Endovascular Management of an Unique Left Common Iliac Aneurysm

- Operator : Thomas George

Endovascular Management of an Unique Left Common Iliac Aneurysm
- Presenter: Thomas George, MD, Janakiraman Ezhilan, MD
Clinical Information
69 yrs Male Diabetic & hypertensive for 10 yrs presented with Hematuria & Abdominal pain of 15 days. An ultrasound abdomen showed a large renal calculi and an urologist asked for cardiac clearance prior to possible surgical intervention.
A Duplex ultrasonogram revealed a single fused right sided kidney with calculi in its upper pole and a left common iliac artery aneurysm. A renal perfusion scan showed a fused single functioning kidney on right side with areas of infarct on its lower pole that supplied by accessory branch. A multislice CT angiogram was done. The aneurysm measured 22 cm long and 68 cm wide and had a layered thrombus. A single renal artery arising from the aorta on the right side supplied 80% of the fused kidney. An accessory renal artery arising from the Lt common iliac artery above the aneurysm supplied 10% of the renal mass. Another accessory renal artery arising from the aneurysm supplied the lower pole of the fused kidney (Figure 1).
Baseline Peripheral Angiography
Through a right femoral access a coronary angiogram was done. An aortogram from just above iliac bifurcation by a 6Fr pigtail catheter delineated the Lt common iliac artery aneurysm very well ( Movie 1).
Treatment Plan
  • Coil embolization of Lt internal iliac artery (to prevent endoleakage)
  • Coil embolization of accessory renal branch arising from aneurysm
  • Deploying graft stent in aneurysm of Left common iliac artery
Procedure
Access secured by a Left Femoral arteriotomy and percutaneous Rt Femoral access. The anomalous renal artery arising from the aneurysm & supplying the lower pole of the fused ectopic kidney (which showed infarct on renal perfusion scan in its territory) was selectively engaged. A Vertebral guide catheter could not engage the vessel and was replaced by a Cobra catheter which was used to selectively engage into the artery. However it was not giving good support when a terumo wire was being passed distally. Hence a 0.014 coronary Whisper ES wire was passed distally and over this wire the cobra catherter was exchanged for a Glide catheter. This could deep engage the accessory renal artery which was then coiled with 38/5/5 Cook coils ( Movie 2, Movie 3, Movie 4). Next the left internal iliac artery was selectively engaged with a 5 french right judkins 4.0 guide catheter over a 0.35 j tipped terumo wire. It was then coiled with 38/8/8 cook coils (Figure 2, Figure 3). An Amplatz superstiff wire was passed antegradely up from the left femoral artery to deliver the endograft. From the contralateral right femoral access an attempt was made to pass a pigtail catheter above the common iliac bifurcation and image in order to help in positioning the upper part of the stent graft. However it resulted in a long dissection from the femoral sheath up to lower part of abdominal aorta ( Movie 5). A Left Radial access was swiftly taken. Check angiogram was done which showed spontaneous sealing of dissection and flow through true lumen to distal vessel beyond bifurcation ( Movie 6). The main Right renal artery supplying most of the ectopic kidney was found arising from true lumen and thus its vascular supply was not compromised. A 16/13-120 Endurant stent graft was deployed from above the aneurysm in the Left common iliac artery and overlapped with a second 16/13-120 Endurant graft which were then sequentially post dilated ( Movie 7, Movie 8). Multislice CT 3 months later showed exclusion of aneurysm from artery with no evidence of endoleak or aortic dissection (Figure 4). The stent grafts were well apposed and functioning normally.

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