Report.

Foreign body granulomas following endovascular treatment are rare complications and are mostly reported in the brain or cutaneous vascular tissues. To the best of our knowledge, no study to date has reported on foreign body granulomas in the abdomen after injection of N-butyl-2-cyanoacrylate (NBCA)-lipiodol mixture into the abdominal arteries. This study reports a case of foreign body granuloma that appeared 12 months after the embolization of a right internal iliac artery aneurysm using an NBCA-lipiodol mixture, which posed challenges in differentiation from malignant tumors. We present a 77-year-old man who underwent embolization of a right internal iliac artery aneurysm and open surgical repair of an abdominal aortic aneurysm. A contrast-enhanced CT performed 12 months postoperatively revealed a right-sided retroperitoneal mass surrounding the iliopsoas muscle. The mass contained multiple, small, hyperdense areas, suggesting the migration of the NBCA-lipiodol mixture casts from the embolized right internal iliac artery aneurysm. The differential diagnosis included foreign body granuloma, lymphoma, and sarcoma. A biopsy of the lesion revealed a granuloma with various stages of inflammation, no hemosiderin deposition, multinucleated giant cells, and foam cells containing fat, and was diagnosed with a foreign body granuloma. Special staining for microorganisms revealed no findings suggestive of infection. Because the patient was asymptomatic, no treatment was administered. Contrast-enhanced CT at 24 months postoperatively showed shrinkage of the mass, with no change in size noted at 48 months postoperatively. This report highlights a foreign body granuloma that mimicked malignant tumors. Extravascular migration of the NBCA-lipiodol mixture casts likely contributed to granuloma formation. Radiologists should consider foreign body granulomas after embolization using NBCA into the abdominal arteries.

Multimodality Imaging in Rothia dentocariosa Infective Endocarditis and Internal Iliac Artery Infectious Aneurysm.

Background: Aneurysms of the internal iliac artery in infective endocarditis are extremely rare, with few cases reported in the literature, and Rothia dentocariosa infective endocarditis are rare. Analysis: We describe the case of a previously healthy 62-year-old male who presented a Rothia dentocariosa infective endocarditis. Results: Multi-modality imaging revealed an aneurysm of the left internal iliac artery, which was clinically silent. The patient was treated with antibiotics and semi-emergent bioprosthesis aortic valve replacement. Follow-up multi-modality imaging showed the regression of the aneurysm. Conclusion: This case shows that an aneurysm of the internal iliac artery in infective endocarditis can regress under antibiotherapy alone. This case also highlights the ability of PET/CT to identify and follow such an aneurysm.

A hybrid approach to complex bilateral common iliac artery and internal iliac artery aneurysm repair.

A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, with bilateral stent grafts deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. One week later, an open infrarenal aorto-bi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion.

A hybrid approach to previously excluded, expanding internal iliac artery aneurysms.

Previously excluded internal iliac artery (IIA) aneurysms can continue to expand and pose a risk of rupture. In this case series, we present three patients with previously excluded, expanding IIA aneurysms after endovascular stent coverage or open surgical ligation of the proximal IIA. We describe a hybrid approach to treat these patients safely and effectively.

Long-term results of large common iliac artery aneurysms caused by Kawasaki disease in four patients.

Among Kawasaki disease patients with systemic artery aneurysms, the brachial and internal iliac arteries are the most commonly affected, and occlusions of both arteries are often found. However, the long-term fate of large common iliac artery aneurysms remains unknown, because their prevalence is very low. The long-term outcomes of common iliac artery aneurysms caused by Kawasaki disease in four patients (three females, one male) were investigated retrospectively based on their medical records and angiograms. Their ages ranged from 30 to 36 years-old. The onset age of Kawasaki disease ranged from 4 to 8 months, and the interval from the onset of Kawasaki disease to the latest angiogram ranged from 17 to 21 years. All patients had bilateral large coronary aneurysms and common iliac artery aneurysms with maximal diameters greater than 10 mm. Although all patients had multi-vessel coronary artery stenotic lesions and systemic artery aneurysms, they were asymptomatic. The three female patients underwent coronary artery bypass grafting, and the male patient underwent replacement of artificial vessels for large bilateral common iliac artery aneurysms at 3 years old of age. Over the long-term, common iliac artery aneurysms greater than 10 mm persisted as calcified aneurysms. However, they had no symptoms due to their common iliac artery aneurysms, and their ankle brachial pressure index was preserved, even if the stenosis of the common iliac artery developed as a late outcome, because the collateral arteries were well developed. The progression of stenosis of the common iliac artery after Kawasaki disease was slower.

Synchronous Type 3 EVAR Endoleaks at Multiple Sites Following Transfemoral Transcatheter Aortic Valve Replacement.

We describe a complication following transfemoral transcatheter aortic valve replacement in a patient who underwent remote endovascular abdominal aortic aneurysm repair. This report highlights technical complications to be vigilant of when using intravascular catheterization in patients with previous aneurysm repair while also showcasing synchronous type 3 endoleaks at multiple sites. (Level of Difficulty: Advanced.).

Internal Iliac Artery Aneurysm Ruptures with No Visualized Endoleak 2 Years after Endovascular Repair.

We report a case of an 83-year-old man with a ruptured internal iliac artery (IIA) aneurysm after endovascular repair, which was treated via the ligation of IIA and tight suture of the aneurysm sac. Although there were no findings of obvious endoleak after endovascular treatment, the IIA aneurysm increased in size and eventually ruptured. We presumed that pressure to IIA aneurysm via the embolized IIA led to rupture. Aneurysm sac expansion may lead to a rupture despite no endoleak being detected; therefore, close follow-up or re-intervention must be considered. Tight embolization of IIA may prevent endotension in the same case.

Modalities of endovascular management for internal iliac artery aneurysms.

BACKGROUND: Internal iliac artery aneurysms (IIAA) are uncommon. Open repair is technically challenging and has been associated with increased morbidity and mortality compared with repair of abdominal aortic aneurysms. The aim of this study is to assess the outcomes of endovascular treatment of IIAA and incidence of postoperative pelvic ischaemia. METHODS: A single-centre retrospective analysis was performed for IIAAs treated with endovascular repair between January 2005 and December 2017. Aneurysm morphology, mode of presentation and operative technique were evaluated. Primary outcomes were 30-day mortality and incidence of pelvic ischaemia. Secondary outcomes were technical success, major complications and reintervention. RESULTS: Twenty-nine IIAAs were treated in 23 patients with a mean age of 74 */- 9 years. Six patients had isolated IIAAs (26%); the remaining 17 patients had aortoiliac aneurysms. Five patients (22%) required emergent repair for ruptured IIAAs. Mean IIAA size was 4.1 cm */- 1.8 and ruptures occurred at mean 6.1 cm */- 2.6. Endovascular techniques used: stent graft occlusion of the internal iliac artery (IIA) ostium (n = 16), deployment of iliac branch device (n = 9), and other endovascular techniques (n = 4). The 30-day mortality was zero. Three patients (13%) experienced post-operative pelvic ischemia which were all minor chronic gluteal claudication after IIA occlusion. Primary technical success was achieved in 27 repairs (93%). There was one late reintervention (3%). CONCLUSION: IIAAs are often asymptomatic and diagnosed incidentally, however, a significant proportion present emergently. Endovascular treatment is feasible for both ruptured and non-ruptured aneurysms with low perioperative morbidity, mortality and reintervention rates.

Custom-made iliac fenestrated endoprosthesis for the treatment of internal iliac artery aneurysm with preservation of the superior gluteal artery.

A 56-year-old man with huge bilateral internal iliac artery aneurysms (IIAAs) had emergently undergone right common iliac artery replacement. Intermittent claudication was induced by 8 minutes of walking on postoperative day 16. Endovascular repair using a custom-made iliac fenestrated endoprosthesis for the treatment of the left IIAA with preservation of the superior gluteal artery was performed on postoperative day 20 without discharging the patient. The patient had no ischemic complications. When an IIAA with a short length (<55 mm) and large diameter (>21 mm) of the common iliac artery is anatomically suitable, the placement of a custom-made iliac fenestrated endoprosthesis is a feasible and effective technique.

[Endovascular treatment of common iliac artery aneurisms]. / Rezul'taty endovaskulyarnogo lecheniya anevrizm obshchei podvzdoshnoi arterii.

OBJECTIVE: To demonstrate endovascular management of common iliac artery aneurysms with iliac branch devices and to discuss some technical aspects of these interventions including bilateral procedures. MATERIAL AND METHODS: Endovascular abdominal aortic aneurysm repair with concomitant implantation of iliac branch devices was performed in 9 patients at the Petrovsky National Research Center of Surgery for the period from January 2019 to December 2020. Mean age of patients was 64.8± years (min 52; max 72 years). Preoperative planning and morphometric analysis were based on CT data with a slice thickness of 1 mm. Angiographic reconstruction was made using Osirix 3D software (OsiriX Foundation, Geneva, Switzerland). Abdominal aortic aneurysm was combined with common iliac artery aneurysm in 7 patients (77.7%). Three (33.3%) patients had isolated common iliac artery aneurysm without significant abdominal aorta enlargement (Reber type I). Bilateral common iliac artery aneurysms were detected in 1 (11.1%) patient. All patients had iliac artery aneurysms over 4 cm. Iliac branch device implantation was accompanied by endovascular abdominal aneurysm repair in all patients. RESULTS: Technical success rate was 100%. Six-month results were followed-up in 5 patients (55.5%), annual outcomes - in 2 patients (22.2%). Control examination consisted of a telephone interview, ultrasound of abdominal aorta, pelvic and lower limb arteries and computed tomography. All patients had no endoleaks, stent-graft thrombosis, as well as signs of ischemia of pelvic organs and lower extremities. Incidence of iliac artery aneurysm combined with abdominal aortic aneurysms is about 20%. Until recently, treatment of these patients was performed exclusively with covering of internal iliac artery. Improvement of technologies and development of iliac branch devices made it possible to preserve blood flow in internal iliac artery after endovascular management. This approach allowed avoiding of ischemic complications associated with embolization of internal iliac arteries.

Percutaneous approach options for embolization of endoleak after iliac artery aneurysm repair: stick the sac or stick the gluteal artery.

Internal iliac artery aneurysms (IIAAs), isolated or associated with abdominal aortic aneurysms, are at rupture risk with growth. Treatment is recommended when symptomatic or greater than 3 cm. Surgical or endovascular therapy should exclude the arterial origin and outflow branches. If all outflow branches are not completely embolized, an endoleak can develop, pressurizing the sac leading to growth and rupture. Accessing the arteries involved can be technically challenging and understanding potential targets is critical. We describe two percutaneous approaches for treatment: percutaneously accessing the sac from an anterior trans-iliopsoas approach and percutaneously accessing the gluteal artery from a posterior approach.

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.

Internal iliac artery aneurysm embolization with direct percutaneous puncture and thrombin injection.

Endoleak it is the most common complication after endovascular abdominal aortic aneurysm repair and it represents the failure of endovascular treatment. In particular type 2 endoleak is associated with retrograde flow in the aneurysm sac from one or more arterial branches. We describe a reperfusion of the aortic aneurysm sac with slow-flow type II endoleak from the right internal iliac artery aneurysm through the posterior door previously closed with coils, and treatment with direct puncture of the internal iliac artery aneurysm with infixion of human thrombin under ultrasound guidance, not previously described in the literature. In this case the direct puncture of the aneurysm sac was the faster and safer way to treat this patient just because the back door was closed by coils and the entry by the iliac graft. Thrombin reduces significantly the presence of artifacts and give to us the exact extension of thrombosis into the aneurysm sac and the echo-guided offers the advantage of being able to monitor the progression of the thrombotic process induced by thrombin injection in real time.

Isolated internal iliac artery aneurysm causing rectal necrosis due to compression early after endovascular repair: A case report.

INTRODUCTION: Recently, endovascular repair has become the first-line treatment for internal iliac artery aneurysm (IIAA). However, rectal necrosis due to the compression of the residual IIAA early after endovascular repair is rare. PRESENTATION OF CASE: We present a rare case of a huge, isolated left IIAA that severely compressed the rectum and ureter. The patient underwent emergency endovascular repair; however, rectal necrosis occurred 10 days later because the repair failed to shrink the size of the aneurismal sac. DISCUSSION: We hypothesize that the compression of the residual IIAA caused rectal necrosis. During open surgery, endovascular repair disrupted blood flow within the IIAA, which probably allowed for aneurysm dissection and residual hematoma removal. CONCLUSION: Endovascular repair alone could not immediately release compression on the surrounding organs; however, open surgical removal of aneurysms after successful endovascular repair may be a useful option for IIAAs with compression of surrounding organs.

Endovascular treatment of hypogastric artery aneurysms.

OBJECTIVE: Internal iliac artery aneurysm (IIAA) is a rare entity. Its treatment can be technically challenging. The aim of this study was to evaluate the treatment possibilities in an era of advanced endovascular techniques and their potential to preserve iliac blood flow while reliably excluding the aneurysm. METHODS: A retrospective analysis of 46 consecutive patients with endovascularly treated IIAA was performed. Data were collected from a single-institution aortoiliac database. The following end points were recorded: technique of aneurysm exclusion, technical success rates, perioperative morbidity and mortality, primary patency, and midterm follow-up. RESULTS: Between September 2009 and May 2016, a total of 46 patients with 55 IIAAs were identified. The majority of patients (n = 39 [84.8%]) had aortoiliac aneurysms and seven had isolated IIAAs (15.2%). The following surgical techniques were used: implantation of iliac branch devices (IBDs; n = 29), occlusion of the internal iliac artery (IIA) by ostium coverage with or without prior coil embolization (n = 23), and other endovascular techniques (n = 3). Primary assisted technical success was achieved in 93.1% of IBD implantations and in 100% of occlusions by ostium coverage and other techniques. Overall 30-day mortality was 4.3% (n = 2) and 0% in electively treated patients. Assisted midterm patency after IBD implantation was 93.1%. Gluteal claudication occurred in seven patients (15.2%) who had undergone intentional or accidental occlusion of the IIA or the superior gluteal artery. Reintervention rates within the midterm follow-up were 13.8% (n = 4) after IBD implantation and 4.3% (n = 1) after coverage of the IIA ostium. No ruptures were observed during follow-up, and no complications occurred during reinterventions. CONCLUSIONS: Implantation of IBD devices for the treatment of hypogastric artery aneurysms shows good technical results with a high primary patency and a low rate of perioperative complications. Although successful aneurysm exclusion while preserving pelvic blood flow is associated with a higher rate of reinterventions during midterm follow-up, it should be taken into consideration, especially in complex endovascular aortoiliac aneurysm repair.

Bilateral GORE Iliac Branch Endoprosthesis with prior open abdominal aortic aneurysm repair.

The GORE Iliac Branch Endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) has been approved by the Food and Drug Administration for use in the treatment of aortoiliac and common iliac aneurysms, with promising results to date. The efficacy of using the device to overlap with a Dacron graft has yet to be elucidated. We present the case of a patient with prior open abdominal aortic aneurysm repair who we treated with bilateral iliac branch endoprostheses.

Huge internal iliac artery aneurysm and post-renal AKI.

We report a rare case of a huge internal iliac artery aneurysm (IAA) complicated by post-renal acute kidney injury. Huge internal IAA should be considered for one of differential diagnoses for post-renal acute kidney injury.

Unusual Access for the Treatment of Iliac Artery Aneurysm in Association with Type II Endoleak After Endovascular Repair of an Aortoiliac Aneurysm.

Internal iliac artery aneurysms (IIAAs), although rare, are associated with a significant risk of mortality, if they rupture. Endovascular approach with exclusion of the aneurysm sac from antegrade and retrograde perfusion is proved to be a feasible treatment option. However, this option is not always technically possible with a preexisting endovascular aneurysm repair (EVAR) or surgical aortoiliac reconstruction with ligation of internal iliac artery origin. We report another safe treatment option of an enlarging IIAA associated with a type II endoleak after EVAR and a standard endovascular treatment was not possible. The access to the aneurysm sac was achieved retrograde via percutaneous access to the superior gluteal artery under fluoroscopy followed by treatment with embolization of the inflow and outflow vessels.

Surgical Repair of an Arteriovenous Fistula in the Posterior Wall of the Right Common Iliac Vein.

We present the case of a right internal iliac artery aneurysm with arteriovenous fistula in the posterior wall of the right common iliac vein. The fistula would have been difficult to close using endovascular treatment. We strongly anticipated difficulty in controlling bleeding; therefore, we performed cardiopulmonary bypass. Closing the fistula with suture would have been difficult, so we ligated the right common iliac artery and vein around the aneurysm. Femoro-femoral bypass was also performed to preserve blood flow in the lower right leg. The use of cardiopulmonary bypass should be considered in such difficult cases.

Clinical outcomes of hypogastric artery occlusion for endovascular aortic aneurysm repair.

PURPOSE: To determine the midterm outcomes of internal iliac artery (IIA) coverage by a stent-graft in endovascular aortic aneurysm repair (EVAR) under specific anatomic and technical circumstances. MATERIAL AND METHODS: From January 2003 until January 2014, 57 patients with aortoiliac aneurysms, including 20 with 24 IIA aneurysms (IIAAs), underwent EVAR with IIA coverage. IIAA diameter change or IIA thrombosis, buttock claudication, type II endoleak, and secondary interventions related to the IIA were studied. RESULTS: Twenty-five of the 37 patients without IIAA were embolized prior to stent-graft placement, all unilateral, and in 12, the IAA orifice was only overstented. Buttock claudication occurred in only nine (20%) of the embolization patients (9/49 IIA's) (p = .14), while one IIA-related type II endoleak, occurred in the nonembolization group (p = .16). In patients with IIAA(s), the aneurysm diameter decreased in 16 cases (67%). Buttock claudication occurred in 75% of bilateral, and in 14.6% of unilateral embolizations (p = .046). CONCLUSIONS: Carefully selected patients with aortoiliac aneurysm without IIAA may safely undergo hypogastric artery overstenting without preemptive embolization during EVAR. IIA embolization is associated with buttock claudication and should be avoided if possible. Otherwise, at least one IIA should be preserved.