Percutaneous exclusion of an iliac aneurysm by a self -expanding stent graft

Clinical History

Exclusion of an iliac aneurysm by self-expanding stent graft and balloon-expandable stent.

Imaging Findings

Patient was admitted because of hypertension. No claudication was present. Diagnostic angiography for renal arterial stenosis revealed an irregular aneurysm of the right common iliac artery with a very small proximal neck, extending to the orifice of the internal iliac artery (Fig. 1) After contralateral femoral puncture a cross-over embolization of the internal iliac artery by coils was performed to prevent retrograde perfusion of the aneurysm (Fig. 2). A 4 F cobra catheter with a 0.038 in lumen was used to place macrocoils of 5 and 6 mm of diameter. Then, an ipsilateral retrograde puncture was performed and an 8 mm Wallgraft (BSIC Inc.) stent graft covered by PET (Polyethylene teraphtalate) was inserted into the aneurysm via a 10 F sheath (Fig. 3 a). After stent graft, deployment, residual perfusion of the aneurysm was still visible because the stent graft slightly collapsed synchronously to arterial pulsation thus opening the proximal neck allowing blood flow into the aneurysm (Fig. 3 b). After balloon angioplasty had failed to seal the leakage, a balloon-expandable Palmaz stent was placed within the proximal portion of the stentgraft in order to fix it to the wall. By that, the aneurysm was sufficiently excluded (Fig. 3c)

Discussion

For percutaneous exclusion of iliac aneurysms, several differnt types of stent grafts are commercially available. In that particular case we decided to use the Wallgraft, because it is well visible and was supposed to nicely fix into the proximal and very short neck. Furthermore, it is available in an appropriate length avoiding insertion of more than one stent graft (cost-benefit ratio). The flexibility of the graft turned out to cause some problems with leakage that could be solved by additional placement of balloon-expandable stent.Another option would have probably been to use a larger diameter for the stent graft. However, for thelarger diameter Wallgraft, a 12 F sheath would have been required which might cause problems at the access site. It is questionable, whether an asymptomatic patient should be treated in case of an iliac aneurysm. However, danger of rupture is possible although large series are not published in the literature.

Differential Diagnosis List

Final Diagnosis

Successful exclusion of an iliac aneurysm by embolization, stentgraft and stent

URL:	https://www.eurorad.org/case/486
DOI:	10.1594/EURORAD/CASE.486
ISSN:	1563-4086