| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
Interact CardioVasc Thorac Surg 2009;8:491-492. doi:10.1510/icvts.2008.194936 © 2009 European Association of Cardio-Thoracic Surgery
Endovascular occlusion of a common iliac artery aneurysm after open repair of an abdominal aortic aneurysmDivision of Vascular Surgery, Hospital Clinic, Thorax Institute, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain Received 24 September 2008; received in revised form 13 December 2008; accepted 16 December 2008
*Corresponding author. Tel.: +34 932275515; fax: +34 932275749.
Endovascular therapy is a safe alternative to treat the late complications of open aortic surgery. Here we report the endoluminal treatment of a recurrent common iliac aneurysm. A 68-year-old man, who submitted five years previously to an aorto bifemoral in order to exclude a juxta renal aortic aneurysm, developed a recurrent aneurysm of the left common iliac artery. He underwent an occlusion of the external iliac artery with a self-expandable nitinol mesh occlusion device and the aneurysm was embolized with detachable coils, with a good outcome. Endoluminal therapy does not expose patients to elevated risks, and may be indicated in selected cases to treat the complications of open surgery.
Key Words: Endovascular; Aneurysm; Iliac artery; Iliac aneurysm; Aortic aneurysm; Recurrent aneurysm
Endovascular therapy is a safe alternative in the treatment of patients that present late complications of traditional open aortic surgery. In this work, we report and discuss a case of a patient that presented an isolated recurrent true common iliac artery aneurysm, in the late postoperative period of an aorta bifemoral, performed in order to exclude a juxta renal aortic aneurysm.
A 68-year-old man was submitted five years previously to an aorta bifemoral in order to treat and exclude a juxta renal aortic aneurysm. The surgery was performed in the traditional fashion, and the exclusion of the iliac arteries was performed with a continuous suture at the level of the aortic bifurcation using a Prolene 3-0. In his five-year follow-up, it was detected in a routine duplex evaluation, a true aneurysm of the left common iliac artery that extended to the external iliac artery. He was submitted to a CT angiography that confirmed the finding of a left common iliac artery aneurysm of 43 mm, extending to the external iliac artery (Fig. 1). The anastomosis of the aorta and femoral arteries did not present any complication and there was a good run-off to the extremities. His medical history was notable for hypertension, hypercholesterolemia, past use of tobacco, mitral valvular insufficiency and coronary artery disease, with a previous aortic coronary bypass. In the preoperative evaluation he was presumed to be at Risk III in the American Surgical Association (ASA) score. He was submitted to an endoluminal embolization of the aneurysm sac. The procedure was performed under local anesthesia and sedation, with a short incision of 3 cm in the groin. An anterograde left superficial femoral arterial access was gained by using a single wall entry needle. A 7F sheath was placed in the superficial femoral artery, and systemic anticoagulation with heparin was achieved. Subsequently, selective catheterization of the common iliac aneurysm artery using a multipurpose catheter was performed. The aneurysm sac was embolized with detachable coils and the external iliac artery was occluded next to the neck of the aneurysm with a self-expandable nitinol mesh occlusion device (AMPLATZER Vascular Plug II - AGA Medical Corporation, Minnesota, USA) (Fig. 2), with a diameter of 14 mm and 10 mm in length. There was exclusion of the aneurysm. The superficial femoral artery puncture site was closed with a single suture Prolene 5-0.
The postoperative period was uneventful and the patient was discharged on the first postoperative day. In his 30-day follow-up the aneurysm sac was excluded (Fig. 2), and there was no delayed complication.
The open repair of abdominal aortic aneurysms has two possibilities, the use of a tube graft or of a bifurcated graft. A decision algorithm suggests that a tube graft is performed when the common iliac arteries have <12 or <18 mm in diameter, or the life expectancy of the patient is less than eight years, with a celiac aorta diameter <25 mm. If it is not the case, a bifurcated graft is indicated. The tube graft has as advantages, shortened operative time, reduced blood loss and reduced morbidity/mortality. As a disadvantage, there is the risk of iliac aneurysmal dilatation. The bifurcated graft has as advantages, the treatment of atherosclerotic aorto-iliac disease at the same time and the prevention of iliac aneurysmal dilatation. As a disadvantage there is greater morbidity/ mortality [1]. In this case, the common iliac artery was ectasic at the first operation and the patient had a life expectancy of eight or more years. We decided to use a bifurcated graft, in order to avoid an aneurysmatic degeneration of the reperfused common iliac artery. This was not true, and this work outlines that possibility. In all cases reported previously in the literature, the operatory finding was of rupture of the reperfused aneurysm [2, 3]. This report calls attention for the importance of surveillance in the open surgery for aneurysms. The bifurcated graft up to the femoral arteries does not protect entirely for the possibility of an aneurysmal degeneration. As far as we know there is no report of an elective, endovascular correction of a recurrent common iliac artery aneurysm published before. The isolated true iliac artery aneurysm is rare. The iliac aneurysms are more common in association with the abdominal one. When isolated, in order of appearance, it is more prone to occur in the common iliac artery, followed by the internal, and then in the external iliac arteries. Generally it is asymptomatic, and may be discovered only in its rupture, that is the most important complication of this pathology. The appearance of an iliac artery aneurysm in the late postoperative period of a traditional open aorta bifemoral, performed to treat an abdominal aortic aneurysm, is a very uncommon complication of this kind of surgery. Plate et al. [4] in 1176 patients operated reported the occurrence of six cases of recurrent aneurysms of the iliac segment. If the recurrent common iliac aneurysms are caused because of the connected run off, is still unclear. The embolization of an isolated common iliac aneurysm in the situation of a previous aortic surgery, is a far more safer surgery, when feasible, when compared to the open traditional approach, because it avoids the dissection in a field normally with dense adherences in patients that present generally severe comorbidities, that sometimes may preclude an open surgery, as in this case. Another possibility would be the exclusion of the aneurysm with a ‘U’ stent graft as described for Kotsis et al. [5], and preservation of the flow to the ipsilateral hypogastric artery. This alternative is useful because of the concern of occluding a sole permeable hypogastric artery, and its complications, such as buttock claudication, medular ischemia, colic ischemia and impotence. In conclusion, the endoluminal therapy does not expose the patients to elevated risks, and may be indicated for selected patients to treat the complications of the open surgery.
Related Article
This article has been cited by other articles:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Abstract
1. Introduction
