Hybrid repair of isolated internal iliac artery aneurysm

Figure 1. Computed tomography of an isolated internal iliac artery aneurysm. (a–c): Images before the operation: An isolated internal iliac artery aneurysm on the left with a diameter of 36 mm can be seen. The left common iliac artery and the neck of the left internal iliac artery aneurysm were severely calcified (arrows). (d) Image four months postoperatively: The aneurysm sac has become smaller because its wall was resected as much as possible. The vascular plug in the internal iliac artery is visible distal to the aneurysm (arrow).

Figure 2. Arteriogram of the left internal iliac artery during the embolization procedure as the first stage of hybrid intervention. (a) Arteriogram before embolization: The left internal iliac artery stem distal to the aneurysm (black triangle) and the anterior (white arrows) and posterior division of the internal iliac artery (black arrows) are shown. (b) Arteriogram after coiling of the posterior division of the left internal iliac artery: Metal coils are visible from the posterior division of the left internal iliac artery to the superior gluteal artery. The microcoil was used because it provides good control in these narrow and tortuous arteries. (c) Arteriogram after vascular plug deployment: The left internal iliac artery stem and its anterior division were embolized using an Amplatzer vascular plug because they were wide and straight enough to insert the 5 Fr guiding catheter. Triangles: the vascular plug. The black arrows indicate the tip of the plug. The blood flow in the artery persisted after the plug had been deployed. The completion of embolization with metal devices needs time.

Figure 3. Intraoperative findings during the open procedure as the second stage of hybrid intervention. (a) Dissection of the vessels proximal to the internal iliac artery aneurysm: We clamped the common iliac artery and external iliac artery for proximal control. The neck of the internal iliac artery aneurysm was very short (arrow). (b) Without surgical clamping of the distal branches, we opened the aneurysm. The origin of the distal internal iliac artery and the tip of the vascular plug obstructing it are visible. No bleeding into the internal iliac artery aneurysm can be seen. The first-stage embolization had completely controlled the distal blood flow. Arrow: the tip of the vascular plug. Circle: the orifice of the internal iliac artery distal to the aneurysm. (c) We ligated the origin of the distal internal iliac artery with a 4–0 pledgeted suture to avoid dislodgement of the vascular plug and delayed bleeding. Arrow: one of the two pledgets used in the ligation. (d) The common iliac artery could not be directly closed. We interposed the artery for proximal repair. The aneurysm wall was resected as much as possible. CIA: common iliac artery, EIA: external iliac artery, IIAA: internal…