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

Figures

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  Fig. 1. 71-year-old man with prior history of embolization of left internal iliac artery aneurysm with two Amplatzer plugs presented for endovascular treatment of type II endoleak via anterior trans-iliopsoas puncture of the aneurysm sac. (A) Axial CT angiogram of the pelvis shows the inferior aspect of a partially thrombosed left internal iliac artery aneurysm (short arrows). Calipers delineate the planned course of direct trans-iliopsoas puncture of the patent flow channel of the endoleak within the aneurysm sac. (B) 3D volume-rendered image demonstrates a robust collateral arising from the profundal femoris artery (long arrow) and providing inflow into the endoleak through reversal of flow in the obturator artery (arrowhead). Asterisk marks the Amplatzer plugs.

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  Fig. 2. Pre and post embolization fluoroscopic images of the Case 1 endoleak and involved arterial branches. (A) Angiography was performed through the side arm of a check flow valve which was placed on the back of a 19-gauge Temno coaxial needle. The brisk injection forces contrast back into the obturator artery inflow (long arrow) and exits through superior (short arrow) and inferior gluteal artery (arrowhead) outflow. (B) The branch vessels seen in Fig. 2A have been coil embolized and the endoleak channel filled with a combination of coils and ethylene vinyl alcohol. The Amplatzer plugs are marked by the brackets.

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  Fig. 3. 80-year-old man with prior history of left internal iliac artery aneurysm treated with a common iliac-to-external iliac artery covered stent and an Amplatzer plug presented for endovascular treatment of type II endoleak via direct puncture of the superior gluteal artery. (A) Axial CT angiogram of the pelvis in the prone position shows a partially thrombosed left internal iliac artery aneurysm (arrowhead) and an enlarged left superior gluteal artery with prominent atherosclerotic calcifications (arrow). (B) Ultrasound and CT guided direct puncture of the left superior gluteal artery with a 21-gauge micropuncture needle was aided by prominent calcifications which served as landmarks.

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  Fig. 4. Pre and post embolization fluoroscopic images of the Case 2 endoleak and involved arterial branches. (A) Angiography performed through percutaneous puncture of an enlarged superior gluteal artery (black arrow). A covered stent extends from common iliac to external iliac artery with an Amplatzer plug (arrowhead) in the origin of the internal iliac artery. (B) Multiple coils and Onyx fill the lateral sacral artery (white arrow), superior gluteal artery (black arrow) and aneurysm sac (asterisk).